How health systems should be preparing now for the future of hospital at home

As CMS signals longer-term changes in acute RPM reimbursement and Amazon teams with major providers to push for new policies, clinical and IT leaders should start planning ahead, says one expert. "Everyone has to be thinking about this."
By Mike Miliard
11:43 AM

Telehealth proved its mettle this past year. Now more hospitals and health systems are looking to expand their efforts beyond video visit-based virtual care, and push for expanded remote patient monitoring programs – up to and including the provision of acute care at home.

But some big questions still need ironing out, as regulations and reimbursement mechanisms are in major flux. But the fact that these ideas are even being discussed points to how far the conversation has shifted since the onset of the COVID-19 pandemic.

About the same time as Amazon made waves this past week with its 50-state expansion of Amazon Care, we reported that the company has teamed with blue chip health systems such as Ascension and Intermountain for the new Moving Health Home collaborative, whose goal is to "change the way policymakers think about the home as a site of clinical service."

The group plans to lobby policymakers to broaden coverage for care services in the home – including extension and expansion of the Centers for Medicare and Medicaid Services' Hospital Without Walls provisions – advocate for bundled-payment models, home-based care and more.

Meanwhile, there's real-world progress being made at some of the more forward-thinking health systems. Mayo Clinic CEO Dr. Gianrico Farrugia, for example, has recently highlighted some early successes of the health system's Advanced Care at Home program.

The COVID-19 crisis has forced providers to think more creatively about care models and revenue. And as many contemplate expansion of their telehealth and RPM initiatives, they're understanding the need to start laying the groundwork now.

As momentum builds behind the concept of hospital at home, we spoke with Tom Kiesau, director and leader of Chartis Digital at the Chartis Group, about what those next steps should be. He highlighted the importance of identifying the right patient populations – those who most stand to benefit from acute care RPM – now.

And he described how health systems should be prioritizing their investments: patient-facing tools and technologies, command centers, delivery services, administrative support, IT infrastructure and more.

Q: Telehealth obviously made some remarkable strides in 2020 and has vast potential for growth. Now many health systems are looking toward more advanced remote patient monitoring initiatives – including delivery of acute care to patients at home. Do you think we're at an inflection point for virtual care and RPM?

A: Yeah, I really do. The home is a care setting. And you have all these subcategories that have historically been served by physical care provision. When you think of the home as a care setting with some level of physical interaction – not just a virtual visit at home, but everything else – you can think about observation in your home, you can think about a hospital in your home, you can think of post-acute care, replacing SNFs, you can think about end of life care, replacing a hospice.

And what you're seeing is there's kind of a confluence of factors about comfort with digital care. A big thing that happened last year, a massive change that catalyzed a lot of the activity that we're seeing is that CMS finally cleared a pathway with the Hospital Without Walls initiative in April. And then the big one being the waiver that came out in November.

They cleared the path for parity reimbursement during the public health emergency. So there's a time limit on it. But at least my belief, and a lot of folks who work in the space, is it's been long overdue and proven to be effective. Johns Hopkins has been doing research on this for years, Mount Sinai has been doing research. It's a better product in a lot of ways. And I think it's absolutely here to stay.

Q: Will the latitude given by CMS during the pandemic continue going forward, do you think, and pave the way for policies more conducive to hospital at home initiatives?

A: I think you're going to continue to see it adopted. But I think you're going to see, appropriately, pushback on parity. We're lowering the threshold for people using services. And so if we're going to lock in the institutional cost models of traditional in-person care, we're going to actually accelerate our cost problem that we have in healthcare America as opposed to restructuring it and redefining it.

The fact of the matter is that hospital at home is cheaper. And it gives better outcomes. The research studies that have been conducted show that it is dramatically cheaper, reduces readmissions and is just structurally a better product for the patients it's appropriate for. It doesn't solve everything. It's not a replacement for all acute care, but it is a better replacement for some acute care.

The research has been there since the mid-'90s. It's just that now we have the digital components, the digital infrastructure to support it. And the payment [reform] to get the ball rolling. And so I don't think we're going back in the world of pure physical acute healthcare. Hospital at home is here to say. It's just, to my mind, a question of how fast, and where it levels out.

Q: You probably saw the new Moving Health Home initiative that launched a couple of weeks ago with some big name health systems, Amazon Care and others. What do you make of that?

A: Whenever I see a policy reform, I go through and look at it and try to figure out what are the economic incentives for the participants. I'm happy to see big healthcare providers in there, which I think will help make sure hospital at home doesn't get constituted as a purely cannibalistic, outside traditional healthcare, standalone service offering. But I do think the power of hospital at home is complementary to acute care capabilities.

You run the risk of operations getting stood up that are all virtual and their only real capability for when things go wrong is to throw somebody in an ambulance and let the hospital figure it out. You see some of this in markets that don't have a relationship with a hospital. They got maybe a very broad coverage agreement, but it doesn't reach the same level of integrated health outcomes.

But with the players that are in there, you've got big lobbying power in Amazon, who's obviously making a big splash now in healthcare. And you've also got some of the biggest legacy players that really understand the value of integrated care. So I am cautiously optimistic. I think it's the right group of players to push the boundaries a little bit on the technical standards that need to be in place. I think it's a good thing, really. To have a group like that advocating for the policies is really important.

Q: I was going to ask about the Amazon piece. I wonder whether the new Amazon Care expansion could itself be enough to push the conversation forward.

A: Amazon has made a major business of taking legacy costs and turning them into a revenue center for themselves. AWS is one of their fastest growing and most profitable businesses. It's hard to look at healthcare and not see there's opportunity for the same thing. And they've been doing it for years with Amazon Care for their employees. The question was not a matter of if they were going to roll Amazon Care out; the question was how big it was going to be.

