Home Sweet Home: Healthcare Moves Away From the Hospital

Supported by new technology that can access more data from any location, healthcare organizations are using remote patient monitoring strategies to bring care into the home. 

Editor's note: This article appears in the March/April 2022 edition of HealthLeaders magazine.

With the healthcare industry's gradual shift to patient-centered care over the past two decades, healthcare organizations are realizing it's more effective to bring care to the patient, rather than forcing the patient to go somewhere to get care.

That strategy is based on the idea that healthcare is continuous, rather than episodic, and that a care provider will learn a lot more by going to the patient to learn about lifestyle, daily routines, and habits than waiting for that visit to the doctor's office, clinic, or hospital. It also requires a lot of data, from a lot of sources, so that a care provider can better understand the patient and the patient's environment while making decisions that impact care.

The remote patient monitoring (RPM) movement began roughly three decades ago, alongside the consumer health movement. Spurred by an interest in self-help health and wellness, consumers were showing an interest in improving their lifestyles through better diets, exercise, and healthy habits, and they were spurred on by a growing market in self-help resources, including technology such as activity bands, smartwatches, and online resources. Those with chronic conditions, such as diabetes, COPD, asthma, and congestive heart failure, were especially targeted with devices and resources that could help them manage their care at home, in between visits to the doctor.

Healthcare only gradually found interest in this. Early technology was designed to attract the consumer, rather than meet clinical care needs. The devices were stylish, but they weren't accurate enough to appeal to care providers, who wanted specific and reliable data that they could use to make clinical care decisions.

That changed, though, as a few forward-thinking providers and health systems realized that charting activity at home could help them influence patients to become more mindful of care management. Having someone living with diabetes measure their activity, for example, could lead to a healthier lifestyle that reduces negative health events, improves clinical outcomes, and curbs unnecessary health expenses; could help those with Alzheimer's or Parkinson's track the progression of their disease at home and improve functionality; or could help those living with cancer stay active during chemotherapy and boost their chances at recovery.

As time has passed, the technology is getting more sophisticated, with devices that can accurately measure vital signs and other biometric data at home or elsewhere and, through mHealth apps and online portals, send that information directly to care providers.

Health systems are now designing programs around these tools and capabilities. They're identifying populations that would benefit from RPM, giving them the devices they need and creating workflows that allow care providers to track them, gather data, communicate, and change care management plans when necessary. More sophisticated programs are adding smart devices in the home, charting factors such as home and family life, diet, and cultural influences; some programs are even combining virtual care with in-person visits from home health programs, specially trained paramedics, or care teams dispatched by the health system.

Easing into an RPM workflow

Less than 10% of the nation's health systems were using RPM prior to the COVID-19 pandemic, according to studies sponsored by the Brookings Institution, McKinsey & Company, and others. Many were small deployments, focused on specific populations or aiming to tackle a certain data point, such as reducing rehospitalizations in patients discharged after an inpatient stay.

That all changed with the pandemic, which pushed virtual care into overdrive. Everyone moved to reduce in-person care to decrease surging hospital traffic and lower the chances of spreading the virus, particularly to care providers and those at risk of serious complications. Many health systems tried out RPM platforms to care for COVID-19-infected patients at home, then modified their platforms to target other groups of patients who could benefit from remote monitoring.

At Heart of Florida Health Center, a federally qualified health center serving about 28,000 patients through seven clinics in rural Ocala, executives launched an RPM program in 2021 targeting uncontrolled hypertension with the help of a three-year grant from the Health and Human Services Department's Health Resources and Services Administration. The goal was to use the platform to help community members, many of whom face barriers to accessing in-person care, monitor and control their blood pressure, thus improving their health and reducing the chances of a heart attack, stroke, or other serious health issue.

"For us, this was getting our toes in the water," says Carali McLean, LCSW, Heart of Florida's director of quality, risk management, and compliance, noting the health center had tried an RPM program for diabetes care management without much success. "We wanted to have the ability to empower the patient to monitor their own health."

With the program, Heart of Florida is tackling a real health concern, one that kills more than half a million Americans a year. According to the Centers for Disease Control and Prevention, roughly 47% of American adults are diagnosed with hypertension, and yet only one in four have their blood pressure under control.

Through RPM, a patient takes blood pressure readings at least once a day (the frequency and times can be set by the provider if needed) and sends that data to Heart of Florida, where nurses review the readings and determine whether follow-up care is needed. If those readings go above or below a certain threshold established by the care team, an alert is triggered and a physician is called in. This could lead to an immediate intervention if serious, or a scheduled visit with a doctor.

Yasmin Ramasco, MSN, APRN, a nurse practitioner and support educator, says the platform allows Heart of Florida clinicians to regulate a patient's medications on the fly, adjusting them as needed to address changes in blood pressure. Previously, care providers would have had to wait to review data when the patient visited the doctor for a scheduled visit, sometimes weeks or months distant, and then modify the medications.

"We can better manage them and have them involved in that management," she says. "Our patients have been motivated and willing to participate."

McLean says Heart of Florida has seen a roughly 28% reduction in the number of patients with unchecked hypertension through the program, which translates to patients better managing their blood pressure and a reduced chance of adverse health events, including hospitalizations. With that success, the center has hired a nutritionist to work with patients to improve their eating habits.

"This is where we can make a difference," she says. "Preventive care's not a thing you go to a doctor for, like if a limb's broken," she points out. By using an RPM program, care providers can connect with patients when and where they're most comfortable talking about their health and life, and they can help patients make changes and forge new habits that take effect over time.

McLean expects that Heart of Florida will build on this success and branch out to other populations, including those living with diabetes.

Scaling up to manage more complex patients

While RPM programs often target patients who need help managing their care at home, some programs are springing up to handle those with critical care needs, including patients who would otherwise be in a hospital.

Much of the growth in what's being called the "hospital at home" movement is tied to the pandemic, and to a federal program aimed at supporting hospitals for caring for patients at home. The Centers for Medicare & Medicaid Services (CMS) launched its Acute Hospital Care at Home program in 2020, building off the agency's Hospitals Without Walls program, unveiled earlier that year to support the use of RPM and other services to offset the COVID-19 surge in hospitals.

The new program incentivizes health systems to create care programs for patients who would otherwise require hospitalization, combining in-person care with RPM devices and telehealth platforms for daily care management. And it inspired many health systems (more than 200 are part of the program as of the beginning of 2022) to rethink how they care for patients both inside and outside the walls of the hospital.

"The home hospital approach has repeatedly demonstrated its enormous benefit and value as an important treatment option for patients," past Massachusetts General Hospital President Peter Slavin, MD, said in a press release issued by CMS highlighting the first six health systems approved by CMS to join the program. "This innovative model has made available safe, cost-effective hospital-level care to patients at home—a reassuring environment that is comfortable, familiar, and healing. CMS' decision to cover home hospital care will not only make this program more viable but will also enable more patients and families to experience this high-quality high level of care in their own homes in their own communities."

California-based Adventist Health launched its Hospital@Home program in May 2020, focusing on eight specific diagnoses. Hospital executives say the CMS program gave them the support they needed to move forward, but they'd long been talking about reimagining healthcare delivery.

"We are moving from a healthcare organization to a health organization," says Lesa McArdle, RN, director of operations for the program, who notes the program is part of a strategy that maps out the health system's growth through 2030. "We are looking to increase our virtual and digital presence, and this fits right into that plan. It's a unique care model."

Adventist Health exemplifies the evolution of the RPM model, with a care plan in place for patients with more complex needs. In this format, patients are evaluated after they've been admitted to the hospital and sent back home with the appropriate devices and training if they meet the criteria for home-based care.

The program includes regular home visits by care providers, as well as virtual visits and RPM monitoring, depending on the care plan. And patients have four channels through which to contact their care team: through an iPad® (a care provider responds within an average of 17 seconds), through a dedicated phone number to an assigned nurse, through a waterproof PERS (personal emergency response) device, or through a biometric screening tool connected to the iPad that alerts care team members if the patient is in distress.

McArdle says safety and redundancy are crucial in a program like this. Wi-Fi and cellular connectivity are both included, in case one platform fails, and backup power is also on standby (a necessity in California, where weather-related power outages have been known to happen).

"When the patient is outside the walls of the hospital, how can you be sure?" she says, noting the program's goal is to replicate the in-person model of care as much as possible. "It's important that we have all this in place because we need to be able to know what the patient is doing at any time," just as if there were a nurse down the hall who could pop into a hospital room for a quick checkup.

Aside from a minimum five "vital touches" and two clinician visits per 24 hours, the service manages medications and even plans out meals. Home visits are scheduled through the telehealth vendor (in this case Medicity) or a home health service in California, while Adventist's Oregon facilities make use of a community paramedicine program.

The success of this program—or any hospital at home program—depends on the outcomes, and because the Acute Hospital Care at Home model was introduced roughly three years ago, a lot of that data hasn't been collected and put into reports just yet.

Some of the early CMS participants, such as Brigham and Women's Hospital in Boston, have published studies. A cardiac care pilot launched by David Levine, MD, MPH, MA, a physician and researcher in the Division of General Internal Medicine and Primary Care, found that the program reduced overall medical costs by 38% compared to in-person care, due in large part to fewer consults, imaging, and tests.

"This work cements the idea that, for the right patients, we can deliver hospital-level care outside of the four walls of the traditional hospital and provide more of the data we need to make home hospital care the standard of care in our country," Levine said in a 2019 press release issued by the hospital. "It opens up so many exciting possibilities—it's exciting for patients because it gives them the opportunity to be in a familiar setting, and it's exciting for clinicians because we get to be with a patient in that person's own surroundings. As a community-minded hospital, this is a way for us to bring excellent care to our community."

Adventist's program is seeing those results and proving popular with both clinicians and patients.

Per Danielsson, MD, the program's medical director, says the Hospital@Home program has reduced the health system's admission rate by 43% and all but eliminated infections and pressure ulcers in patients.

"Even though the patient is at home, there are so many touch points we have with them, and they're able to connect easily with us," he says.

Danielsson sees the program expanding as the health system builds out the infrastructure to support it, and as new RPM technology improves data capture at home. The program recently saw its first home dialysis patient, and future programs will be built around oncology, post-surgery, chronic care management, and hospice care.

"People are forecasting that the hospital of the future will be one large ICU," he says. "We'll be taking care of only the sickest patients in the hospital, and everything else can be done in the home. [The Hospital@Home program] is a step in that direction. It's beneficial to so many stakeholders."

But it isn't there yet. Danielsson also notes the concept is in its early stages, hindered by a healthcare industry that's slow to adapt to change. Some of the technology is still clunky, and federal and state regulations limit the use of telehealth and other digital health technologies at home. And payers must support the strategy, beginning with CMS.

"Things will change immensely over the next three or four years," he says.

Taking two steps forward, and one step back

In many cases, the success of RPM and hospital at home programs (especially those involved in CMS' Acute Hospital Care at Home program) has been due to the COVID-19 pandemic, which led to a surge in telehealth adoption across the country and emergency federal and state directives aimed at expanding access to and coverage of telehealth and digital health services. With the barriers dropped, RPM and hospital at home programs were launched in a matter of weeks, if not days, with the goal of separating healthcare workers and potentially infected patients and reducing the stress on crowded hospitals.

Some programs may have been launched on the idea that they'd last only as long as the public health emergency kept those state and federal emergency rules in place. But many healthcare executives saw the crisis as an opportunity to push innovation that would last well past the pandemic, and they developed strategies that would have taken years, perhaps decades, in more normal circumstances.

Executives at South Shore Health in southeastern Massachusetts had already launched a mobile integrated health (MIH) program that used specially trained paramedics to deliver care to targeted patients in the community. And they had an eye on the struggles faced by skilled nursing facilities (SNF), which were grappling with staffing shortages and high rates of rehospitalizations.

The health system launched its SNF at Home program in March 2021, with a goal of providing care at home for patients who would otherwise be living in those SNFs. The program was enhanced by the MIH platform, launched a year earlier.

Kelly Lannutti, DO, South Shore Health's director of clinical transformation and co-medical director of MIH, and program development and clinical innovation physician, says the program was designed to reduce stress on both the hospital and SNFs by giving more patients with complex care needs an opportunity to receive that care at home. It included round-the-clock real-time monitoring and in-person visits at least five times a week.

