Over the next two decades, the adult demographic over 50 years of age will increase by 25 million, and with over 75% expressing a strong desire to age in place, it’s imperative to champion care models that support safe, high-quality care within the home. Despite proactive care models to support aging in the home, acute needs still arise.
Health systems stand to gain manifold by embracing the paradigm shift to care in the home. By moving more advanced care delivery into peoples’ homes, systems can effectively curb acute healthcare utilization, decreasing hospital-acquired conditions and drastically improving patient and family experience. When avoiding the hospital is not possible, substantially shortening inpatient length of stay to the point of stabilization and providing people with a soft landing at home significantly reduces 30-day readmissions and provides an unparalleled transition experience. Supporting the transition home with advanced in-home therapies, proactive in-home transitional care, and continued telehealth support until the primary care system can re-engage the patient will improve outcomes.
Embracing these in-home advanced care models opens bed capacity, both through hospital avoidance and length of stay reduction. This capacity can be used to cater to new, potentially more critical or high-acuity patients. Additionally, the quality of inpatient care is improved as patients no longer endure prolonged wait times to be seen or boarding time awaiting an inpatient bed.
Patients and their families win as we transition more acute care into the home. Health systems do as well through increases in bed capacity, which avoids acute hospital care altogether, reductions in length of stay, reduced readmission rates, and improved patient outcomes and experience.
Hospital bed capacity
Hospitals have three main ways to free up bed capacity: one, avoid lower acuity observation and inpatient admissions; two, significantly reduce the length of stay; and three, the most expensive, build more capacity.
Hospitals can partner with providers to proactively identify symptomatic people who can be cared for in the home, especially patients who have a 33% chance or higher of being admitted. In a recent case study with a New York City-based PACE program, of the 416 high-acuity patients with acute symptoms seen by an in-home acute care team, 91% were treated and successfully kept at home for the following seven days. Of the remaining, 4% were seen in the ED and discharged, and 5% were placed in observation or admitted. Conversely, the case study found that if the in-home acute care team had not seen those 416 patients, 68% would have had an ED discharge, and 32% would have been placed in observation, equating to $2.7M in projected savings.
In addition to diverting patients, hospitals can free up bed capacity by decreasing the length of stay. The average length of stay in the US remains steady at 4.5 days. Yet, for elderly, medically complex patients, this average is increased by 1.5 days, adding nearly $3,000 per day.
The past 10 years have focused on throughput, discharge rounds and early discharge planning initiation. In many cases, this has had a modest impact on length of stay. Assuming 1 in 4 patients could be discharged home 1-2 days earlier, an average 400-bed hospital (50% medical beds) could admit an additional 766 more high-acuity patients annually. Further, once those patients are supported in an integrated model, their risk of readmission decreases significantly.
Another way hospitals can win by focusing on in-home acute care is by significantly reducing readmission rates. In the United States, over $52 billion per year is spent caring for patients with 30-day readmissions, with hospitals now facing readmission penalties and claims rejections. Home-based acute care providers focusing on the highest readmission risk are essential to significantly impacting this systematic problem.
Finally, early acute care-at-home studies show that patients experience better outcomes when they receive treatment or recover from a previous hospitalization at home. At-home care empowers patient decision-making and incorporates more goals-of-care discussions. It also provides control over the patient’s environment and ensures that patients continue participating in things that bring them joy, purpose, and connection.
Finding the right in-home care model and partner
For health systems looking for an in-home acute care partner, I can’t overstate the importance of finding a partner that aligns its payment model with its outcomes. In layman’s terms, this is equivalent to a “money-back guarantee,” meaning the risk is eliminated because the service provider sets a predetermined rate. That fee is waived if a patient is readmitted within the agreed-to timeframe.
In addition, I believe that acute care models should be able to provide in-home services for high-acuity symptoms within 90 minutes. This is important because patients and caregivers otherwise get nervous and call 911. Finally, you should test the care model and ensure that it can easily integrate with your own teams and be seen as an extension of your care team in the home. Acute care models that market directly to patients do not support the patient-clinician relationship and will, ultimately, cause physician abrasion and more discontinuity, precisely what our most complex patients need least.
In-home acute care represents a paradigm shift and a big opportunity for health systems and hospitals. Those who choose to lean in early and embrace this opportunity will add bed capacity for complex medical and surgical patients, avoid expensive capital investments, reduce hospital and complications, and save money due to a dramatic reduction in readmissions.
Marcy Carty, MD, MPH, is president and chief medical officer at myLaurel.
