Acute Hospital Level Care at Home
As care continues to move outside of the walls of the hospital, CMS is allowing at home care for acutely ill patients typically requiring inpatient admission.
Summary
CMS has provided regulatory flexibility to treat acutely ill patients at home instead of in the hospital.
Hospital must submit a detailed waiver request to CMS of the care plan to ensure patient safety.
Outcomes:
Not enough mortality data to evaluate
Improved resource use; patient satisfaction and costs
Lower complication rates and cost of care
Improved escalation rate requiring ED visits; inpatient readmission, SNF admission
Patient selection criterion and evaluation is a critical success factor
Background
1. For decades, health systems have seen a significant movement toward outpatient care.
2. Hospital revenue from inpatient and outpatient services are converging
3. The drivers of this trend include:
a. Value based care
b. Technological advances in clinical procedures
c. Regulatory changes (Observation status patients)
d. Patient preferences
e. Cost of care
Review
Acute Hospital Care at Home
November 25, 2020: CMS announces regulatory flexibility to treat eligible patients at home as opposed to a traditional hospital stay.
The expected value is:
Patients prefer being at home with family and caregivers
Increased COVID-19 inpatient capacity
Avoid COVID-19 exposure of patients and families not currently diagnosed
2. Care Delivery Model
It is the patient’s choice to receive care in the home or traditional hospital setting
CMS has indicated it believes up to 60 different acute conditions can be treated in the home setting (i.e. asthma, heart failure, pneumonia, COPD, etc.)
Health system must apply for a waiver from CMS for their proposed program.
Waiver submission requires the health system to indicate ability to provide each of the following at home:
a. Workflow requirements for waiver eligibility
i. Patient enters Program from ED or inpatient hospital stay.
ii. In-person history & physical exam by physician/advanced practice practitioner
iii. Daily Clinician Visits:
1. At least 2 in-person visits by clinicians each day
a. Must be at least 1 in-person (or remote) visit with a Registered Nurse (RN).
2. Daily visit (with examination if necessary) by MD/APP – maybe remote if warranted.
iv. Emergency Responses:
1. Provide algorithm and timing for each step of immediate and in-home emergencies.
2. Immediate On-Demand remote audio visit with team with immediate connections between patient and either an RN or MD
3. In-home Emergency response team to patient’s home within 30 minutes
v. Specific Patient Selection Criterion
vi. Metrics:
1. 3 required metrics weekly
2. Metrics:
a. Unanticipated mortality
b. Escalation rate of care (transfer from home to ED or hospital inpatient)
c. Volume of patients treated in the program
vii. Include an evaluation methodology for appropriateness of acute hospital care at home eligibility
3. Additional Medical and Non-Medical Factors
a. Working home utilities
b. Assessment of home physical barriers
c. Screening for domestic violence
d. Location within geographic region
e. Disease states warranting close monitoring (i.e. cardiac monitoring)
f. Clinically unstable
3. Major Findings
Major published findings
Most recent study
Conclusions
Limited number of trials with small number of patients evaluated
Has been evaluated in Australia, New Zealand, Romania, Spain, and UK
An effective alternative to inpatient hospitalization in SELECT group of patients
Defining the appropriate patient group is not a simple task – Eligibility criteria is important
Volume of patients recruited into trials from eligible patients has been low
Family support is important
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