Growing interest in the hospital at home concept and other approaches to delivering medical care in seriously ill patients’ homes has raised some important questions for the palliative care field. Starting with: how does palliative care interface or overlap or collaborate with the new home-based medical models?
Hospital at home is now being tested by health systems, the Veterans Administration, managed care organizations and home care providers as an approach for treating acutely ill adults cost-effectively in more familiar and comfortable surroundings. Recent experience with the COVID pandemic, which made a powerful case for not keeping seriously ill patients in the hospital if there is an alternative, has driven a lot of the recent innovation.
The hospital at home concept is defined as an innovative model for health care organizations to deliver acute, hospital-level care in the patient’s home as a full substitute for hospital care for those who have medical conditions that otherwise would require hospitalization.
The model, with daily encounters by doctors or nurses, in person and via telehealth, has been promoted for years by the John A. Hartford Foundation and Johns Hopkins Medicine. More recently, the Centers for Medicare and Medicaid Innovation has also been studying it through the Acute Hospital Care @ Home Program, launched in November 2020 in response to the pandemic.
This program incorporates 60-plus medical conditions and has named 11 participating health care organizations to date. The CMMI model requires screening protocols and an in-person evaluation by a physician before home care can begin. It waives traditional hospital conditions of participation but requires at least two in-person encounters per day, counting paramedics. Admissions come from the emergency department or inpatient hospital beds. CMMI is monitoring data from participants regarding patient volumes, mortality rates and the like. The program also includes demonstrations of other segments and services, such as Palliative Care at Home.
This kind of care “encompasses a variety of care models that often serve the most medically complex and socially vulnerable people,” writes Christine Ritchie, MD, MSPH, director of research for the Division of Palliative Care and Geriatric Medicine at Massachusetts General Hospital in Boston; Johns Hopkins’ Bruce Leff, MD, a leading authority on hospital at home; and colleagues in a recent California Health Care Foundation report: “Medical Care at Home Comes of Age”, published in January.
A Variety of Models
Although the semantics of the various models can get complicated, home-based primary care encompasses long-term and preventive care. Home-based palliative care, on the other hand, is more focused on distress management and goals-of-care clarification. The two approaches “will benefit from working together within a population health framework,” Dr. Ritchie noted in a 2018 article in the Journal of Pain and Symptom Management.
Two things these approaches have in common are their recognition that many seriously ill patients are homebound or have great difficulty getting to a doctor’s office to obtain needed medical management of their condition. A growing body of evidence has shown that providing these individuals with medical care in the home can be cost-effective overall. Studies have shown a range of better outcomes while reducing unwanted hospitalizations and revolving door emergency room visits.
Palliative care has been woven into the fabric of hospital care and, to some degree, into ambulatory care, Dr. Ritchie says. If care is occurring in the homes of seriously ill patients, palliative care needs to be there too. “If patients are sick enough to need this level of medical care, they probably have high symptom burden, psycho-social needs, caregiver issues, a need to think about their future—all the things palliative care leans into. To me, it’s a natural thing to include home-based palliative care.”
She recommends looking at these models as a coordinated continuum, rather than a multitude of stand-alone approaches. Palliative care leaders need to understand the menu of opportunities for them in the broad array of acute and longitudinal home-based care models. Palliative care can offer real value through consultative services, education and training or shared practice—if it understands how to support the evolving ways this kind of care gets paid for.
Different sub-populations will need different kinds of care, but the number of people who are homebound is greater than is commonly realized, Dr. Ritchie says. “We all stand to gain if everyone providing care in the home has palliative care skills.” But there will be times when patients’ palliative care needs exceed primary palliative care skill sets and require specialists. “If I ran a palliative care program that wasn’t currently working in the home, I’d want our program to get trained in home-based care and the relevant reimbursement models.”
The Home-Centered Care Institute, an organization that promotes home-based primary medical care, is partnering with The Center to Advance Palliative Care to develop cross-pollinated training, says Thomas Cornwell, MD, its executive chairman. Dr. Cornwell has been doing primary medical care in patients’ homes since 1993. “I’d say home-based primary care and home-based palliative care overlap. We’re both dealing with the sickest of the sick, who also need goals-of-care conversations and excellent symptom management to improve their quality of life.”
Experiments with Home-Based Care
Martha Twaddle, MD, FACP, director of Palliative Medicine & Supportive Care at Northwestern Medicine Lake Forest Hospital in Illinois, also sees overlaps between home-based primary care and palliative care. “What is critical is the logistics of scaling these supports to the right people at the right time so that the competencies of the clinician are augmented to serve a very sick population at home.”
The complexity of the patients and their needs would seem far beyond what is “routine” primary care, she says. “I think these models are fabulous to get people the right care in a safe and effective environment. Yet the devil is in the details, and the cost structures seem to me to be prohibitive.”
Todd Cote, MD, chief medical officer of Bluegrass Care Navigators, a diversified hospice and palliative care organization based in Lexington, Ky., says his organization had a discussion several months ago with a large health system that was considering a hospital at home program but lacked community practice insight. “They were interested in our input for their program. They were thinking about physician and nurse teams. We had discussions about possibly utilizing our nurse practitioners for the program. The incentive for them was to get post-COVID-positive patients who were in their hospital home sooner.” As the pandemic waned, so did that conversation.
But he still thinks organizations like his, which are experienced with community-based home care, will be good collaborators for hospital at home programs. “We are focusing on primary care, including ‘urgent care’ in the home, to help keep people out of the hospital. We anticipate assisting any hospital at home program that comes along. Someday we may start our own.”