A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.

Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period.

BACKGROUND: Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. METHODS: A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. RESULTS: Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower. CONCLUSIONS: HaH combined with 30-day post-acute transition care was less costly than inpatient care.

Hospital at Home services: An inventory of fee-for-service payments to inform Medicare reimbursement.

BACKGROUND: Hospital at Home (HaH) is a growing model of care with proven patient benefits. However, for the types of services required to provide an episode of HaH, full Medicare reimbursement is traditionally paid only if care is provided in inpatient facilities. DESIGN: This project identifies HaH services that could be reimbursable under Medicare to inform episodic care within fee-for-service (FFS) Medicare. SETTING: All data are derived from acute services provided from the Mount Sinai HaH program between 2014 and 2017 as part of a Center for Medicare and Medicaid Innovation (CMMI) demonstration program. PARTICIPANTS: The sample was limited to patients with one of the following five admitting diagnoses: urinary tract infection (n = 70), pneumonia (n = 60), cellulitis (n = 45), heart failure (n = 37), and chronic lung disease (n = 24) for a total of 236 acute episodes. MEASUREMENTS: HaH services were inventoried from three sources: electronic medical records, Medicare billing and itemized vendor billing. For each admitting diagnosis, four reimbursement scenarios were evaluated: (1) FFS Medicare without a home health episode, (2) FFS Medicare with a home health episode, (3) two-sided risk ACO with a home health episode, and (4) two-sided risk ACO without a home health episode. RESULTS: Across diagnoses, there were 1.5-1.9 MD visits and 1.5-2.7 nursing visits per episode. The Medicare FFS model without home health care had the lowest reimbursement potential ($964-$1604) per episode. The Medicare fee-for-service within ACO models with home health care had the greatest potential for reimbursement $4519-$4718. There was limited variation in costs by diagnosis. CONCLUSION AND RELEVANCE: Though existing payment models might be used to pay for many HaH acute services, significant gaps in reimbursement remain. Extending the benefits of HaH to the Medicare beneficiaries that are likely to derive the greatest benefit will require new payment models for FFS Medicare.

Choosing Inpatient vs Home Treatment: Why Patients Accept or Decline Hospital at Home.

BACKGROUND/OBJECTIVES: Hospital at home (HaH) provides interdisciplinary acute care in the home as a substitute for inpatient hospitalization. Studies have demonstrated that HaH care is associated with better quality care, fewer complications, and better patient and caregiver experience. Still, some patients decline HaH. The objective of the study was to characterize patients who accept vs decline HaH care and describe reasons for their decisions in the context of a Center for Medicare and Medicaid Innovation demonstration of HaH. DESIGN/SETTING/PARTICIPANTS: A total of 442 patients with Medicare or other eligible insurance, 18 years or older, who met study eligibility criteria were offered HaH at Mount Sinai Hospitals in New York, NY, between September 1, 2014, and August 31, 2017. MEASUREMENTS: Reasons for accepting or declining HaH were recorded. Age, sex, insurance type, and admission diagnoses of HaH acceptors and refusers were compared in univariate analyses. RESULTS: Of the 442 patients offered HaH, 66.7% accepted. Main reasons for enrolling in HaH included being more comfortable at home (78.2%) and being near family (40.7%). Specific reasons given for refusing HaH included preferring in-hospital care (15.0%) and concern that HaH would not meet care needs (12.9%). CONCLUSION: Two-thirds of patients offered HaH care opted to receive it. The reasons for declining HaH provided by those who chose not to participate should be considered for quality improvement, and reasons for acceptance may be helpful in marketing and other efforts to promote HaH participation. J Am Geriatr Soc 68:1579-1583, 2020.

Starting Up a Hospital at Home Program: Facilitators and Barriers to Implementation.

BACKGROUND: Hospital at home (HaH) is a model of care that provides acute-level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully. OBJECTIVES: This study examined facilitators and barriers to implementation of an HaH program. DESIGN: A HaH program that included a 30-day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators. SETTING: Large urban academic health system. PARTICIPANTS: Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation). RESULTS: To facilitate successful development and implementation of a high-quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work-arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors. CONCLUSION: Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships. J Am Geriatr Soc 67:588-595, 2019.

Hospital at Home-Plus: A Platform of Facility-Based Care.

OBJECTIVES: To describe the evolution of a hospital at home (HaH) program to a HaH with a 30-day posthospitalization transition period (HaH-Plus) and results of a retrospective review of cases. DESIGN: After launching HaH-Plus, we used the same interdisciplinary clinical team to provide acute home-based care for a broader range of home-based acute-level services than originally conceived in the Hospital at Home model. These included a palliative care unit at home (PCUaH), an observation unit at home (OUaH), a post-acute care rehabilitation at home (RaH), and a program for the hospital averse - those patients needing to be in the hospital but who refuse. SETTING: Urban health system. PARTICIPANTS: Individuals 18 years or older residing in specified catchment area with Medicare fee-for-service or accepted Medicare/Medicaid Advantage plans requiring facility-based care. INTERVENTION: Provision of facility-based acute-level care at home to 685 participants. MEASUREMENTS: Length of stay, readmission, and mortality. RESULTS: HaH-Plus cared for 685 individuals. The PCUaH had the oldest participants (mean age 87), and all groups were predominantly female and dually eligible for Medicare and Medicaid. Diagnoses and length of stay were similar in all groups except that those in RaH had a larger group of diagnoses, than those accepted in to HaH-Plus and those in OUaH had a shorter stay. Rate of readmission was highest for RaH (19%). Mortality during the active treatment episode was highest for PCUaH and hospital averse as compared to HaH-Plus, OUaH and RaH. CONCLUSION: Providing a broader range of facility-based care in the home has significant advantages for patients and increases the scalability of HaH. Developing a spectrum of services was possible by leveraging a robust, 24-hour HaH team. Community- and home-based care could become a greater part of the U.S. healthcare system if a platform of HaH services along with advances in technology and payment models were developed. J Am Geriatr Soc 67:596-602, 2019.

