Editorial: It's Time to Study "Hospital at Home" After Surgery
Key findings
- Hospital at Home (HaH) programs, offered since the 1990s for patients with acute medical illness, have shown excellent results in terms of mortality, adverse events, patient satisfaction and cost containment
- HaH may also be well suited to postsurgical patients who have certain selected complications that traditionally require readmission and those who are typically admitted after surgery but could have postoperative care provided entirely at home
- The two major advantages of HaH in surgery are lower costs, by replacing postoperative inpatient readmissions or reducing the length of stay, and reduced inpatient congestion, which leads to increased surgical patient throughput
- Building patient and surgeon trust is key to the success of HaH programs
- In this editorial, surgeons share how they are making HaH work in their departments
Introduced in the late 1990s, Hospital at Home (HaH) is a health care delivery model in which patients with acute medical illness receive services in their home that are practically identical to inpatient hospital care. HaH involves enrolling patients through the emergency department as an alternative to inpatient admission or discharging them to their home early during inpatient hospitalization. HaH is part of routine care in Australia, Canada and the U.K.
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Past research determined that HaH programs are associated with the same or lower mortality rates as standard inpatient admissions, the same or lower rates of adverse events and consistently higher patient satisfaction, with 19% to 30% lower costs.
Kyan Safavi, MD, MBA, of the Department of Anesthesia, Critical Care & Pain Medicine, and Marcela del Carmen, MD, a gynecologic oncologist in the Department of Obstetrics and Gynecology and a clinician in the Center for Gynecologic Oncology in the Cancer Center at Massachusetts General Hospital, and colleagues are now pioneering HaH in surgery. In Annals of Surgery, they report that HaH is well suited for postsurgical patients with certain complications that traditionally require readmission, as well as those who are typically admitted after surgery but could have postoperative care provided entirely at home.
Potential Value of HaH After Surgery
HaH has a number of potential advantages for both patients and hospitals:
- Lower costs by replacing postoperative inpatient readmissions or reducing the length of stay
- Reduced inpatient congestion, leading to increased surgical patient throughput
- Reduced nosocomial complications
- Increased patient satisfaction
Challenges for HaH After Surgery
Patients may not trust an unfamiliar alternative care pathway. They need to be educated about HaH during the preoperative office visit or at the beginning of their postoperative recovery.
Surgeons, too, must be educated about HaH. They should find it as easy to send a patient to HaH as to the emergency department. At Mass General, a practitioner in a navigator role receives HaH requests, performs intake evaluations and coordinates services.
Clear expectations need to be established about the content, frequency and mode of communication between HaH care personnel and surgeons. In addition, surgeons or representatives from their teams must be available to consult when urgent needs arise.
Suggestions for Success
The authors suggest establishing management algorithms for various patient populations. Inclusion criteria should be specified in the algorithms, and staff should verify that each patient meets them before enrolling them in HaH.
At Mass General, these criteria include:
- Hemodynamic stability
- Clear mental status
- Ability to toilet independently
- A stable home environment
Each patient's risk of decompensation should be linked to adjustments in their HaH care, such as the frequency of staff visits. Rapid response protocols must be in place so that if a patient experiences acute decompensation, they are transferred to an inpatient setting without delay.
Certain quality metrics for HaH are worth tracking, including:
- Nosocomial complications
- ICU transfer
- Mortality
- Time to provider response
- Need to transfer to an inpatient facility
Care Resources
Mass General partners with an independent home infusion organization that delivers compounded medications and fluids to patients' homes. That organization's personnel also obtain intravenous access, including peripheral intravenous central catheters. To ensure that care staff see enough patients to make their time cost-effective, the Mass General program has a defined catchment area of eight to 10 miles.
Secure, HIPAA-compliant provider-to-provider photo sharing and video conferencing can enable surgeons to engage with the patient and care provider in the home.
Conclusion
The authors call on other institutions to develop HaH pathways and study them rigorously. Building a reliable evidence base will encourage the Centers for Medicare & Medicaid Services and other insurers to reimburse appropriately for HaH. That would allow the programs to be scaled effectively, with the potential to transform postsurgical care in the U.S.
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