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When Randy Gibson landed in Tampa General Hospital last year with sepsis and an E. coli liver infection, his doctors gave him a choice: He could remain in the hospital to get treated, or he could receive treatment at home. Gibson opted to go home.

“They were talking at first like I was going to have to stay in the hospital quite awhile, and I was really not wanting to stay in the hospital. It’s just a place you don’t want to be,” says Gibson, who is 79 and lives about 15 miles away from TGH in Riverview. “They came to the house. They took care of me like I was their private patient or something. It just really felt good.”

TGH, which launched its TGH At Home program last July, uses a combination of technology and house calls — a nurse and a doctor visit at least twice a day — to provide in-home acute care to patients.

A small FDA-approved electronic chest sensor, manufactured by Biobeat, continuously monitors a patient’s heart rate, blood pressure, temperature and oxygen levels. The data is streamed via an iPad to the TGH At Home team. The patient can also use the iPad for telehealth appointments with TGH providers.

To help bridge the physical gap, TGH uses digital stethoscopes and other devices from a company called TytoCare to enable remote examinations. Patients who live alone or have a high risk of falling can wear a 4G watch. If they run into trouble, they tap a button on the watch and are immediately connected to their care team.

“We’ve built the program around patient safety. I think that’s always at the top of our mind,” says physician Peter Chang, who is leading the program at Tampa General as part of his role as the hospital’s vice president of health care design. “These are patients that meet acute patient care criteria. They’re sick. We want to make sure the standards for monitoring and touch-in with patients is high.”

TGH isn’t the only Florida hospital changing where it cares for patients. Half a dozen hospitals or hospital systems across the state have signed up with the Centers for Medicare and Medicaid Services (CMS) for waivers to provide acute hospital services at patients’ homes.

Mayo Clinic was the first hospital in the state to operate an acute care-at-home program. “We were planning it in 2019 with an opening in 2020,” says Michael Maniaci, an internist at Mayo Clinic in Florida and physician leader of the hospital’s Advanced Care at Home program. It turned out to be perfect timing. As the COVID-19 pandemic pushed hospitals to the brink, federal health authorities enacted an emergency initiative, allowing Medicare-certified hospitals to treat certain patients with common acute conditions in their homes and get reimbursed at the normal in-patient rate. The waiver also removed certain patient care standards for in-home care, including suspending a requirement that an RN be present in the home at all times.

Today, Mayo operates a 5,000-sq.-ft. command center on its Jacksonville campus from which it oversees care for about 25 to 30 hospital- at-home patients in four states — Florida, Wisconsin, Arizona and Minnesota — on any given day. By the end of the year, Mayo expects to handle 60 to 70 patients a day, and it’s aiming to ramp up to more than 100 by 2024.

At the start of the program, Mayo limited the program to patients with infections, chronic obstructive pulmonary disease (COPD), heart failure and asthma flare-ups. As time went on, it expanded the program to include certain patients recovering from surgery and patients receiving bone marrow transplants.

The typical autologous bone marrow transplant (which uses stem cells from the patient’s own body) usually requires a two-to-four week hospital stay, with patients spending most of that time in their room. Now, patients can return home the day after their transplant — receiving their antibiotics, IV fluids and blood draws at home and only returning to the hospital if they need a blood transfusion or other more advanced care. The patients “like it much more than being stuck in the hospital,” Maniaci says, and it lowers their risk of getting an infection at the hospital.

Patients receiving care at home tend to remain more mobile — whether from getting up to go the bathroom or going to the kitchen to make a meal. As a result, they tend not to need the extra rehab that many patients require after a hospitalization.

Health First, Brevard County’s largest health care system, has handled more than 415 patients through its Health First At Home Inpatient Services program, which launched in 2021. None has ended up with a hospital-acquired infection. While 10% of patients have to be transferred to a Health First hospital (either because their conditions worsened or they needed services that couldn’t be provided at home), the 30-day re-admission rate for Health First’s at-home patients is 8.5% — versus 13% for those receiving in-hospital care. “I think our results, basically, are spectacular,” says Mark Rosenbloom, Health First’s vice president of clinical transformation.

TGH’s Chang says psychological benefits of at-home care are also important. “It really rang true for me when one of my patients who was admitted two days before Christmas was transferred home for the remainder of their care,” Chang recalls. “Arriving at their home in the morning to see them in a hospital bed, but at home, getting IV antibiotics, opening presents with their grandchildren around them — it really meant to me the most important component of this program, which is that emotional connection patients continue to have with their loved ones and their pets and their home environment.”

