By DANIELA J. LAMAS, M.D.
Mr. Fernandez, 82, would have to be officially admitted to receive intravenous antibiotics for his urinary tract infection. But he could stay at Mount Sinai, or he could receive treatment at home.
If he chose to be hospitalized at home, doctors and nurses would visit daily. He would receive lab draws and intravenous medications, even X-rays or ultrasound scans if he needed them. The costs to him would be no greater than if he were physically in the hospital. In three or four days, he would be discharged — and he would not have to go anywhere.
For Mr. Fernandez, a retired house painter from Venezuela who lives with his wife on Manhattan’s Upper West Side, the choice was clear. He was hospitalized at his daughter’s apartment, just a couple blocks away, a few hours later.
He had a urinary catheter, but Mr. Fernandez could still wear his own clothes during the day and his pajamas at night. His wife and his daughter cooked him meals of arepas, vegetables and black beans, and served them to him in bed.
“Hospitals help you, but there’s so much noise that you can’t sleep and you’re lonely,” said Mr. Fernandez’s daughter, Ana Vanessa Fernandez. “Here, there was no timing for visitors. There was no curfew. It’s like being at home, but the hospital is home with you.”
Under pressure to reduce costs while improving quality, a handful of hospital systems have embarked on an unusual experiment: They are taking the house call to the extreme, offering hospital-level treatment at home to patients like Mr. Fernandez who in the past would have been routinely placed in a hospital room. And as awareness spreads of the dangers that hospitalization may pose, particularly to older adults, patients are enthusiastically seizing the opportunity.
“I always laugh when people say, ‘Do you really think you’re as good as a hospital?’ ” said Dr. Melanie Van Amsterdam, the lead physician for Presbyterian Healthcare Services Hospital at Home program in Albuquerque. “Have you been to the hospital? For many of these patients, it’s a little scary.”
Dr. Bruce Leff noticed that back in the late 1980s while making house calls to homebound patients, part of his primary care training at Johns Hopkins University School of Medicine. When some of his patients fell ill, they simply refused to go to a hospital.
He understood why: He had seen firsthand the delirium, infections and deconditioning that too often land older patients in nursing homes after hospitalization. “Being in the hospital could be toxic,” said Dr. Leff, a geriatrician who is now a professor of medicine at Johns Hopkins.
So Dr. Leff and his colleagues had an idea. What if patients could be hospitalized in their own beds?
Some patients need the moment-to-moment monitoring that only a hospital can provide. The first task was to determine which common conditions required admission but could be treated with technologies placed in the home. These would be patients who clearly needed to be hospitalized, but who weren’t going to need the intensive care unit. Intravenous medications and X-rays can be readily adapted for the home; ventilators cannot.
Dr. Leff and his colleagues settled on four diagnoses that could be treated without the patient’s being physically in the hospital: heart failure, exacerbations of emphysema, certain types of pneumonia, and a bacterial skin infection called cellulitis.
“I’m a doctor. I can talk to a patient, I can examine a patient, I can bring home oxygen and IV meds and fluids, I can do home X-rays. I can do quite a bit,” Dr. Leff said. “We felt that it could be done, and the hypothesis was that by doing so, we could reduce harm.”
With a grant from the John A. Hartford Foundation, Dr. Leff and his team offered outpatient hospital-level care to nearly 150 patients with these four diagnoses who would otherwise have been treated at one of three hospitals, and compared those patients with a similar group who were hospitalized in the usual way. They called their program “Hospital at Home.”
The findings, published in The Annals of Internal Medicine, were promising. Offered the opportunity, most patients agreed to be treated at home. They were hospitalized for shorter periods, and their treatments cost less. They were less likely to develop delirium or to receive sedative medications, and no more likely to return to the emergency room or be readmitted.
The results caught the interests of hospital systems nationwide. But payers were less enthusiastic. When it comes to fee-for-service Medicare, there are no existing payment systems even now to reimburse hospital-level care provided in the home.
But systems like the Veterans Affairs and Presbyterian Healthcare Services, in Albuquerque, were not so constrained. Presbyterian has its own health plan and so, not limited by the lack of fee-for-service reimbursement, began offering a hospital-at-home option in 2008.
