Home Based Primary Care's (HBPC) Hospital at Home Program

Program Brochure:
Hospital at Home Brochure

General Description:
The Southeast Louisiana Veterans Health care System (SLVHCS) Hospital at Home provides critical hospital-level care to specific hospital diagnoses amenable to treatment in the comfort of a person’s own home setting.  The hospital at home model has been utilized in Europe for several years.  In the U.S. it was developed and tested as part of a National Demonstration and Evaluation Study through Johns Hopkins School of medicine and School of Public Health, funded by the John A. Hartford Foundation and Department of Veterans Affairs, at clinical sites in Buffalo, New York, Portland, Oregon, and Worcester, Massachusetts.  Results from this U.S. study and other hospital at home programs report high patient satisfaction.  This U.S. study also showed that quality and safety standards are consistent with traditional hospital care.

In addition to staying in the comfort and familiar surroundings of one’s own home, all Southeast Louisiana veterans admitted into Hospital at Home will receive the following benefits of services:

• Daily physician oversight of all evaluations, including physician home visit(s).
• Daily registered nurse evaluations in the home.
• 24-hour telephone access to a registered nurse and physician.
• Each nurse will be limited to up to 3 patients at any time allowing for greater availability for medical needs.
• VA coverage of medical expenses
• Access to laboratory services, oxygen, IV medications, electrocardiograms in the home setting.
• Access to Lifeline services
• The option to continue receiving home care services upon discharge to assure close follow-up and access for clinical needs.

Purpose of the Southeast Louisiana Veterans Health Care Hospital at Home  Program

The overall purpose of the Hospital at Home program is to provide critical hospital services utilizing a patient-centered, interdisciplinary care model in the setting of the home, while upholding high clinical standards of care as well as high patient and provider safety. 

Hospital at Home Mission Statement

• To provide critical hospital services within the comfort of a persons’ home setting;
• To assure a patient-centered, interdisciplinary model of care-delivery, following established standards of clinical care; 
• To regard patients in Hospital at Home as equivalent to hospital inpatients, receiving the same critical elements of hospital service, including physician and nursing care, medicines, and appropriate diagnostic and therapeutic technologies.
• To recognize that Hospital at Home patients should not incur additional health-related charges related to expenses such as inpatient medications, access to inpatient consultative services for evaluation or use of hospital equipment when compared to the usual inpatient care patients.  
• To recognize that participation in Hospital at Home is voluntary – patients and their caregivers must agree to have their care provided at home; 
• To assure a safe environment for patients, caregivers, and providers. 
• To educate and instruct patient and/or caregiver on appropriate steps for care in order to assist in maintaining functional and cognitive abilities throughout the Hospital at Home admission; and
• To provide and maintain a qualified, competent staff through continuing education, membership in appropriate medical organizations, and professional certification. 
• To ease the transitions of care as patients move site to site while associated with Hospital at Home, including the hospital settings, home setting, and clinic setting

Background

Alternative models have developed over the years to reduce reliance on inpatient care due to the persistence of excess demand over supply of acute hospital beds, growing health care technology, greater emphasis on cost-containment measures to reduce hospital admission rates, and concerns that inpatient care may not always produce optimal clinical outcomes for some groups of patients – particularly the elderly.  The hospital at home model is an alternative example to reduce inpatient admissions by providing hospital-equivalent care to patients in the home-setting.  In this model, patients may typically access the hospital at home service either as an “early discharge” from a hospitalization or as a “substitutive” model in which patients are admitted directly from an emergency department, clinic, or home.   

There is a substantial amount of studied evidence on hospital at home care.  Established models for delivering hospital-level care in the home setting exist internationally, including Israel (since 1991), Australia (since 1994), the United Kingdom, and France.  The international literature suggests several positive clinical outcomes, as well as high patient satisfaction scores.  The satisfaction scores reflect the comfort of patients’ own bed and home, better sleep and food, greater peace and quiet, the support of having family and friends around them more easily, and the undivided attention of the nurse in contrast to a busy inpatient floor.  A meta-analysis involving 22 randomized, clinical trials of the hospital at home model concluded that patients who received this type of care delivery had outcomes similar to usual inpatient care.  While there is evidence that patient satisfaction is higher, the burden on family caretakers may be greater.  It should be noted, however, that this meta-analysis was hindered by the impact of small trials and wide variations in structure and choice of outcomes, causing the meta-analysis to be underpowered.  Cost-savings conducted in other studies are mixed, also reflecting the wide variation in format and outcomes studied.       

