Michigan Medicine expands hospital at-home program

Medicare patients seeking emergency care at Michigan Medicine's University Hospital in Ann Arbor will soon have the option of returning home instead of being hospitalized in a cutting-edge hospital at-home program.

Over the last year, doctors at Michigan Medicine have been developing various programs and alternatives to hospitalization for patients with congestive heart failure, cellulitis, chronic obstructive pulmonary disease, pneumonia or urinary tract infections, said Dr. Grace Jenq, a geriatrics specialist and associate chief clinical officer for post-acute care at Michigan Medicine.

The five health conditions were selected based on the ability to treat at home and because of the high readmission rates for the conditions, Jenq said. The program is expected to improve patient outcomes, reduce readmissions and save money, she said.

"We are developing programs where we can take patients who come to the emergency department acutely ill requiring medical attention and then provide that care — IV fluids, monitoring, nursing and physician care —in the comfort of the patient's home," Jenq said.

Earlier this year, Michigan Medicine was notified by the Centers for Medicare & Medicaid Services that they were approved to join the Acute Hospital Care at Home program for traditional Medicare participants. The first patients may be enrolled by spring.

It is believed to be the first such Medicare-approved program in Michigan, but one that many hospitals are expected to offer in the coming years as telemedicine programs and monitoring devices become more commonplace.

"The pandemic has driven the desire by patients to be at home whenever possible, and the need for hospitals to innovate in expanding our ability to care for patients with COVID-19 and those without," said Jenq. "We take great care to ensure that each patient who receives care under these programs can do so safely, and with the help of our skilled team members and partners."

It works like this. A patient is evaluated, treated and screened in the hospital emergency department for immediate care and also the hospital at-home program. If eligible, the patient will be offered remote care equipment and scheduled for home health, post-acute care visits.

Patients discharged to home are monitored by Michigan Medicine physicians, nurse practitioners, nurses, paramedics, social workers and other remote-monitoring team members.

Remote-monitoring equipment for patients includes for loan a special computer tablet for telemedicine conversations and a kit of Bluetooth home-monitoring tools that analyze blood pressure, blood-oxygen levels, weight, blood sugar, temperature and other vital signs.

Partners with Michigan Medicine include the Huron Valley Ambulance service of Emergent Health Partners, Health Recovery Solutions, TridentCare for mobile diagnostics and Advanced Medical Solutions Inc. for medical equipment.

The program also involves Michigan Medicine's Home Care Services division, including Michigan Visiting Nurses, HouseCalls and the HomeMed Infusion Pharmacy program.

After returning home, a patient would be seen and cared for by a nurse, a nurse practitioner or a physician. Laboratory tests would be drawn, their condition assessed and medication administered.

Based on the patient's status, adjustments in therapy could be made by a doctor or nurse practitioner. If necessary, the patient could receive a second nursing visit later in the day and be supported by physical therapists and home health aides. Recovery time could be three to five days, depending on the condition.

Jenq said recuperating at home is typically more restful than in the hospital. She said once patients experience care at home, they might refer friends and family, creating more demand for the model.

Steve Anderson, Blue Cross' vice president of provider contracting and network administration, told Crain's Blue Cross learned of this type of care model from a similar approach at Mount Sinai Hospital in New York.

Patients reported fewer readmissions, fewer emergency department visits and better experience, he said. "It's an innovative approach to meeting people where their needs are while being able to rest and recover in their own beds," said Anderson in a previous interview.

If the model is successful, Anderson said Blue Cross is likely to expand it to other hospitals and possibly physician organizations that contract with hospitals. "There are quite a few levels (of care) in the hospital: emergency department, observation, swing beds in smaller hospitals, medical and ICU," Anderson said. "We asked UM to evaluate this and they were quite enamored with it."

Michigan Medicine already has three other smaller hospital at-home programs underway.

Last fall, Michigan Medicine began offering an at-home program for COVID-19 patients who have been hospitalized. Some 43 patients with COVID-19 have recovered at home with the university's post-acute care team and another 35 are active in the program, Jenq said.

"In just our first months of using this program, we've had many saves where patients received needed adjustments to their medications, or scheduled for diagnostic tests," Jenq said.

Another pilot program funded by Blue Cross Blue Shield of Michigan offers Washtenaw County patients who qualify for an inpatient stay but can be transitioned directly to home participation in the at-home program. Eligible patients include those with some commercial and Medicare Advantage Blue Cross plans.

"We started the commercial program with Blue Cross back in July, but we actually struggled quite a bit because what we found is that the commercial patients are a younger population who don't have these illnesses like congestive heart failure, skin infections, kidney injury, and urinary tract infections," Jenq said. "It was actually quite difficult to find eligible patients for the program."

One Blue Cross commercial patient treated was in his mid-50s and had a case of complicated diverticulitis, Jenq said.

"All he needed was a day or two of IV antibiotics. He received that at home via our nursing staff and the community paramedics, and then we transitioned to oral medications. And he did well," she said.

Last December, Michigan Medicine and Blue Cross opened up the at-home program to Medicare Advantage patients, Jenq said.

"We're still trying to work out (the details of the program) and enrolling patients in Medicare Advantage, but we believe for patients with heart failure and infections are dehydrated need some fluids, we can help them," Jenq said.

While not all Medicare patients will qualify, Jenq said a subset of patients with multiple chronic conditions, who have probably had experiences in the hospital for a flareup of one of their illnesses, can be enrolled, Jenq said.

On average, Michigan Medicine admits eight to 10 Medicare patients from Washtenaw County every day.

"Of those eight to 10 patients, probably one or two are eligible for the program," Jenq said. "That means that they have an acute illness, that we think that we can safely provide care in the home, meaning that all they really need is some IV fluids, IV medications like antibiotics or a diuretic to help get water off."

Jenq said some patients will decline because they might feel more comfortable in a hospital bed.

"There are other patients who have experienced the hospital before, and may be more reluctant to go," Jenq said. "They may say, 'I don't really want to have to go into the hospital where I don't get to see my family, I don't get to be in my home. If you can bring me the medications and the nursing and the doctors out to my home, come to my house,'" Jenq said.

Earlier in 2020, when the COVID-19 pandemic was just striking, Michigan Medicine began a telemedicine program called Patient Monitoring at Home, which has helped hundreds of patients with a wide range of conditions, officials said.

It was funded by the Federal Communications Commission's COVID-19 Telehealth Program. More than 100 patients are enrolled at any given time.