Dr. Van Amsterdam started out as the program’s only full-time doctor. She spent hours trolling hospital records for patients who might be eligible for the new program: sick enough to require a hospital stay, but not so sick that they might need to go to an I.C.U.
Some of the patients she approached said no. One man did not want visitors because he had big dogs at home, she recalled. Another said that if he felt short of breath at night, he would prefer to be in a hospital. But more than 90 percent agreed.
Today, as she drives through New Mexico, Dr. Van Amsterdam finds herself delivering a different kind of care from what she did years ago as a doctor in a hospital.
“The hospital system is one where you get more information from the computer than you do from your own ears, eyes and nose,” she said. “I rely far more on my physical exam skills to take care of these patients. You get a lot more comfortable with uncertainty, I think.”
Even with the most careful admitting criteria, the unexpected happens. Dr. Van Amsterdam and her team have had to move patients to the hospital for worsening medical conditions, sometimes by calling 911. Still, it is an infrequent occurrence: only 2.5 percent of these patients must be moved into the traditional hospital.
The challenge of knowing which patients are appropriate for hospitalization at home bothers Dr. Bruce Vladeck, a health care consultant and former administrator of the Health Care Financing Administration.
“I think in order to make this work in a way that makes clinical and ethical sense, you really have to be careful about evaluating your patients on the front end,” said Dr. Vladeck, who is a member of the advisory committee for Mount Sinai’s continuing program. “And you have to be prepared to change your mind.”
At Mount Sinai — whose program is funded by a nearly $10 million grant from the Centers for Medicare and Medicaid Services — hospitalization at home is called “mobile acute care,” but the principle is the same. Patients with a set of specified diagnoses, expanded from Dr. Leff’s earlier work, are approached in the emergency department after the emergency doctor has decided they need to be admitted.
Those with worrisome vital signs — heart rate too high, blood pressure too low — are not eligible. Nor are patients without electricity or running water at home, or without space at home for oxygen or intravenous supplies, should they be needed — a pertinent question for residents in Manhattan apartments.
To measure the costs of patients who are hospitalized at home, patients will be followed for one month after their home hospital stay, during which they are eligible for services ranging from health coaching to home doctor visits. The team at Mount Sinai will collaborate with Dr. Leff and his colleagues at Johns Hopkins to compare outcomes to a similar group of patients who are hospitalized and to measure patient satisfaction.
Even for Mount Sinai, whose house calls program has been around for two decades, bringing the key elements of the hospital to a Manhattan apartment hasn’t been easy. A well-meaning family member of one of the first patients in the program decided to store her intravenous antibiotics in the freezer, rendering them unusable.
But before gearing up to enroll their first patient this past November, the Mount Sinai team arranged a complex system of backups. Patients have 24-hour physician and nurse coverage, and an arrangement with emergency medical service providers ensures that rather than reflexively transport all patients to the hospital if they are called, the providers will deliver all the care they can at home.
“I am very confident that we’re going to be able to show that patients want to be home, that we can do this safely, and that we can do this with savings,” said Dr. Linda DeCherrie, an associate professor of geriatrics and palliative care medicine at Mount Sinai and clinical director of the new program.
The trend toward taking hospital patients out of the hospital “will continue to evolve and get tested, but I think this will see its day,” Dr. Leff said. In the past two years, he has received calls from at least a hundred system administrators eager to learn more about how to hospitalize patients in their homes.
“My sense is that over time, hospitals will become places that you go only to get really specialized, really high-tech care,” he said.
On a recent night, Mary Hull sat in her living room in Albuquerque, waiting for her doctor to check on her. Ms. Hull, 43, had been admitted to the hospital, at home, a few days before being treated with intravenous antibiotics for a skin infection on her leg and abdomen.
A portable X-ray machine had arrived. She was receiving daily lab draws. A nurse visited three times a day. She hadn’t even needed to find someone to watch her cat.
“I’m hoping to be discharged soon,” Ms. Hull said. “But I guess it doesn’t matter much. I’m home.”