'Hospital at Home' for COVID-19 Care

Hospital-level care at home for non–COVID-19 patients who don't require intensive care, freeing up beds needed by more critically ill patients.

APRIL 29, 2020 -- Tufts Medical Center in Boston is partnering with Medically Home, a Boston-based company, to provide hospital-level care at home for non–COVID-19 patients who don't require intensive care, freeing up beds needed by more critically ill patients.

"Long before the COVID-19 pandemic disrupted our way of life, we began researching innovative ways to provide care for the subset of patients who could receive hospital-level medical services in the comfort of their own homes," said Tufts Medical Center President and CEO Michael Apkon, MD, PhD, in a news release.

"In the face of this crisis, we've been able to accelerate our timeline in the hopes of having as many beds available as possible for patients whose care can only be delivered in the hospital, especially those who will require a ventilator."

Medically Home is currently treating 14 non–COVID-19 patients who were discharged from Tufts Medical Center.

"Right now, we're only evaluating and discharging patients [to at-home treatment] who don't have COVID," said Sucharita Kher, MD, a pulmonologist and director of the outpatient pulmonary clinic at Tufts, in an interview with Medscape Medical News. "We're in the process of developing criteria to identify and assess which COVID patients can be safely discharged to be cared for at home."

Among the patients who can be treated safely at home, she noted, are those with congestive heart failure, pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.

These patients can be discharged to the hospital-at-home program either from the emergency department (ED) or from inpatient wards. "As soon as they come into the ED, we evaluate whether they can be cared for at home under our criteria," Kher said. "They can go from the ED to home [treatment] if they can be stabilized in the ED. Alternatively, they can be stabilized for a day or so in the inpatient setting and then be sent home to continue their care at home."

The criteria that Kher and colleagues are developing for COVID-19 patients, she said, are related to oxygen levels, breathing rates, vital signs, and new blood tests "that have been shown to predict more serious disease, potentially requiring ICU stay or long hospitalization. Those are not the patients you want to be sending home."

Medically Home uses telemedicine and remote monitoring technologies to connect patients at home to its own doctors and nurses in a "medical command center." Patients can speak to members of their care team 24/7 via audio/video conferencing, and their vital signs are continually monitored.

A patient doesn't need to have high-speed Internet at home to be treated there, Pippa Shulman, DO, MPH, chief medical officer of Medically Home, told Medscape Medical News. The company brings in a network device that can plug into the patient's Internet router, if the patient has it, or can generate a high-quality signal from cellular service. The patient doesn't even need to have a smartphone. "We bring in a phone, a tablet, and biometric devices, as well as the network," Shulman said.

In-person Visits

Medical professionals visit the patient at home when needed. For example, a nurse practitioner or a specially trained paramedic goes to the patient's home on the day that he or she is admitted to the 'hospital at home.' On the second day, a nurse practitioner visits, IV therapy is initiated, and durable medical equipment is delivered. Other personnel visit to perform mobile x-rays and lab tests. Additional care may be delivered in person by home health aides and physical therapists.

Tufts' physicians are only peripherally involved in all of this, Kher said. Before the patient is admitted to the hospital at home, she said, the doctor who has principal responsibility for his or her care calls the physician who will take that responsibility at Medically Home.

Besides going over the patient's history, condition, and plan of care, the Tufts physician gives the hospital at home doctor the names and contact information for the specialists who cared for the patient in the hospital. Those specialists may be called for consults as needed. When the patient is ready to be discharged, there's a "warm handoff" to the patient's primary care physician and/or any specialists who will be involved in the patient's continuing care.

Tufts' medical staff enthusiastically supports the hospital-at-home concept, Kher said. "After we did some education with the clinicians, we really had their buy-in. Physicians understand that if we can provide hospital-level care in the patient's familiar environment, that may be the best thing for the patient."

The hospital at home is not new, she added. "Studies have shown that providing hospital-level care at home reduces hospital stays and prevents readmissions. There have been a lot of benefits."

A Commonwealth Fund brief on the subject cited a hospital-at-home program that Johns Hopkins Hospital has had since 1994. Johns Hopkins found that the cost of at-home care was 32% less than that of inpatient care, that the mean hospital stay was one third lower, and that the incidence of delirium dropped. There was no difference in the readmission rate or the subsequent use of medical services, and patients and family members were more satisfied with at-home than with traditional hospital care.

Patients are amazed to discover that they can be cared for at home, Shulman said, and they often find that they're better taken care of than they would be in the hospital. "Any time of day or night, if the patient has a question or concern, they can speak with their care team — their doctor or nurse — and can see them on the video if they want. We take care of their needs in the home in a way that you don't often get in the hospital, particularly in an environment where the clinicians may have to don and doff PPE between every visit."

Long-Lasting Trend?

Will this trend outlast the pandemic? Shulman believes so, partly because hospital at home can give hospitals surge capacity when they need it — and the COVID-19 crisis has shown them that they'll always have to be prepared.

"Hospital at home allows the hospital to say, 'I need surge capacity in eastern Massachusetts so I can flex beds up and down,' " she noted. "And that's where hospital at home can be an incredible ally and support."

Kher agreed. "Every time we discharge a patient, it releases beds for folks who need them," she said.

Tufts CEO Apkon views hospital at home as an integral part of Tufts' strategy going forward. "Our partnership with Medically Home is allowing us to optimize our space and resources at a critical moment, but even after this crisis has passed, we believe Medically Home will remain an important part of our overall strategy to meet the unique needs of each patient we serve," he said in the news release.

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