In the United States, multiple aspects of the hospital at home model have been studied by Dr. Bruce Leff, an Associate Professor and geriatrician at Johns Hopkins University School of Medicine in Baltimore, Maryland.  In 2001, he conducted a multi-site study as a national demonstration and evaluation of the clinical feasibility and efficiency of providing hospital-level care in a patient’s home, using validated illness-specific selection criteria for admission.  To be eligible, all participants were elderly (> 65 years old) with hospital admission diagnoses restricted to community-acquired pneumonia, chronic obstructive pulmonary disease, cellulitis, or congestive heart failure.  These diagnoses were selected due to their frequency of admission, relative ease in establishing the diagnoses, and relatively clear treatment protocols that were amenable to safe treatment in the home setting.  This study demonstrated that the substitutive hospital at home model met clinical processes and quality standards at rates similar to those of an acute hospital.  Length of stay was shorter; mean cost was lower.  This study also demonstrated that patients in this intervention had a lower chance of developing delirium, requiring sedatives, or needing chemical restraints.  Both patients and family members were more satisfied with care compared to those treated in the hospital. 

One of the sites participating in the above-mentioned national demonstration study was the Portland, Oregon VA Medical Center, led by Dr. Scott Mader, Director of the Rehabilitation and Long-term Care Division.  Since completion of the multi-site study, under Dr. Mader’s leadership, the program has continued in a modified form.  The illness-specific selection criteria, limiting admission to the four clinical diagnoses listed above, have continued.  However, the modified model has also expanded the age–group to all adults, expanded the admission criteria to include early hospital discharges (currently representing the majority of the admissions), reduced the minimum daily nursing visits to once per day, and the minimum physician visit to one plus daily oversight of the nursing evaluations.  Over the 19 month period subsequent to completion of the research study, 162 veterans were admitted to the Portland VAMC “Program at Home” program. 

Market Summary

During the recovery phase since Hurricane Katrina, SLVHCS successfully expanded an established ambulatory clinic system and re-established the Home-Based Primary Care Program.  The region experienced significant growth with the number of registered veterans within SLVHCS increasing 151% from approximately 11,000 in February 2006 up to approximately 27,000 in February 2007.  Across the board, all parishes in the southeast Louisiana region experienced significant growth of registered veterans.  In Orleans Parish, the number of registered veterans grew from 852 in February 2006 to 3444 in February 2007, reflecting a growth rate of 304%.    

Inpatient services for veterans are currently provided through the Tulane Hospital VIP service (starting June 2007), local non-VA hospitals and through the network of VA facilities within VISN 16.   Based on data collected by Utilization Review since January 2006, over 2000 hospitalizations were recorded in approximately 33 acute-care hospitals in southeast Louisiana.  The greatest concentration was in the New Orleans area with over 650 hospitalizations recorded during this same interval.  Prior to establishment of the Tulane VIP service for veterans, this Tulane University Hospital had the greatest number of veteran admissions with over 200 tracked.  Fee-basis costs for these hospitalizations since December 2005 through December 2006 totaled $1.8 million, averaging $140,000 per month.  Transportation costs to VISN 16 facilities from FY2005 through January 2007 totaled $370K. 

Anecdotally, veterans expressed some dissatisfaction with the current inpatient structure, citing increased personal costs from insurance coverage gaps for hospitalizations, as well as additional costs associated with time or travel to hospital facilities, particularly to facilities across VISN 16.  Additionally, the inpatient system prior to the VIP service was notable for fragmentation and inefficiency due to incomplete retrieval of hospital records from local non-VA hospitals with increased challenges from medication reconciliation, unknown diagnoses, and redundant laboratory or diagnostic testing.

Potential Benefits from the Hospital at Home Program  

Based on the current inpatient resource for veterans in SLVHCS, it is believed that the general focus and features of Hospital at Home program present many beneficial and complementary opportunities for SLVHCS by:  

• Providing patient-centered care in the least-restrictive environment for eligible veterans;
• Increasing local and VISN hospital bed capacity within an overburdened acute care system; 
• Utilizing and coordinating available resources more efficiently and effectively; and
• Enhancing the current SLVHCS clinic/outpatient health care systems by improving transitions from the hospital/ER to outpatient settings.
• In addition to the established model at the Portland VAMC, the SLVHCS program may serve as a model for the entire VA health care system

Program Description
An early-discharge model will be implemented initially for the SLVHCS Hospital at Home program.  The initial service area base will be in New Orleans, working within a a 25 mile/30 minute radius from the New Orleans clinical site of 1601 Perdido Street.  With this “early discharge” model, patients are offered the benefit of timely initial laboratory and radiology evaluations, providing appropriate assessment of the clinical risk and safety profile for treatment. 

SLVHCS Hospital at Home will be structured as follows: