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The American Journal of Managed Care October 2015
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Scalable Hospital at Home With Virtual Physician Visits: Pilot Study
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Scalable Hospital at Home With Virtual Physician Visits: Pilot Study

Wm. Thomas Summerfelt, PhD; Suela Sulo, PhD; Adriane Robinson, RN; David Chess, MD; and Kate Catanzano, ACNP-BC
Results suggest that this scalable model of Hospital at Home is safe, feasible, highly satisfactory, and may be associated with substantial reductions in hospital readmissions.
ABSTRACT

Objectives: To evaluate the safety, feasibility, and efficacy of a substitutive Hospital at Home (HaH) model where physician care was provided via 2-way biometrically enhanced tele-video for a 34-day care episode. 

Study Design: Prospective, nonrandomized, quasi-experiment. 

Methods: Using medical record and patient survey data, we compared patients cared for in HaH (n = 50) versus the traditional acute care hospital (n = 52). 

Results: Patients in HaH had substantial contact with the HaH physician, as well as in-person visits with nurse practitioners and other care providers. HaH patients were more satisfied with their care in multiple domains and met illness-specific quality standards at similar rates to hospital comparison patients. Functional outcomes were notable for a trend toward improvements in activities of daily living among HaH patients. Compared with hospital patients at 90 days after discharge, HaH patients were less likely to experience a hospital readmission (adjusted odds ratio, 0.39; 95% CI, 0.21-0.72). 

Conclusions: This pilot study suggests that a scalable substitutive model of HaH using biometrically enhanced 2-way tele-video, virtual physician visits, and caring for patients over a 34-day episode is safe, feasible, highly satisfactory, and may be associated with substantial reductions in hospital readmissions.
 
Am J Manag Care. 2015;21(10):675-684
Take-Away Points
 
  • Hospital at Home (HaH) provides acute, hospital-level care at home as a substitute for hospital admission. 
  • Despite a robust underlying evidence base, widespread implementation of HaH has been limited by scalability issues. 
  • This study tested the safety, feasibility, and efficacy of a scalable HaH that provided physician care via 2-way biometrically enhanced tele-video and cared for patients for a 34-day episode. 
  • This scalable model was safe and efficacious. Compared with hospitalized patients, HaH patients had better satisfaction and lower readmission rates at 90 days.
Hospital care is not only expensive, but can be unsafe for patients with iatrogenic complications, with adverse events being common.1-5 Previous literature has found that the Hospital at Home (HaH) model provides hospital-level care in the home as a substitute for acute hospital admission (substitutive HaH), and when compared with usual hospital care, is associated with better outcomes in multiple domains.6-13 Further, a meta-analysis of randomized, controlled trials of substitutive HaH use demonstrates a 38% reduction in mortality compared with usual hospital care.14
 
Scaling and implementing HaH on a widespread basis is a challenge.15 HaH was implemented widely in Victoria State, Australia, where it provides a volume of services equivalent to a 500-bed hospital.16 In the United States, the Johns Hopkins Hospital at Home has been implemented in several Veterans Affairs hospitals and an integrated delivery system17-19; however, widespread implementation has been limited by payment, attitudinal, and scalability issues. Widely adopted, HaH could make a significant contribution toward achieving the Triple Aim for healthcare: better patient outcomes,  a better system of service delivery, and lower costs.
 
Models of substitutive HaH that provide substantial physician care do so in the form of in-home physician visits. Methods to deliver the physician component of HaH care in a scalable manner could improve the ability to widely implement HaH. High-quality, 2-way, real-time, biometrically enhanced tele-video capabilities now allow for in-home evaluation of patients via a virtual physician. The goal of this paper is to evaluate the safety, feasibility, and efficacy of a scalable, substitutive HaH model that followed patients for 34 days and used virtual physician visits, and remote biometric monitoring.

METHODS
Patients
The target sample was English-speaking, community-dwelling adults 18 years and older, living in a specific geographic catchment area, who required acute hospital admission for 1 of the target conditions and who met clinical and social stability criteria, which were based on previously validated Hospital at Home medical eligibility criteria.20 The target conditions were exacerbation of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), deep vein thrombosis (DVT), asthma, or community-acquired pneumonia. The most common reasons for medical ineligibility were severe hypoxemia, active cardiac ischemia, uncontrolled arrhythmia, end-stage cancer, or other conditions that required intubation or extreme interventions. The most common social stability ineligibility criteria were impaired cognitive and ambulatory status and inadequate support care at home.
 
Study Site
The study was conducted at Advocate Christ Medical Center, a 695-bed community-based tertiary hospital in Oak Lawn, Illinois. It is part of the Advocate Health Care system, which is Illinois’ largest healthcare provider and includes 12 acute care hospitals and over 250 sites of care.
 
Study Design
The study was a prospective, quasi-experiment. Treatment group patients were recruited between February and October of 2010. Patients meeting HaH admission criteria were identified in the emergency department (ED) or observation unit Monday through Friday. An independent physician, who was blind to group assignment, assessed all patients to validate that they would have required acute hospital admission in the absence of HaH.
 
Comparison patients were recruited between July 2010 and January 2011. These patients met HaH eligibility requirements, but were admitted to the hospital at times when HaH was not accepting patients (ie, outside of HaH hours or beyond the HaH recruitment period). In order to assure that the groups were as equivalent as possible, an independent physician also assessed all comparison cases to ensure they would have met HaH eligibility, as described by Leff et al,20 had the program been open for recruitment during their contact with the hospital. 
 


 
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