Sep 22

Sep 22 The benefits of treating patients at home instead of in the hospital

By Rose Hoban, North Carolina Health News, September 14, 2022

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This past February, Betty Ratcliffe was headed off to western North Carolina to have a late winter getaway with her husband Jack. She and Jack stopped at the Publix to pick up their prescriptions, and Betty walked across the store to use the restroom.

That’s when the octogenarian started having trouble.

“She carries an oxygen indicator with her and she says ‘I can hardly breathe, we got to go to the urgent care,’” Jack remembered. Betty has had chronic asthma for more than 40 years and carries a portable oxygen compressor to help her breathe. But this was worse than usual.

The two were near Chapel Hill, so they decided to head over to the UNC Health emergency room. It was at the height of the Omicron surge and the emergency department was crowded with patients who potentially had coronavirus infections.

“She was there for close to 24 hours, and they could not get her room,” Jack said. “She was on a floor with a whole bunch of people that may have had COVID-19 for 24 hours.”

The potential exposure worried the couple. They’d been careful about being exposed to the coronavirus and the thought of catching it in the hospital was scary.

So, when doctors at the hospital offered them the opportunity for Betty to receive hospital-level care and monitoring while at home, they jumped at the chance.

Betty Ratcliffe became one of more than 500 people who have received “hospital at home” services from UNC over the past year.

“They explained fully to us what it was going to be, and I would have to go home and be there when the paramedic came,” Jack recalled. “And before she was delivered, the paramedic came, I met him, he came up and put up all the technology in our room.”

Several months later, Jack, 79, also became a hospital at home patient when he developed a urinary tract infection. The two were really happy to avoid the hospital.

“We were ecstatic with the service,” Jack said. “I mean, there was absolutely nothing that went on that we had any problems with.”

Slow build

The research behind hospital-at-home programs has been building over the past decade or so. Studies done both in the U.S. and European countries have found that patients who are pretty sick, but have stable diagnoses are able to be maintained at home. They get services that are more intense than the usual home health care.

Patients receive nursing and visits from UNC paramedics and have electronic monitoring at their bedsides for vital signs such as blood pressure and pulse. But they’re able to move around at home, eat home-cooked meals and they can avoid the super-infections that often stalk hospital hallways.

“If a doctor needed to be involved there, we have a physician who is on call, who can even get on the video with the patient in the middle of the night,” said Meera Udayakumar, an internal medicine specialist. She’d been working exclusively in the hospital until she got involved with the hospital-at-home program several years ago. “We can send a paramedic to the home, on demand in the middle of the night. And respond to things similar to what you would get in a hospital setting.”

One study done in 2019 found that people receiving hospital at-home services had fewer laboratory orders, fewer trips to X-ray and other imaging labs, fewer specialty consultations, and they ended up costing less to care for. They also spent less time lying in bed or confined to a chair, likely because they had a place to go, such as the garden or kitchen. And in an indication of the quality of the service, the hospital-at-home patients were less likely to end up in a revolving door of hospitalizations. They were readmitted to the hospital less frequently than patients who had inpatient treatment, then were discharged and had complications that put them back in the hospital within the month. A Cochrane Collaborative study, which reviewed existing studies performed up until 2016, found that six months after the hospital at home admission, there was little difference in mortality compared to patients with similar diagnoses who had been admitted as an inpatient.

“Actually, outside of the United States, it’s been around significantly longer. It’s just been slower to adopt in this country because of our particular regulations and our health care system just being more complex,” Udayakumar said.

There’s also been a learning and comfort curve for practitioners in this country to get used to the hospital-at-home model, she said.

“So we need to look for alternate ways and locations to provide care so that we can serve the greatest number of patients,” Udayakumar said.

But it’s not for everyone. Another study in which patients with respiratory infections had good outcomes noted that there needs to be someone in the house who can help. That study also noted that “cost savings are at least partially explained by the fact that the care was largely carried out by trained family members, reducing labor cost, which is a large proportion of hospital cost.”

Pandemic changes stick

As many have experienced, the pandemic ushered in an increased emphasis on remote health care, with rates of remote physical and mental health appointments skyrocketing during the lockdowns and beyond.

Atrium Healthcare used the hospital-at-home concept during the pandemic to reduce the load in their inpatient units, said Scott Rissmiller, chief physician executive at the Charlotte-based health system.

His organization’s hospital-at-home program had a longer history, he told a legislative committee this summer. He said that the system started investing tens of millions of dollars in virtual health as much as a dozen years ago. So, when the pandemic hit, they were able to pivot quickly.

“Some of our clinicians got together and started talking about how can we do this differently, how can we provide care for these patients in their house,” Rissmiller said. “Very rapidly with our virtual health platform and IT platform that had been developed over the past decade, we were able to get this up and running in literally three weeks.”

Atrium saw close to 5,000 patients in their “virtual” hospital throughout the course of the pandemic, he added.

“These aren’t patients with sniffles, these were patients who had oxygen, who were receiving IV fluids in their home. We are one of the first to provide IV remdesivir in their home. These were sick patients,” Rissmiller said. “We did it with virtual check-ins throughout the day, technology that was continuous, that was monitoring their blood pressure and their oxygen saturations. We would give them these tools at home that digitally connected to their phone and were uplifted to the care team. And then once a day we would send in our community paramedicine team into the house to provide IV fluids and to check others.”

“The one big silver lining throughout the pandemic was our acceleration of virtual health,” he added.