"It's really a shift in the acuity of the patients themselves who can be cared for at home," she says. "It's definitely a different mindset."

In many cases, programs like SNF at Home may be the next step in the RPM journey, as health systems develop the technology and workflows to care for more complex patients at home. But that step isn't without controversy, with critics wondering if home-based care is appropriate and safe enough for some patients with advanced care needs—especially those who would otherwise be in a structured healthcare setting like a hospital or SNF.

Lannutti says the program was structured to carefully review patients in the hospital before sending them home. It was also designed and launched during the height of the pandemic, when hospitals and SNFs were struggling to handle an excess of patients and saw home-based care as a good opportunity to cut traffic and curb the chance of infection.

"In the home setting it's very, very different," says Lannutti, noting that while the program was designed to replicate clinical care at home, it didn't equal the round-the-clock monitoring and care that a hospital or SNF offers.

South Shore Health has since dropped its SNF at Home program and adopted a platform that hews toward a hospital at home program. Lannutti says the decision was due in part to a lack of payer reimbursement for those services, which required a lot of time and effort from the health system, and some technological challenges around continuous monitoring.

"There's a difference between acute and critical care," she says, "and certain things we can't do at the home right now. We eased back."

The shift has given South Shore Health an opportunity to look more closely at what goes into home-based care, and to better define which patients are best suited for the program. They're now tailoring the RPM technology to the needs of the patient and creating workflows that benefit not only patients and caregivers, but also the nurses and doctors who keep tabs on them from the hospital.

"The home is a very different setting from the hospital," says Lannutti. "It forces care providers to think differently. You can't just take a nurse from the clinical setting and put them into [the program] and expect things to work out."

And nurses are a crucial part of the program.

"We would love to include more nurses," she says. "Everyone needs more nurses," and RPM and hospital at home programs fit snugly into nursing workloads, giving them the time and space to gather data, interact with patients, and call in doctors or specialists only when the situation demands it.

(Across the country at Adventist Health, the platform has been a welcome relief for nurses as well. McArdle points out that several nurses were pregnant when the program launched, and the health system saw this as an ideal way to keep them away from inpatient care and the heightened threat of catching the virus.)

It's evident that South Shore's program will evolve much differently than Adventist's, and that Adventist's is moving in a different direction than others. Healthcare executives are intrigued by the idea that these programs can be taken apart and put back together in many ways to meet the individual needs of the patient and the health system. One program might lean heavily on RPM tools to monitor vital signs on demand, while another could skew toward telehealth platforms that allow patients to check in with their care providers when they want or need to. Some programs may require daily visits from clinicians, while others may spread those visits out over the week or per a patient's specific needs.

South Shore is one of a handful of health systems that uses its own MIH program, a relatively new concept that falls into the community paramedicine mold. And that may grow in popularity as health systems look to acquire their own EMS services or partner with local ambulance companies and community health organizations to improve home-based care and reduce unnecessary 911 calls.

MIH "is an absolute game-changer," says Lannutti, who notes the paramedics "are thrilled to be able to do something other than taking people to the hospital."

Lannutti expects South Shore's program to expand, perhaps even going back to the SNF at Home model, as the health system explores its options. This includes talking to accountable care organizations and other risk-bearing programs, many of whom have a significant interest in the postacute care space and want to see alternatives to expensive clinical care.

"We've learned a lot of lessons, all of them positive," she says. "We have a better understanding of what the patient wants now, and they now realize that they can receive care from their home."

That may be a more important factor than anyone realizes. With all the talk of patient-centered care, it's the patient who may dictate how RPM and hospital at home programs evolve. Patients will ask for more care at home, and perhaps base their future healthcare interactions on who can provide those services. Savvy health systems will offer more of these programs to additional populations, taking advantage of newer devices, even wearables and smart home technology.

"We all go into healthcare to make a difference in people's lives," says McArdle, of Adventist Health. "And with this model, we have nurses and doctors in the patient's home virtually, sometimes even physically. We become a part of their lives. We truly have a more holistic view."