Mount Sinai Home Hospital Program

summary

The home care delivery model treats patients where they live instead of hospitalizing them. These programs, which support patients with acute illnesses such as pneumonia, cellulitis, and exacerbations of congestive heart failure and chronic obstructive pulmonary disease, are among the most studied innovations in healthcare. This research has shown variable but clearly positive impacts on mortality, clinical outcomes, readmission rates and costs. However, the establishment and operation of home hospital initiatives is complex. This article details Mount. Sinai program and addresses the main challenges facing organizations, especially regulatory barriers and reimbursement.

Since the first pilot tests of the model of home hospitalization in the United States more than 20 years ago, the promise of treating patients where they live instead of hospitalizing them has caused the attractiveness of providers health care.

These programs, which support patients with acute illnesses such as pneumonia, cellulitis and exacerbations of congestive heart failure and chronic obstructive pulmonary disease (COPD), are among the most studied health care innovations. . This research has shown variable but clearly positive impacts on mortality, clinical outcomes, readmission rates and costs. A 2012 meta-analysis of 61 randomized controlled trials, for example, found that the six-month mortality rate for home-stay patients was 19% lower than that of hospitalized patients. Another review found that the rate had been reduced by 38%. Caregivers and patients themselves also give high marks to the home hospital. But despite the excitement of these programs, they took a long time to take off in the United States. At Mount Sinai Health System in New York, our experience is a good example.

For a long time, we have been aiming to take the lead in dealing with the major trends in the health care industry by focusing less on hospital stays than on preventive care, outpatient care and home care. To support these goals, in 2014 we launched the Mobile Acute Care Team (MACT), a pilot program for the delivery of seriously ill patient care that replicates the services they would have received at the hospital. , at their home. He has treated more than 750 patients and is now the heart of a new range of services called Mount Sinai at Home, which also offers rehabilitation, observation and primary care home services.

Insight Center

Mount Sinai at Home differs from home health care, the most common and common offering, which most often describes a visiting nurse service offering non-acute treatments such as wound care and care management chronic.. In our program, we treat critically ill patients who would otherwise require hospitalization, providing them with a suite of integrated services that may include daily visits by nurses, doctors, and social workers; IV support; oxygen; X-rays; and physical therapy. Our research found that patients receiving in-home care had fewer complications and readmissions; they also place greater importance on their experience in health care.

Our protocols allow us to provide safe in-home hospital care for a range of specific conditions, including community-acquired pneumonia, congestive heart failure, COPD, cellulitis and dehydration. Patients are referred to the program by their primary care physician or enrolled after visiting the emergency department. Once at home, they receive a combination of in-person visits, video tours and surveillance. One of the first steps is to have a nurse visit the patient at home and set up a tablet with a connected blood pressure monitor, allowing the patient to send a blood pressure reading while talking to the patient at a distance. 'nurse. However, in-home care of acute care patients requires the availability of 24-hour services. We have doctors available 24 hours a day, and we work closely with community paramedics whom we can dispatch. at the patient's home at any time. Let's say it's 2 am and a patient is not feeling well. We immediately send a paramedic who can establish a video link with a doctor in accordance with the laws on the protection of patient privacy; then, in consultation with the doctor, the paramedic provides the treatment or, if necessary, transports the patient to the hospital.

Take on the challenge

Designing and managing a home hospitalization program is not easy. How do you bill for care and get reimbursed? How do you evaluate your initiative? How do you approach regulatory barriers? For example, in the state of New York where we are located, home nursing visits are regulated separately from hospitals, so we have partnered with a home health agency for our nursing services.

Other challenges include providing the right services to the right patient at the right time. For example, we had trouble supplying oxygen. Here in New York, you can get pizzas and Chinese food at midnight, but you can not get oxygen outside of office hours. So we asked our suppliers to rethink their delivery model.

Each health system will encounter its own set of obstacles, depending largely on the system structure and regulatory context of the state in which it operates. But everyone also brings their own strengths. In our case, for example, Mount Sinai's traveling doctors program, created in 1995 to provide care for frail, elderly, and sick adults (now part of Mount Sinai at home), helped pave the way. Other institutions might have different assets on which they could play. For example, some hospitals already have their own home health care agencies; we do not have it.

The main challenge in setting up a home hospital program that we all face in the United States is financial. The American health care system is simply not capable of designing a payment model for an entirely new mode of care. Abroad, home hospitals are much more common: Australia, Israel and Italy, in particular, have strong programs. But these countries have single-payer systems, in which an agency or ministry pays for most, if not all, health care.

In the United States, the Home Hospitals model has been used most effectively in the Veterans Affairs network, essentially a single payer system for its population. Health systems involving hospitals and insurance plans would have the same opportunities. But those, like us, who must not take another path. For example, to allow private insurance companies to pay for home hospitalization, we formed a joint venture with Contessa Health to facilitate the development of contracts with health plans and other payers.

Medicare is the biggest barrier to payments. Although our program is not exclusively geriatric, many of the illnesses we can take care of, such as pneumonia, are more likely to result in hospitalization for older patients, and Medicare would count for the majority of patients eligible for hospitalization in Canada. home.

The launch of our mobile acute care team was a direct result of a $ 9.6 million grant we received as a health care innovation award from the University of Ottawa. Medicare's lead agency, the Centers for Medicare and Medicaid Services (CMS). Subsequently, we proposed a payment system for Medicare in home hospitals. In September 2017, our payment model was approved by the Medicare Physician-Led Payment Model Technical Advisory Committee, which recommends payment models to CMS. But CMS itself has not yet acted on this proposal.

We have seen tremendous benefits in providing patient-centered home care for critically ill patients. Mount Sinai at Home is the cornerstone of our commitment to the health of the population and our ability to meet the needs of the people. This is the kind of medical care we think is needed in the next century. We hope CMS will agree and establish a way for the US health system to expand these programs nationally.