If you think about the logistical complexity of hospital at home, the dispatched care services and dispatched equipment that goes with it, it has short-term immediate delivery requirements that nobody else has anywhere near the infrastructure to be able to deliver holistically.

It is not a stretch, to my mind, that they can build capabilities to be an integral part of the hospital at home dispatch service supply chain and be able to supply the entire technical infrastructure in partnership with a healthcare provider.

You're offering as an employer, and now you've got this first layer: You can provide all the primary care, ambulatory, the whole milieu of non-regulated services, and then we can provide home-based care when appropriate, across all these different levels of acuity – that could be enormous cost savings for an employer.

They've always represented an existential threat to any industry that is complacent and fat and happy, and I think in healthcare we've been complacent with some of this stuff. 

Q: Leaving Amazon aside, let's talk about the broader concept as hospital at home continues to evolve. Say the policy stuff gets ironed out and more providers decide they want to embrace something like this. What should they be thinking about to prepare?

A: I make a big point with clients to really do the work of segmenting out your clinical populations. The first thing I would say is home-based care is the umbrella. Hospital at home is really the goal of delivering acute care level services in the home. So I tend to look at things like chronic care management as the target for RPM, where the tool is the driver.

As opposed to hospital at home, which is an integrated and comprehensive wrapper that can provide all the same services – literally all the same services – that you would find in an acute care setting. As well as the backstops for the true, emergency, hands-on situation.

There's a bit of a paradox here. You have to be able to identify the clinical populations that are appropriate for the care. Mount Sinai has done a great job there. They posted a paper and made a lot of their research public. But there are a lot of clinical populations – cellulitis, COPD, congestive heart failure, pneumonia, diabetes – they're a large population that often, even the consideration for comorbidities and they rule people out, it'll represent as much as 25-30% of a hospital's admissions.

And so you start thinking about that, is that the addressable market? Then you have to put in how do we put in place all the tools to serve them? And then every payer has a different implication. For Medicare, before the waiver, there was no reimbursement. There was no incentive to move Medicare as a whole [toward hospital at home].

So when health systems are going to go about looking at hospital at home specifically, that acute care wrapper, there's a specific analysis of what populations are clinically appropriate and what are the financial implications and the economic viability of moving those populations.

Because before the waiver, large chunks were not covered. We're starting to see a lot more signs that the Medicaid plans are going to start considering paying for this. I heard anecdotally that both Massachusetts and California have some legislation being formed around paying for hospital at home for Medicaid. There are now increasing examples of commercial payers either partnering with health systems to offer it or paying directly on a fee-for-services basis.

So if you think of it as a Venn diagram, that economic viability bubble is slowly moving further over that clinical appropriateness bubble. And it's making it easier for organizations to put in place the basic elements that you have to have in place to operate a hospital at home program: the 24/7 clinical command center, the remote monitoring tools that are on the patient, the dispatch services, the legal element, the payer contracts, the rev cycle and then the technical infrastructure that links all that stuff together, the AI that helps triage routes. You can't do all those things unless you've got enough of a population to justify the cost.

And so you kind of hit this structural hold-up, where no one can make those investments materially until they solve that Venn diagram overlap. But I think we're getting to the point now where you're seeing enough population appropriateness. It's my belief that it will be a part of every health system's delivery channel in the next five years. Everyone has to be thinking about this.

Q: We hear often and always about the importance of the IT and clinical side working together in tandem. Let's say I'm a CIO and my colleague is a CMIO. What are the things we should be doing as prep work right now as we look to the future?

A: It's really about working through the understanding of the population that you intend to serve. It's an analytical exercise: looking at the data, looking at whom you target, how it would impact them and then working through that patient's journey.

But a lot of organizations have focused on the back end as the starting point: "We're going to shave a few days off [inpatient stays] for these Medicare patients, it'll be a better experience for them than staying in a hospital, they'll get a better outcome, we'll minimize readmissions." But it's not enough. The CMIO, the CIO, the medical director of the ED, the COO – everyone needs to commit to the vision of this different care model.

Bruce Leff is the godfather of hospital at home, and he's said that there's nothing intrinsically about this that's not solvable. But it's sort of like riding a bicycle backwards. Your training muscles group completely differently. And so the job for the CIO, to my mind, is not focusing on the technology. It's focusing on their use requirements and then demonstrating the efficiency and the effectiveness of the technology.

Because what we found as the impediments to this are usually not technical. It's more, can you put a patient into this program and make them comfortable enough that they will actually use it?

And you're needing to cover all of the considerations of the ways things could go wrong – from, you know, the most mundane stuff, like your internet isn't reliable or doesn't work, to how does someone get into that house if that patient is by themselves and there's a medical emergency? It is working through the entire journey in a holistic way.

You're going to continue to see more health systems seek to understand this. And if hospitals don't do this, we need to ensure that one of the other constituents will, whether it's payers, home health, the tech vendors themselves, multi-specialty physician groups. I mean, if you're a large orthopedic group, you're already moving most of your stuff to outpatient.

If you can run a hospital-at-home program, you can do the surgery at an ASC and put the patients into an acute care at home program, why wouldn't you? You could essentially obviate the need for a hospital for the vast majority of your patients.

You're going to see more and more and more health systems start discovering what this could be, and deciding whether they want to be early adopters. I wouldn't even say early adopters. At this point you're seeing the fast followers. The early adopters are already out there. Now it's, do we want to be a fast follower and get on this now? 

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Healthcare IT News is a HIMSS publication.

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