Hospital at Home and Emergence of the Home Hospitalist

Widespread dissemination and implementation of HaH has been hampered by several barriers. First, despite growing interest in HaH, the culture of healthcare and health system leadership, for the most part, remains focused on facility-based care.¹¹

Second, while HaH makes financial sense in the managed care arena, given the strong evidence for high-quality, lower-cost care, there is currently no standard payment mechanism for HaH in fee-for-service Medicare or in the commercial insurance space. However, there are indications that this may soon change. In the fall of 2017, a proposal for a bundled payment mechanism for acute HaH care plus 30 days of postacute care was unanimously approved by an Advisory Committee to the Secretary of the Department of Health and Human Services (HHS).^12,13 The HHS Secretary recently noted that “the Department of Health and Human Services is keenly interested in ideas for home-based, hospital-level care, and agrees … that this proposal holds promise for testing.”¹⁴

Third is the need to create the logistics and supply chain to support HaH. There currently exists a well-established supply chain for providing hospital care. A hospitalist orders a dose of intravenous antibiotic or oxygen, and it is supplied in a timely manner. Similarly, the postacute sector of healthcare has a robust supply chain, though it operates on a somewhat different clock from the acute care setting. However, there is currently no easily replicable supply chain to meet the needs of providing acute care in the home. Each HaH has had to create its own system of logistics with the existing healthcare assets in its local environment. Developing this capacity at scale will require significant capital investment.

There are examples where HaH has scaled. Beginning in 1994, in the state of Victoria, Australia (population 6.3 million), the health authority reimbursed HaH care at the same rates as traditional hospital care. At last report, HaH provided approximately 5% of all hospital bed days of care in Victoria. Providing HaH on this scale helped avoid the need to build a new 500-bed hospital to care for those patients.¹⁵ The avoided costs of building new hospital beds (and the ongoing need to fill those beds) represents significant societal return on investment attributable to HaH.

A key element in implementing a HaH program is its physician staff in terms of the types of doctors who provide HaH care, how they are organized, and how they interact with patients. To date, HaH physicians have been predominantly geriatricians, but internists and family medicine physicians, employed as full-time members of a dedicated HaH team, also provide care by physically visiting patients in their homes. The reason for significant involvement of geriatricians in HaH may relate to the fact that geriatric fellowship training includes training in home-based medical care, whereas this is less common in family medicine and internal medicine residency training programs.

In order to provide HaH on a nationwide scale, there will be a need for a larger workforce. There is an opportunity here to leverage existing hospital physician staff, such as hospitalists. In addition, while there is significant value in physicians seeing patients in their homes, more scalable versions of HaH are being developed and implemented that leverage biometrically enhanced telemedicine approaches for a dedicated physician component of care, with in-person visits provided by other members of an interdisciplinary team.

We believe that hospitalists can play a key role as HaH physicians as the HaH model continues to evolve and expand. Hospitalists bring valuable expertise relevant to HaH care delivery, including extensive experience with the triage of acutely ill patients, an understanding of the natural course of acute illness and team-based care, and for some, experience with telemedicine care.

While a hospitalist providing HaH care would leverage many of the competencies of the traditional hospitalist, we suggest that such a provider should receive additional training and clinical experience in home-based medical care to help them better understand the unique aspects of providing care in patients’ homes.¹⁶ Such training could include experience in making house calls, which can be a transformational experience in helping physicians improve their skills in dealing with social determinants of health, diagnosing and managing geriatric syndromes, and mobilizing community resources in the care of their patients, as well as managing care transitions. Hospitalists delivering care in HaH may also need to upgrade specific clinical skills commonly addressed by home-based medical care providers: wound care, caregiver-related issues, social and ethical issues specific to home-based care, problems with functional status, psychiatric and cognitive issues, management of gastrostomy tubes and bladder catheters, and dermatologic problems, as well as palliative care and end-of-life symptom management. These skills are slightly different from the usual realm of the typical hospitalists’ wheelhouse. However, it is all learnable.¹⁷ Similarly, geriatricians can learn from hospitalists as the HaH model evolves; there are HaH programs in existence today that take care of a sicker tranche of patients than earlier versions of HaH, with continuous telemonitoring of patients and the ability to rapidly deploy providers, labs, imaging, and medications. Going forward, as healthcare organizations begin to develop HaH programs staffed by hospitalists, it is probably wise for hospitalists and geriatricians to collaborate on the optimal physician models for HaH.

There may emerge a new specialty. Ticona and Schulman described a “home intensivist” with competencies including informatics of remote monitoring technology, leadership of multidisciplinary care teams, and the interpersonal skills required for compassionate end-of-life care.¹⁸ We prefer the term Home Hospitalist. Home Hospitalists would develop an enhanced understanding of the transitions of care and social determinants of health, and they would gain valuable knowledge about the social and environmental challenges many patients face after discharge from the hospital.

When this vision is realized, there will be enormous benefits to both HaH and Hospital Medicine. HaH could tap into a large and competent workforce to enhance its implementation and dissemination. Hospital Medicine would gain a new pathway for its providers and could develop new collaborative efforts with geriatric, internal, and family medicine.