Johns Hopkins Health System - Baltimore, Maryland
Hospital at Home SM
Overview: Developed by researchers at the Johns Hopkins School of Medicine, Hospital at Home is an innovative health care model that provides hospital-level care in a patient's home as a full substitute for acute hospital care. The program grew from the experiences of homebound older patients and the physicians who cared for them. Many of these patients experienced adverse events when admitted to a hospital, while still others refused hospitalization because past hospital experiences were so difficult. Physicians sought to develop a high-quality, home-based alternative to traditional hospital care that was clinically effective and cost efficient.
The Hospital at Home program typically is offered to patients who require hospital admission for certain diseases, such as community-acquired pneumonia, chronic heart failure, chronic obstructive pulmonary disease, and cellulitis, among others. Patients who meet specific medical eligibility criteria and agree to participate receive hospital-level care, including diagnostic tests and treatment therapies from doctors and nurses in their own home.
A typical Hospital at Home program employs the following steps:
1. A patient requiring hospital admission for one of the Hospital at Home target illnesses is identified in the Emergency Department or ambulatory site. The patient's appropriateness for care in the program is assessed using validated criteria.
2. If the patient is eligible and consents to participate in the program, the Hospital at Home physician evaluates the patient. The patient is then transported home, usually by ambulance.
3. Once home, the patient receives extended nursing care for the initial portion of their admission. When appropriate, nursing care transitions to intermittent nursing visits. Nurses are available 24 hours a day/7 days a week for any urgent or emergent situation.
4. The patient is evaluated daily by the Hospital at Home physician who completes an assessment and continues to implement appropriate diagnostic and therapeutic measures. The physician makes one or more home visits per day and is available 24 hours a day/7 days a week for any urgent or emergent situation.
Illness-specific care maps, clinical outcome evaluations, and specific discharge criteria provide a pathway for care. The patient can receive diagnostic studies such as electrocardiograms, echocardiograms, and x-rays at home, as well as treatments including oxygen therapy, intravenous fluids, intravenous antibiotics and other medicines, respiratory therapy, pharmacy services, and skilled nursing services. Diagnostic studies and therapeutics that cannot be provided at home, such as computerized tomography, magnetic resonance imaging, or endoscopy, are available via brief visits to the acute hospital. The patient is treated until stable for discharge. When the patient is discharged by the Hospital at Home physician, care is safely and carefully transitioned to the patient's primary care physician.
Impact: After pilot work on the Hospital at Home care model was completed at Johns Hopkins, a National Demonstration and Evaluation Study of the Hospital at Home care model, coordinated by Johns Hopkins investigators and funded by the John A. Hartford Foundation, was performed in several Medicare managed care organizations and a Veterans Administration medical center. The study, a prospective quasi-experiment, was conducted from October 2000 through September 2002. Study results demonstrated that Hospital at Home care was feasible and efficacious. Overall, 60% of acutely ill older persons who were medically eligible and offered Hospital at Home opted for it. Patients received timely hospital-level care at home that met quality standards. Compared with patients treated in the acute hospital, those treated in the Hospital at Home intervention suffered fewer important clinical complications including incident delirium, sedative medication use, and chemical restraints. Patient and family member satisfaction was higher in Hospital at Home and caregiver stress was lower. Patients treated in Hospital at Home had better functional outcomes, as well. In addition, the average amount paid for patients in Hospital at Home was approximately 30% lower than those in the acute hospital setting.
Challenges/success factors: Hospital at Home care is a complex clinical model; as such, adopting organizations must commit fully to implementation. While Hospital at Home care is not an easy model to "pull off the shelf," the developers of Hospital at Home at Johns Hopkins have created a robust set of technical assistance tools and can provide consultation for successful implementation for interested hospitals and health systems. The process takes approximately one year of dedicated work by several project teams and collaboration among stakeholders within and often between organizations.
In the United States, the Hopkins team has been successful in disseminating Hospital at Home in Medicare managed care and other integrated delivery systems, such as the Veterans Administration. In the fee-for-service health sector, the paramount barrier to widespread dissemination of Hospital at Home care is the lack of a payment mechanism to reimburse for the full complement of Hospital at Home services. Development of a payment mechanism for Hospital at Home care in the fee-for-service arena using a Medicare-demonstration-mechanism waiver is pending approval. If accomplished, this would provide the economic incentives to spur more widespread development of Hospital at Home programs in the United States.
Future direction/sustainability: Hospital at Home has been adopted in several health systems across the country and is being adopted by innovators in health systems, home care organizations, and managed care programs as a new tool to cost-effectively treat acutely ill older adults while improving patient safety and satisfaction. Recent health care trends toward bundled payments and the focus on hospital readmissions and care transitions will work in favor of Hospital at Home dissemination.
Advice to others: Is Hospital at Home right for your organization? Organizations that wish to adopt innovative care delivery models often need to develop new systems and roles, while overcoming organizational inertia and resistance to change. In particular, Hospital at Home requires that certain conditions and resources are available for the program to be successfully implemented. If you answer yes to one or more of the following questions, then Hospital at Home may be appropriate for your organization:
1. Is your health system experiencing problems from a lack of hospital capacity?
2. Does your health system have established home health care delivery capabilities?
3. Do you have physicians with an interest and ability to care for patients in the home environment?
4. Does your health system experience a large volume of Medicare admissions for common problems such as community-acquired pneumonia, heart failure, or chronic obstructive pulmonary disease?
5. Does your institution view itself as an innovator in developing new models or systems of care?
During early organizational planning, leaders will need to determine system "fit" defined as follows:
- Does Hospital at Home mesh with our overall organizational (enterprise) strategy?
- Does Hospital at Home address our crucial system needs (for example, emergency department diversion, bed shortage)?
- Does Hospital at Home align with our system goals (for example, quality, cost, patient satisfaction)?
- Does Hospital at Home integrate within our existing organization? That is, do we have home health services and all the needed ancillaries? Do we have a physician group to provide care at home? Can we say "all the elements are in place?"
Clinical and business experts of the Johns Hopkins Hospital at Home team are available to support your decision to adopt the program at your institution. More information is available at www.hospitalathome.org.
Contact: Bruce Leff, MD
Associate Professor of Medicine
Johns Hopkins University School of Medicine
Telephone: (410) 550-2654