When a patient turns up in the emergency department at one of Allegheny Health Network's hospitals with uncomplicated pneumonia, a bacterial skin infection or another lower-risk ailment, that patient may now get the choice to skip the hospital bed and go home to receive care.
Highmark Health, the parent company of Pittsburgh-based Blues insurer Highmark and integrated system Allegheny Health Network, is introducing a program to deliver inpatient hospital care to patients in their homes, where it says certain healthcare services can be provided in a safer, lower cost way through a combination of in-person home visits and telehealth.
"We firmly believe that a certain percentage of patients do not to need to be hospitalized if you have the capability to (care for them) at home in a safe environment," said Dr. Tony Farah, chief medical and clinical transformation officer at Highmark Health.
Highmark Health is now rolling its program out to certain commercial plan members in Western Pennsylvania and will expand it to Medicare Advantage members on Jan. 1. It has plans to push the program out to all of its members in central and Western Pennsylvania in the next year.
Highmark is following in the footsteps of a small number of health systems embracing hospital-at-home programs. It launched the program with the help of Nashville-based company Contessa, which has worked with Mount Sinai Health system, Dignity Health and the Marshfield Clinic on similar programs. The two created a joint venture company called Home Recovery Care.
When patients come to the ED, Home Recovery Care's coordinators will screen them to see if their conditions can be treated at home and if they are Highmark's health plan member. Eligible patents may get the option to be transported home to receive inpatient care, so long as their homes are generally safe for the patient and caregiver, meaning they have central air or heat and water, for instance.
Once at home, the patients begin 30-day episodes of care. During the first few days, nurses visit the home twice a day to check vital signs, conduct basic lab tests and give infusion services, and once a day the nurse and patient check in virtually with an Allegheny Health Network hospitalist. For the rest of the period, the patient will be monitored via a telehealth kit left in the home
Contessa CEO Travis Messina said the company meets with the patient an average 27 times over the 30-day episode, either in-person, virtually or by telephone. It contracts with the health plan for 44 different conditions, including pneumonia, chronic obstructive pulmonary disease, congestive heart failure, cellulitis and diverticulitis. The medical conditions included in the program account for about 40% of hospitalizations, Messina said.
Contessa's contracts with Highmark and others are bundled-payment arrangements, in which it pockets the savings if it can deliver care below an agreed-upon amount. Messina said its program typically provides about a 15% discount on the historical cost of a 30-day episode of care for Medicare Advantage patients, and a 20% discount for commercial members.
But the cost savings are a "byproduct" of higher quality care, Messina said.
"While hospitals have a lot of great things to offer, you are susceptible to bad outcomes (there.) You are around other people who have other illnesses. You can catch infections. You avoid that when you are in the confines of your own home," he said.
Providing acute inpatient care at home aligns with the broader shift in the U.S. healthcare system toward providing more care in lower cost settings and away from expensive hospitals. Though some hospitals, such as Baltimore-based Johns Hopkins Medicine, have been delivering acute care at home for years, it's still an emerging model for most.
Some research shows that delivering care at home can produce better outcomes and save money compared to caring for a patient in a hospital.
According to a 2018 study in JAMA Internal Medicine, patients who received care from Mount Sinai Health System's hospital-at-home program had fewer readmissions and emergency department visits and reported a better patient experience than patients who stayed at the hospital. Mount Sinai tested its program as part of a demonstration under the Center for Medicare and Medicaid Innovation.
Danville, Pa.-based Geisinger executives wrote in the Harvard Business Review last week that with the hospital's Geisinger at Home program they've seen a 35% decrease in ED visits, 40% decrease in hospital admissions, and an average annual reduction in spending per patient of almost $8,000 for more than 5,000 patients enrolled in the program. The program involves delivering acute care, wound care, regular home assessments and specialty care to medically complex patients where they live.
There are clues the CMS is supportive of home-based care. Beyond its Medicare demonstration pilots, the agency this year loosened restrictions in Medicare Advantage that made it easier for plans to provide in-home supports to help with activities like bathing, dressing and cooking. It also allowed plans to pay for palliative care in the home.
Farah said his conversations with CMS Administrator Seema Verma and HHS Secretary Alex Azar in the last several months have led him to believe that the CMS will continue to provide more protections and incentives for programs like Highmark Health's.
"This type of program will expand across the country as time goes on," Farah said. "Just like anything else that's brand new it requires many things to be in place. One is to have all the required elements that are well-coordinated, and two, an incentive to make this work, and we believe that the federal government is very much supportive of such types of programs because of improved quality and lower total cost of care."