The economics of hospital-at-home programs also make sense. Studies suggest it’s approximately 30% less expensive to treat patients at home, and early adopters are already reporting savings. Joe Lavelle, Health First’s vice president for hospital-based providers, says Health First came close to breaking even on its at-home hospital program by the end of its first full year of operations last year despite startup costs and lower patient volumes. During the first four months of 2023, Lavelle says, the operating margin for at-home patients exceeded that of patients treated in the hospital with the same diagnosis.

Lavelle, who heads Health First’s at-home care unit, says at-home patients tend to have a shorter length of stay, which lowers costs. Studies have shown they also tend to undergo fewer tests and received fewer consultations than they would in the hospital, which also drives down the price of care. The savings are even more substantial considering the growing elderly population and shortage of hospital beds. “Even if we wanted to treat them all in the hospital, we couldn’t,” says Mayo’s Maniaci. “We’d have to build a zillion buildings, which we don’t have the money for. Nobody does.”

Challenges

While hospitals are reimbursed for hospital-at-home care by Medicare and Medicare Advantage plans offered by private companies, most private insurers don’t pay for at-home hospital care yet. Some physicians have also been reluctant to jump on board, citing a lack of data on outcomes and potential liability concerns. The logistics of in-home hospital care are also complex, requiring on-demand supply chains that can provide medication, medical equipment, meals and the appropriate clinical personnel directly to a patient’s home.

Congressional Action

The omnibus spending bill passed by Congress in December extended Medicare’s acute hospital care-at-home waiver initiative through the end of 2024. The bill also directed the Secretary of Health and Human Services to conduct and issue a report on the quality of care, health outcomes and comparative costs of such programs.

Home Economics

The hospital-at-home movement dates to the 1990s, when Johns Hopkins geriatrician Bruce Leff spearheaded a pilot program to treat acutely ill older adults in their homes. Leff and his colleagues found that their outcomes were comparable to those of patients treated in the hospital, the cost of the care was less and patients were “highly satisfied” with the arrangement. The model spread during the COVID-19 pandemic, as telehealth and hybrid-care models expanded to enhance hospital capacity. Following is a snapshot of what’s happening around the state:

• Cleveland Clinic began piloting an acute, hospital care-at-home program this month in Florida in collaboration with Medically Home Group, a Boston-based company that helps hospitals build and deliver in-home care. Richard Rothman, regional chief of medical operations for Cleveland Clinic Florida, says it plans to start slowly. Patient outcomes over the next six to 12 months will determine whether the approach is sustainable and scalable. “We’ve only put, across the country, 15,000 to 20,000 patients in this acute hospital care-at-home model. That’s a drop in the bucket. We have to better understand the outcomes of our patients before we say, yes, this is the right way to deliver care tomorrow,” Rothman says.
• Tampa General Hospital is taking care of two to five patients at any one time through its TGH at Home program. It aims to expand to 50 patients, making it roughly the size of an in-patient unit at the hospital, and eventually grow capacity to the size of a small community hospital. “What we’ve done is really drive down the cost of care because we don’t have to invest in building a brick-and-mortar hospital,” says Peter Chang, vice president of health care design at Tampa General.
• Health First, Brevard County’s largest health care system, launched its home-based hospital care program in 2021 and will handle about 500 patients this year. “I really believe this will become how we deliver care in the future, and there are estimates varying anywhere from 10% to 30% of what we do in hospitals could move to the home,” says Mark Rosenbloom, Health First’s vice president of clinical transformation.
• Orlando Health, a 3,238-bed system in Central Florida that includes 23 hospitals and emergency departments, launched a Hospital Care at Home program in February. The program serves certain patients with medical conditions, such as cellulitis, COPD, asthma, urinary tract infections, heart failure, COVID-19, pneumonia and gastroenteritis. Patients must live within a 25-mile radius of an Orlando Health facility that participates in the program.
• Mayo Clinic, which started the state’s first hospital-at-home program in 2020, is considering a STAT Care at Home program that would function like an emergency department, with doctors assessing patients through virtual house calls and paramedics making house calls to help determine next steps, such as a hospital admission. Mayo is also working on extending cancer care services beyond traditional hospital and clinic settings with a new Cancer Care Beyond Walls program. “You can really take care of people — all those lab visits and doctors’ visits — at home. Let the visit come virtually. Let the chemotherapy come to you,” says Michael Maniaci, physician leader of the hospital’s advanced care-at-home program. “We’re looking at the people who suffer the most, who have to travel the most, who get stuck the most, and how do we make their lives better and give them the care they need? That’s what we’re doing next.”

Tags: Healthcare, Feature, Health Care Landscape