By Joseph Ebberwein, Co-Founder & CFO
No one can argue with the sobering fact that the cost of healthcare in the U.S. is not sustainable. It is a growing concern for many Americans as healthcare spending currently accounts for 17.5% of the U.S. GDP, making it the economy’s largest sector.
Care in the home is being recognized as part of the solution to this significant problem and an opportunity to reduce hospital utilization while improving clinical outcomes, reducing cost, and improving patient satisfaction. These at-home solutions must mitigate risks associated with patients with multiple comorbidities, such as the risk of development of pressure injuries, with the same rigor as the “bricks and mortar” acute care hospitals.
The adoption of home-based models of care is driven by a confluence of factors, including the aging population, the increasing cost of healthcare, and the need for better outcomes. The movement toward home-based care will profoundly affect how we deliver healthcare to patients with acute illnesses and injuries who would otherwise be treated in an emergency room or hospital, as well as patients with chronic conditions who are confined to the home.
Let’s look at the evolution of at-home models of care, including acute and longitudinal episodes, as well as specific implications for complex patients at risk for developing or having a wound that must be managed in the home.
The “Hospital at Home” model of care is not new. It has been tested by healthcare systems such as Johns Hopkins and the Veterans Administration with favorable outcomes. Johns Hopkins' first national study of the model, which was published in Annals of Internal Medicine in 2005¹, found patients treated via the Hospital at Home model had:
Better clinical outcomes
A shorter average length of stay (3.2 days versus 4.9 days)
Higher patient and family satisfaction
Fewer lab and diagnostic tests compared to similar hospitalized patients
Fewer complications associated with hospital stays, such as delirium, infections, and the need for sedative medications or physical restraints
Lower care costs by up to 30 percent compared to traditional inpatient care
During the height of the Covid-19 pandemic, hospitals utilized the CMS waiver “Hospital Without Walls” as a means to utilize staff, resources, and beds more effectively, moving infectious patients out of the hospital. Hospital at Home programs have continued to grow as a result of CMS launching its Acute Hospital Care at Home program in November of 2020, which allowed hospitals to receive Medicare reimbursement for at-home care services provided to patients for more than 60 conditions. Additionally, other models of care have emerged and continue to be tested throughout healthcare systems and payors.
The California Health Care Foundation (CHCF) published a guide, Medical Care at Home Comes of Age², detailing the emerging care at home models, the core elements of each program, and the related benefits. The guide highlights two fundamental types of home-based care models - Longitudinal and Episodic.
Longitudinal Home Based Medical Models models include - home-based primary care, home-based medical co-management, home-based integrated medical/social care, and home-based palliative care. They share the following commonalities:
Each model provides continuous care over an extended period of time.
All provide home-based care - the care team brings the care to the patient in their home.
All focus on a high-needs, high-cost patient population, from complex, multi-chronicity patients to those needing palliative care.
Use of an integrated, multidisciplinary team.
Key success metrics include a reduction in emergency room visits and hospitalizations, decreasing utilization of high-cost care settings that drive lower costs, and improved patient satisfaction.
Evidence for the majority of these models is moderate.
Reimbursement for these models ranges from traditional, fee-for-service to value-based, Medicare and Medicaid managed care.
Episodic Home-Based Care Models include Hospital at Home, Mobile Integrated Health, Rehabilitation at Home, and Transitional Care. They share the following commonalities:
Each model provides care confined to a single incidence or time-limited episode of care over days to weeks
These models focus on providing alternative care to circumvent a hospital or skilled nursing facility stay
All provide home-based, higher acuity care to the patient in their home
Use of an integrated, multidisciplinary team
Key success metrics include a reduction in emergency room visits and hospitalizations, decreasing utilization of high-cost care settings that drive lower costs, and improved patient satisfaction.
Evidence for these models is solid, ranging from strong to moderate.
None of these models is reimbursement by traditional fee for service but are operating in capitated arrangements with Medicare Advantage Plans and Medicaid HMOs.
Challenges to Home-Based Acute Care still exist to delivering home-based acute care services, which must be overcome and include:
Healthcare providers are poorly equipped with technology that enables them to monitor patients remotely in real-time.
There is no standard protocol for delivering these services, and each provider must develop its own approach based on available resources (technology) and patient needs.
Many payors do not reimburse for home monitoring even though it saves money by reducing ED utilization and hospitalizations.
Care transitions can be challenging for both patients and their families. Moving home after an acute stay can be stressful, especially if patients have significant medical needs.
Broadband access is still not accessible in many areas, which creates a barrier to care in the home related to ongoing monitoring of the patient.
How does Corstrata work with At-Home Programs?
Corstrata solves many of the issues that hospitals experience regarding wound or ostomy care in patients identified for admission to Hospital at Home. First, many hospitals are struggling with staffing registered nurses, including staffing scarce Wound and Ostomy certified nurses who educate and prepare patients with wounds and ostomies for discharge home. Discharges are often delayed because of the lack of access to a WOC nurse to develop a wound or ostomy care discharge plan with proper patient and family education to care for their condition. Additionally, access to a WOC nurse is necessary when a patient develops a new wound or their wound shows signs of decline or requires a change in the treatment plan.
Once the patient is admitted to the Hospital at Home program, it is imperative that the patient-centered plan of care includes an optimal wound care plan utilizing advanced wound dressings to expedite healing. Additionally, it is critical that wound prevention protocols are initiated to prevent pressure injuries that are reportable in outcomes such as “Hospital Acquired Pressure Injuries” (HAPIs) and applicable to Hospital at Home. Inadequate wound care can lead to complications such as infection or sepsis, requiring readmission back into the bricks-and-mortar acute care hospital.
About Corstrata - Our senior-level, wound-certified nursing staff are some of the best and most experienced in the industry. We couple their expertise with the most advanced wound dressing technology, the latest evidence-based research, and our Telehealth infrastructure to ensure that we deliver the right patient support at the greatest point of need – the bedside.
Contact Us to learn more about how Corstrata can assist you with optimizing your @Home program with our board-certified wound and ostomy nurses.
¹Leff, B., Burton, L., Mader, S. L., Naughton, B., Burl, J., Inouye, S. K., Greenough, W. B., Guido, S., Langston, C., Frick, K. D., Steinwachs, D., & Burton, J. R. (2005). Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely III older patients. Annals of Internal Medicine, 143(11). https://doi.org/10.7326/0003-4819-143-11-200512060-00008
²Medical Care at Home Comes of Age. (January 2021.). Retrieved August 16, 2022, from www.chcf.org