Raymond Johnson began to feel unwell late last month. He said it was hard to get around from his apartment in Boston. I couldn't walk up and down the stairs without getting tired.
Like many older adults, Mr. Johnson has a variety of chronic health problems.
When the X-ray showed fluid in Mr. Johnson's lungs, he was told to go to the emergency room at Faulkner Hospital.
One day in a hospital room and three in his own apartment, Mr. Johnson received hospital-level care through an increasingly popular alternative called Acute Hospital Care at Home.
The Home Hospital program run by Brigham and Women's Hospital, which Faulkner Hospital is a part of, is one of the country's largest and provided care to 600 people last year.
According to the program's medical director, Americans have been trained for 100 years to think that the hospital is the safest place in the world. We have evidence that the outcomes are better at home.
The Veterans Health Administration adopted some of the programs 30 years ago. The hospital-at- home approach was put on hold because Medicare wouldn't pay for it. Changes were made in 2020.
Ab Brody, a professor of geriatric nursing at New York University and an author of a recent editorial on hospital-at- home care in the Journal of the American Geriatrics Society, said that hospitals need beds when they are overwhelmed. There was a need for a safe place for older adults.
In November 2020, Medicare officials announced that, while the public health emergency continued, hospitals could apply for waivers of certain reimbursement requirements. The payments for in-hospital care and hospital-at- home care would be the same.
Waivers have been granted to Mount Sinai in New York City and the Scott and White Medical Center in Temple, Texas, among others. Initially, hospital-at- home programs treated mostly acute illnesses like pneumonia, urinary tract infections and heart failure, but more recently they have also started dealing with liver disease treatments, post- surgical care and aspects of cancer care.
The approach from being adopted more widely is hampered by uncertainty over Medicare. At least a thousand hospitals will adopt hospital-at- home care in the next few years if this program is made permanent.
Waivers are not always permanent. Although the public health emergency will likely be extended by the Biden administration, state health officials are expecting it to end by the spring.
Will hospital-at- home care cease to exist? According to a survey done by the Hospital at Home Users Group, 27 percent of programs said they were unlikely to keep offering the option without a waiver, and 40 percent said they were unsure.
Older adults and advocates for their well-being are hopeful that these programs will stay. Studies show the risks of hospital stays to seniors even when the conditions that made the stay necessary are treated well.
Older adults are vulnerable to cognitive problems and infections due to the fact that they lose physical strength from inadequate nutrition and days of inactive lifestyles. Within a month, many patients need another hospital stay. The pattern is called post-hospital syndrome.
Mr. Johnson would have been in the hospital for a long time. He could have picked up infections in the hospital. The doctor said that he could have caught Covid. He could have lost his balance. People over the age of 65 are more likely to become delirious during a hospital stay.
There is a requirement for patients to consent to hospital- at- home care. More than one-third of patients decline to participate because the hospital setting is more convenient.
The doctor told Mr. Johnson that his conditions were not life threatening and that he could be treated at home. He said that he wasn't comfortable in the hospital.
He was seen by a doctor at home three times. Twice a day, a registered nurse or a trained paramedic will visit. The drugs and equipment Mr. Johnson needed were brought with him. He had a small sensor attached to his chest that transmitted his vital signs to the hospital.
The program could have provided Mr. Johnson with additional monitoring to make sure he was taking his medication on time. An ambulance could have taken him to the hospital if necessary.
He recovered without any intervention. Mr. Johnson said after he was discharged that he would recommend hospital-at- home care to anyone.
Patients in hospital-at- home programs spend less time in nursing homes. They are less sedentary and more likely to rate their hospital care highly.
In a New York City study, it was found that hospital-at- home care worked well for patients who qualified for Medicaid or lived in high poverty areas.
According to a 2012 international meta-analysis of 61 clinical trials, hospital-at- home programs are more widely used in other industrialized countries than in the United States.
The studies found a lower cost. The average cost per hospitalization was 38 percent lower for home patients than for those in an in-hospital control group, due to fewer laboratory tests, more consultations with specialists and fewer hospital stays.
It costs a lot to have amazing paramedics and nurses in the field, to have physicians available 24 hours a day, and to have a monitoring system. There are savings compared to in-hospital care.
The future of hospital-at- home care is dependent on the federal government. After the public-health emergency ends, a bill was introduced in the House of Representatives to extend the Medicare Waiver Program for two years. Despite bipartisan support from 29 co-sponsors, the legislation did not move forward.
Some hospital-at- home programs could be kept functioning by a multisite demonstration project.
Is there anyone who needs to be in a hospital? Dr. Leff spoke. That's right, absolutely. Surgeries, complex testing and intensive care need a building and its staff. He said that hospital-at- home initiatives show that more care could be provided outdoors.
In the future, hospitals will have big emergency rooms, operating rooms and intensive care units. Most of the rest will move to the community.
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