Under pressure to reduce costs while improving quality, a handful of hospital systems have embarked on an unusual experiment: They are taking the house call to the extreme, offering hospital-level treatment at home to patients who in the past would have been routinely placed in a hospital room. And as awareness spreads of the dangers that hospitalization may pose, particularly to older adults, patients are enthusiastically seizing the opportunity.
“I always laugh when people say, ‘Do you really think you’re as good as a hospital?’ ” said Dr. Melanie Van Amsterdam, the lead physician for Presbyterian Healthcare Services Hospital at Home program in Albuquerque. “Have you been to the hospital? For many of these patients, it’s a little scary.”
Dr. Bruce Leff noticed that back in the late 1980s while making house calls to homebound patients, part of his primary care training at Johns Hopkins University School of Medicine. When some of his patients fell ill, they simply refused to go to a hospital.
He understood why: He had seen firsthand the delirium, infections and deconditioning that too often land older patients in nursing homes after hospitalization. “Being in the hospital could be toxic,” said Dr. Leff, a geriatrician who is now a professor of medicine at Johns Hopkins.
So Dr. Leff and his colleagues had an idea. What if patients could be hospitalized in their own beds?
Some patients need the moment-to-moment monitoring that only a hospital can provide. The first task was to determine which common conditions required admission but could be treated with technologies placed in the home.
Dr. Leff and his colleagues settled on four diagnoses that could be treated without the patient’s being physically in the hospital: heart failure, exacerbations of emphysema, certain types of pneumonia, and a bacterial skin infection called cellulitis.
“I’m a doctor. I can talk to a patient, I can examine a patient, I can bring home oxygen and IV meds and fluids, I can do home X-rays. I can do quite a bit,” Dr. Leff said. “We felt that it could be done, and the hypothesis was that by doing so, we could reduce harm.”
With a grant from the John A. Hartford Foundation, Dr. Leff and his team offered outpatient hospital-level care to nearly 150 patients. They called their program “Hospital at Home.”
The findings, published in The Annals of Internal Medicine, were promising. Offered the opportunity, most patients agreed to be treated at home. They were hospitalized for shorter periods, and their treatments cost less. They were less likely to develop delirium or to receive sedative medications, and no more likely to return to the emergency room or be readmitted.
Some of the patients she approached said no. One man did not want visitors because he had big dogs at home, she recalled. Another said that if he felt short of breath at night, he would prefer to be in a hospital. But more than 90 percent agreed.
Those with worrisome vital signs — heart rate too high, blood pressure too low — are not eligible. Nor are patients without electricity or running water at home, or without space at home for oxygen or intravenous supplies, should they be needed — a pertinent question for residents in Manhattan apartments.
“I am very confident that we’re going to be able to show that patients want to be home, that we can do this safely, and that we can do this with savings,” said Dr. Linda DeCherrie, an associate professor of geriatrics and palliative care medicine at Mount Sinai and clinical director of the new program.
The trend toward taking hospital patients out of the hospital “will continue to evolve and get tested, but I think this will see its day,” Dr. Leff said
“My sense is that over time, hospitals will become places that you go only to get really specialized, really high-tech care,” he said.
On a recent night, Mary Hull sat in her living room in Albuquerque, waiting for her doctor to check on her. Ms. Hull, 43, had been admitted to the hospital, at home, a few days before being treated with intravenous antibiotics for a skin infection on her leg and abdomen.
A portable X-ray machine had arrived. She was receiving daily lab draws. A nurse visited three times a day. She hadn’t even needed to find someone to watch her cat.
“I’m hoping to be discharged soon,” Ms. Hull said. “But I guess it doesn’t matter much. I’m home.”
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Could this system work in our country? What would be the benefits? What would be the challenges involved?
If you had the choice, as a patient, would you opt to be hospitalised at home?
What do you think?
Image source
It is proposed that our health service should move toward a system where hospitals should only be used for high-tech care; other patients should be 'hospitalised' at home