Acute care at home brings the hospital to patients' living rooms

Dolores Wiese was recently hospitalized for a skin infection. But she wasn't treated in a hospital. Instead, a care team paid regular visits to her living room in a retirement community in Phoenix.

"I like to be active. And to be tied down in bed in a hospital? No. I'll take this any day," Wiese said.

Wiese was one of the first patients in Arizona to receive hospital care at home through a program from the Denver-based provider DispatchHealth. Acute care at home programs can't provide surgery or ICU-level care. But dozens of providers around the country say technology is now good enough that x-rays, bloodwork, and many treatments for non-life-threatening conditions can be handled on-the-go.

And since the start of the pandemic, this care model has gained traction.

"It is absolutely exploding," said Dr. David Levine, an internal medicine specialist with Brigham and Women's Hospital in Boston who has studied home care.

Wiese's nurse practitioner, Kristen Cox treated patients in hospitals for years. But she's convinced patients she treats now at kitchen tables or on living room sofas are getting better care.

"If you're getting better sleep, you're healing better. If you're eating better, you're healing better," Cox said. "So being at home, not only is it comfortable for you, but it tells us as providers that you're getting better."

That's not just anecdotal evidence. A 2018 study found treating patients at home cut costs, and had no differences in quality compared to treating them in the hospital.

"You end up getting readmitted much less often and you end up lying down much less often and moving around much more when you're at home versus in the hospital," said Levine, the study's lead author.

Levine said acute care at home is already the norm in Australia, Spain and Italy. But in the U.S., home hospitalization has faced regulatory barriers.

The pandemic changed things. In late 2020, the Centers for Medicare and Medicaid Services announced strategies to ease stress on health care facilities, including more flexibility for at-home care.

"Essentially, we went from zero approved hospitals to a year later over 185 hospitals all throughout the country approved for this care model," Levine said.

Mayo Clinic is another provider that began offering at-home care during the pandemic. Dr. Michael Maniaci, who oversees that program, said patients have responded really well to virtual doctor visits and regular follow-up calls. But he said under the waiver from CMS that allows such programs, Medicare and Medicaid pay just a lump sum for a program that includes a lot of custom-tailored care.

"There's really no true reimbursement for that that's built yet in the system," Maniaci said.

But Maniaci said everyone will save money in the long run if patients stay healthier. And he said, bringing services to patients at home can free up space for other patients.

"What we're trying to figure out is the true value equation. Even if we're losing money because we're giving extra services, what's the cost of opening up that hospital bed for a cancer patient or surgical patient that needs it more?" Maniaci said.

That's a critical question as the pandemic continues to strain hospitals. Across three states in 2021, Mayo reports it freed up 3,300 hospital bed days by treating patients at home.

"That's 3,300 bed days that we could use for our coronavirus patients or anybody else," Maniaci said.

The challenge, he said, will be scaling up the service to make an even bigger impact. And one hurdle to growing home care programs is paying for them.

A few private insurers have started joining the government, and are covering in-home care now, too. Humana was the first private insurer to cover DispatchHealth's program and is also growing its own in-home care service. Dr. Amal Agarwal, a vice president atHumana Home Solutions, said investing in home care makes sense for patients and the insurer.

"It can provide good clinical care in the right scenario, and it can be done at a lower cost," Agarwal said. "So I think that there's value there and it's a lower cost for the member as well."

The CMS waiver to allow hospitals to expand in-home care was meant to be temporary, but providers and now some insurers really want lawmakers to allow it to continue permanently.

That would be fine with Dolores Wiese. Back in Phoenix, her medical visit ends with laughs and hugs. For someone who's technically hospitalized, it's clear she's having a great time.

In-home treatment, she said, is "the best thing that's happened since running water."

She'd prefer not to be hospitalized again, but if she is, she really hopes it will be in her living room.

This story comes from NPR's health reporting partnership with KJZZ and KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

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