Review of Transitional Care Management and Chronic Care Management Codes for Pulmonologists.

Patients with advanced respiratory illness are often hospitalized, requiring close follow-up after discharge and also requiring care coordination outside of traditional face-to-face outpatient visits. Primary care providers and specialists often provide services outside of outpatient visits that have not been captured and reimbursed with traditional billing evaluation and management codes. Within the last 5 years, the Centers for Medicare & Medicaid added new codes to the Medicare Physician Fee Schedule that reimburse for care coordination services not paid for by traditional evaluation and management codes. Transitional care management includes the 30-day period following hospitalization in which a clinician is responsible for care of the patient postdischarge from the hospital. Chronic care management provides reimbursement for coordination of care for chronic conditions that is performed by any clinician and his or her staff on a monthly basis that is > 20 min in duration.

Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences.

Importance: Hospital-at-home (HaH) care provides acute hospital-level care in a patient's home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care. Objective: To report outcomes of this new payment model for HaH care. Design, Setting, and Participants: Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated. Exposures: HaH care or inpatient care. Main Outcomes and Measures: Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting. Results: Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, -2.3 days; 95% CI, -1.8 to -2.7 days; weighted P < .001); lower rates of readmissions (8.6% [25] vs 15.6% [32]; difference, -7.0%; 95% CI, -12.9% to -1.1%; weighted P < .001), ED revisits (5.8% [17] vs 11.7% [24]; difference, -5.9%; 95% CI, -11.0% to -0.7%; weighted P < .001), and SNF admissions (1.7% [5] vs 10.4% [22]; difference, -8.7%; 95% CI, -13.0% to -4.3%; weighted P < .001); and were also more likely to rate their hospital care highly (68.8% [119] vs 45.3% [67]; difference, 23.5%; 95% CI, 12.9% to 34.1%; weighted P < .001). There were no differences in referrals to certified home health agencies. Conclusions and Relevance: HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare's current portfolio of shared savings programs.

A model for integrating the assessment and management of geriatric syndromes into internal medicine continuity practice: 5-year report.

A geriatric ambulatory curriculum was created to improve internal medicine residents' care of geriatric patients. Second-year residents met for a 3-hour session weekly for 4 consecutive weeks during a block rotation with faculty geriatricians for a curriculum focused on dementia, falls, and urinary incontinence. After a 1-hour case-based didactic session, residents applied learned content and concepts to patient consultations. Consultative encounters were precepted by faculty and shared with the team. After completing our curriculum, residents reported knowledge acquired and enhanced evaluation and management skills of these three syndromes and were more likely to use all recommended screening tests in future practice. This article describes the process and strategies guiding development of a successful ambulatory geriatric curriculum model that can be embedded into preexisting internal medicine clinics to help future internists to better manage these and other common geriatric syndromes.

Time providing care outside visits in a home-based primary care program.

OBJECTIVES: To assess how much time physicians in a large home-based primary care (HBPC) program spend providing care outside of home visits. Unreimbursed time and patient and provider-related factors that may contribute to that time were considered. DESIGN: Mount Sinai Visiting Doctors (MSVD) providers filled out research forms for every interaction involving care provision outside of home visits. Data collected included length of interaction, mode, nature, and with whom the interaction was for 3 weeks. SETTING: MSVD, an academic home-visit program in Manhattan, New York. PARTICIPANTS: All primary care physicians (PCPs) in MSVD (n = 14) agreed to participate. MEASUREMENTS: Time data were analyzed using a comprehensive estimate and conservative estimates to quantify unbillable time. RESULTS: Data on 1,151 interactions for 537 patients were collected. An average 8.2 h/wk was spent providing nonhome visit care for a full-time provider. Using the most conservative estimates, 3.6 h/wk was estimated to be unreimbursed per full-time provider. No significant differences in interaction times were found between patients with and without dementia, new and established patients, and primary-panel and covered patients. CONCLUSION: Home-based primary care providers spend substantial time providing care outside home visits, much of which goes unrecognized in the current reimbursement system. These findings may help guide practice development and creation of new payment systems for HBPC and similar models of care.

Health care utilization among homebound elders: does caregiver burden play a role?

OBJECTIVE: To describe informal caregiver and patient characteristics associated with high caregiver burden in homebound elders and to examine associations between high caregiver burden and patient health care utilization at the practice level. METHOD: We used a cross-sectional and prospective cohort design to study 214 caregiver-patient dyads in a home-based primary care program. RESULTS: Informal caregivers with the highest burden were more likely to help with more activities of daily living and instrumental activities of daily living and spend >40 hr/week in caregiving. Patients whose caregivers experienced the highest burden were more likely to be non-White males without 24-hr paid homecare. There were no significant independent associations between high burden and high calls, high visits, or social work involvement. DISCUSSION: In this medically complex and highly dependent population, further study of how families and other caregivers impact health care utilization is needed.

Primary care training and the evolving healthcare system.

With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians.

The Mount Sinai (New York) Visiting Doctors Program: meeting the needs of the urban homebound population.

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center's Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24-hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, localphysicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical nursing, and social work trainees interested in home-based primary care.