Hospital at Home and Emergence of the Home Hospitalist

Ms. P., an 86-year-old woman with a history of hypertension, hyperlipidemia, coronary artery disease, and transient ischemic attack, presents to the emergency department with a three-day history of cough, fever, purulent sputum, fatigue, and dyspnea on exertion. Her vital signs are notable for a fever of 39.0°C, blood pressure 136/92, pulse 102, respiratory rate 30, and room air oxygen saturation of 91%. She looks ill. She has a white blood cell count of 16,000, lactate 1.9, and a right lower lobe infiltrate on imaging. The emergency department attending physician presents the case to you for admission, and you accept the patient into your inpatient hospitalist service.

Now, let’s imagine a different future in which you are the attending hospitalist on your institution’s Hospital at Home (HaH) service, where you will provide hospital-level care to Ms. P. in the comfort of her own home. Hospitalists should prepare for this paradigm shift.

HaH provides hospital-level care in a patient’s home, for those with qualifying acute illnesses and appropriate degrees of acuity, as a substitute for traditional inpatient care.¹ This is achieved by bringing the critical elements of hospital care to the home—physician and nursing care, intravenous medications and fluids, oxygen and respiratory therapies, basic radiography and ultrasound, durable medical equipment, skilled therapies, and more.²

All hospitalists have cared for patients like Ms. P., and she and many patients like her will have a straightforward hospital trajectory: initial evaluation in the emergency department, inpatient care provided by a hospitalist inpatient service, a few days of intravenous antibiotics and other hospital services, and finally, discharge to home.

However, not all patients will experience a smooth, or safe, hospital course. Studies that launched the hospital safety movement also provide the rationale for HaH, namely, that hospitals are often dangerous environments for patients.³

A complementary approach to improving outcomes for patients at high risk of iatrogenic illness such as functional decline, falls, delirium, adverse drug events, and hospital-associated disability syndrome,^4-6 is to care for patients outside the traditional inpatient hospital environment. Over the past 20 years, many studies—including dozens of randomized controlled trials and several meta-analyses—have shown better outcomes for patients cared for in HaH: decreased length of stay, decreased incidence of adverse events (including substantially lower six-month mortality), better patient and caregiver care experiences, lower caregiver stress, and lower costs.^7-9A recent Center for Medicare and Medicaid Innovation (CMMI) Demonstration conducted at the Mount Sinai Health System found similar results.¹⁰

Interest in HaH has increased markedly over the past few years with increased penetration of Medicare and Medicaid managed care, the development and spread of accountable care organizations (ACOs), and a shift in focus among some health systems towards value-based care, population health, and community-based care. Recently, commercial entities have entered the HaH space and have raised substantial capital to fund development. Despite this growing interest in HaH and substantial evidence of its effectiveness, HaH has not been widely implemented or scaled in the United States.