Patient Experience is Crucial to the Success of Hospital at Home

UMass Memorial Health aims to make a 2-year-old program sustainable by giving patients what they really want: Care at home.

An innovative strategy launched some 20 years ago to help overcrowded hospitals reduce their inpatient populations is now showing positive clinical outcomes.

“The number one benefit is they’re at home,” says Constantinos (Taki) Michaelidis, medical director of the Hospital at Home program at UMass Memorial Health, which launched in August 2021 and has seen more than 1,300 patients receive care at home rather than a hospital, rehabilitation facility, or skilled nursing facility bed. “They’re leaving behind some of the more challenging parts of the hospital and being where they want to be.”

Hospital at Home, also called acute care at home, saw widespread use during the pandemic, when many hospitals struggled to deal with a surge in patients and sought to separate infected patients to prevent the spread of the COVID virus. The Centers for Medicare & Medicaid Services (CMS) created a pathway for Hospital at Home and established waivers to allow hospitals to receive Medicare reimbursement. More than 220 health systems are taking part in that pathway, though the waivers are set to expire at the end of 2024 unless either Congress or CMS acts to extend or make them permanent.

[See also: Healthcare Executives Plot a Long-Term Strategy for Hospital at Home Concept.]

The program has helped hospitals reduce inpatient traffic, cut down on patient length of stay and rehospitalizations (the UMass Memorial program has reportedly helped patients avoid 4,369 days in the hospital), and reduce stress and burnout among staff and care teams. The crucial piece of the puzzle that could make this program sustainable is data that proves patients are healing better and faster at home than in the hospital.

Michaelidis, who was named the 2023 Hospital at Home Clinician of the Year by the Hospital at Home Users Group, and whose program was named the 2022 Hospital at Home Program of the Year by the American Academy of Home Care Medicine, says the key to the program’s success is the patient’s clinical experience. And roughly 90% of the patients surveyed after going through the program have given it high marks.

“They just like it so much more,” he says. “We’re seeing across-the-board improvements [in care outcomes], but the real benefit is hearing from patients and their families. People are in tough situations when they’re in a hospital. They feel crummy. This is different.”

Benchmarks for Success

According to Michaelidis, the UMass Memorial program, which handles care for roughly 15 patients on any given day, has halved the patient mortality rate and reduced 30-day readmissions by 20% to 30%. There are also far fewer adverse health events, especially infections. And patients are usually discharged from the program four to five days after admittance.

Among the program’s biggest fans, Michaelidis says, are payers. UMass Memorial’s patient base is largely underinsured, with about 30% on Medicaid and many more having no insurance at all. It takes longer to get these patients checked into a hospital, and their care tends to be more expensive. The Hospital at Home program reduces those costs, and for 80% to 90% of these patients it replaces an expensive stay in a rehab facility or SNF.

Constantinos (Taki) Michaelidis, medical director of the Hospital at Home program, UMass Memorial Health. Photo courtesy UMass Memorial Health.

More importantly, he says, patients are at home, in their own beds, with family, friends, and pets nearby. They’re eating their own food, watching their own TV, going to their own bathroom, looking out the window to their own neighborhoods, and not being subjected to the noises and activity of a hospital.

“Patients are also spending 60% to 70% less time in bed,” Michaelidis adds. That means more activity, less loss of muscle mass, and a happy, more engaged patient. And a more engaged, active patient will heal faster and better.

That’s not to say Hospital at Home is not a complex program, with many moving parts and a considerable input of resources and cash from the health system.

Michaelidis says the program was launched to address significant pain points for the Worcester-based hospital, the only Level 1 trauma center in central Massachusetts, whose coverage area comprises some of the most underserved communities in the commonwealth. It wasn’t uncommon, he says, to see 60 to 80 patients in the Emergency Department at that time, many in need of a bed that the hospital didn’t have available. And during COVID, many of those patients were being housed in tents set up on the campus to handle the overflow.

Addressing Health Equity

In that environment Hospital at Home was unveiled, with specific guidelines and guardrails. Patients are interviewed for the program after being admitted to the hospital through the ED, in a process that includes questions about their homes and social determinants of health. If they are admitted to the program, they are transported by ambulance back home and met there by a team from UMass Memorial that sets up the technology and helps both patients and family members get acclimated to the new devices and routines.

The process includes assessing the patient’s surroundings, a key component in the health system’s quest to address health equity.

“This allows us to understand them better,” Michaelidis says. “We are laser-focused on health equity,” and that means identifying and recognizing the many societal, cultural, environmental, and technical aspects of one’s life that affect health and healthcare access. Everything from family environment, diet and exercise, job security, finances, transportation, and technological literacy is factored into how care is delivered.

“We have a unique opportunity to detect things before they become worse,” he adds.

(Michaelidis says only one patient couldn’t be helped at home and had to receive care in the hospital: A man whose ‘home’ turned out to be a parking lot. UMass Memorial admitted him to the hospital and is working with social services to find better housing.)

Once the patient is settled at home, the program kicks into gear. Virtual visits with the care team are held every morning, and in-person visits are scheduled at least twice a day. There are also regular “huddles” with the entire care team, including physical therapists and social workers. RPM technology is installed in the home to ensure wireless connectivity and handle virtual visits and monitoring. The health system also has partnerships in place with physical therapists, social services, and a company that handles remote imaging in the home.

Looking for Sustainability

Those services are what make the Hospital at Home program so intricate and expensive, costing health systems millions of dollars in setup costs and making the sustainability argument difficult. Michelidis says UMass Memorial is following the CMS guidelines for Medicare reimbursement, lobbying lawmakers to make those waivers permanent, and gathering the data to reinforce the point that the program both cuts expenses and improves outcomes.

He also says the program doesn’t require extra staffing, and doctors and nurses like it because it allows them to perform at the top of their license. They enjoy going into the home and determining what it takes for a patient to not only manage their health concern but adopt healthier habits.

The patients and their families enjoy that interaction as well.

“These patients are getting one-on-one care for a few hours each day,” Michaelidis points out, noting that is often more time than a patient would get in a hospital.

Family members, meanwhile, are grateful that they don’t have to go to the hospital to see their loved ones and appreciate the support with caregiving duties. In fact, Michaelidis says, care team members often receive handwritten notes after the patient is discharged, and they’re invited back to visit or even attend family events.

“It’s a rewarding experience,” he says.

As UMass Memorial pushes to make the program sustainable, they’re also looking to expand.  Michaelidis envisions a payer-agnostic platform that includes more partnerships with programs focused on health equity, as well more technologies (like AI and wearables), a larger geographical base, and more services, such as post-surgical and C-Section pathways.

“We’re seeing a lot more acceptance for this type of program,” he says. And one can’t overestimate the value of sleeping in one’s own bed.