Assoc. Prof Michael Montalto  -  21 August 2024

International Home Hospital Fellowship

Ariadne Labs is a joint venture institute between Harvard School of Public Health and Brigham and Women’s Hospital, part of the Massachusetts General Brigham Hospital Partners (MGB hereafter) in Boston. Ariadne was created by Dr Atul Gawande to focus attention on several priorities including developing and testing methods of disseminating good practice, such as the pre-surgical checklist which he pioneered, and identifying gaps in health service provision. Its scope is wide, and includes areas such as international maternal and child health to Home Hospital (HH) at Home. I was associated with Ariadne as the International HH Fellow from September 2023 for a year.

Dr. David Levine is among the most active researchers and authors in HH at present, and he is the leader of the HH stream at Ariadne and is a senior clinician at MGB HH. In May and June this year I visited Boston to undertake a face to face visit at Ariadne and the MGB Home Hospital. This allowed me insight into the current clinical and organisational development of the MGB Home Hospital through direct observation of its clinical work and meetings with its leadership group. I also involved myself in the academic work of Ariadne through its Home Hospital (HH) stream. Finally, I was a guest presenter and delegate for the Home Hospital Leadership Conference organised by ICD Conferences in Boston on 6-7 June, where over 150 delegates from around the US attended to discuss the progress in developing HH.

It is important for Hospital in the Home clinicians, academics and policy analysts to gain a deeper understanding of the US HH system as a way of interpreting the research work that will soon dominate the HH literature. That research will need to be interpreted based on the understanding of the nuances of US HH practice, organisation and funding.

The following discussion paper draws from the major observations of the Fellowship visit.

 

 

Funding

Home Hospital (HH) in the United States is a smouldering rocket on a launch pad with a countdown in progress. That countdown is the expectation around the extension of the CMS (Centers for Medicare and Medicaid Services) waiver for another 5 years, which will extend the HH reimbursement policy of equivalent inpatient funding for Medicare patients in the United States. That decision is due in November this year. A waiver has been in place since late 2020, but extensions have been short term until now. A 5 year extension will deliver a signal to the hospital provider market that Home Hospital will become a semi-permanent feature of the mainstream hospital funding mix. This may finally generate the type of interest and investment in HH that until now has been localised and niche.

Some of the broader clinical and policy questions around HH are raised in the Medpac paper released just after my return. Medpac is the clinical advisory arm of the CMS.

The major HH providers in the US are MGB, UMass, Mayo, and Atrium, Kaiser Permanente, and Cleveland Clinic. The first two are Boston based.

CMS only funds Medicare recipients. Medicaid is State funded, and adoption of HH has been variable among the individual states, so not all Medicaid recipients have had access to HH. States also administer hospital registration laws and regulations, and some regulations need to be modified to allow HH to happen – this has not happened in every US state. States that have implemented HH are, however, so far impressed with HH on the basis of much higher patient satisfaction as reflected in no complaints to State authorities - this is notable for its rarity. This State based recognition and approval may be one reason that Massachusetts hospitals are further advanced than other hospital systems.

The private funds are all separate and negotiate with hospitals separately. However, CMS approval and Medicare funding has great influence in the way hospital services are funded privately. It would be reasonable to expect universal private coverage for HH once CMS approves HH, albeit at different negotiated rates.

Most hospital systems in the US are private (either for-profit or not-for-profit). Most hospital businesses involve conglomerates of hospitals called health systems.

 

 

Current Regulations around the Waiver

The rules around the waiver dictates much of the organisation of HH in the US.

All HH patients must present to the hospital first, either the Emergency or the wards. This is a regulation within the waiver, and designed as a mechanism to reduce inappropriate admissions. It reflects the policy concern that direct referrals to HH may result in lowering of admission thresholds. The CMS is very sensitive to the fear that HH will expand inpatient activity inappropriately. Unfortunately, this means direct referrals from primary care, or specialists’ rooms cannot occur. It also means that direct admissions into HH from nursing home residents cannot occur. This is despite the fact that in the US, like Australia, there is significant morbidity and hospital admissions among this group. Similar to Australia, there is a 30 day bed hold for nursing home residents who transfer to inpatient services. While a strong percentage of HH patients are admitted directly from ER, the majority come from the wards.

Another quirk of the US system is the differentiation between Observation status and formal Admission. Some patients can be physically entered into hospital from ED to receive intravenous therapy for a variety of conditions, but because of the patients’ otherwise stable condition or expected short length of stay they are given Observation status for which a lower level of reimbursement occurs. The Observation tag seems a misnomer as the patients are receiving active medical treatment. In many cases, this group is suitable for HH. This status can be upgraded, seemingly automatically, if they need to stay more than 48 hours. So, at present, Observation patients cannot be directly admitted into HH from ED, but can be transferred into HH if their stay extends beyond 48 hours.

There are more objective clinical admission criteria established by insurers and Medicare for admission into hospital (or HH) from ED, for all patients, than in Australia. While I always understood this, I believed these were transparent and known to clinicians, but this is not always the case. The admission is thus applied for and either accepted or denied. These objective admission criteria must still be fulfilled prior to any transfer to HH. This assists in the clarifying the role of HH as a strict substitution of acute hospital admissions. The process diminishes the ability of hospital providers (as can occur in Australia for example), to modify admission thresholds to suit HH activity targets.

The waiver also sets certain minimum inputs by providers to HH patients: these include 2 physical nursing visits each day; one physician face to face contact at home within 24 hours of referral; a physician contact each day (which may be virtual); 24 hour cover with a pre-defined 30 minute response time in the event of unforeseen emergencies; all personal care that is required; meals if required; and the supply of all medication (including all regular and new oral medication which must be ordered and dispensed by the hospital). Most impressive in the MGB HH system is the access to personal carers: HH can (and do) rapidly access personal carers for up to 24 hours to support elderly patients and their families.

Inpatient medical records are maintained, but most hospitals use EMR (EPIC in MGB) and data are entered into those systems by staff. Drugs are ordered electronically and dispensed via that system. I noted a current problem with the ordering and dispensing of oral narcotic: this has proved a barrier to managing some HH conditions, although some systems have worked around the problem.

 

 

Hospitals

Since Covid, many urban US hospital systems are experiencing bed access pressures similar to Australia. Boarding in ED, while a new experience in the US, is now commonplace and a major concern. The other major problem since Covid is staffing which is extremely difficult: nurses and physicians, in particular, are in very short supply.

While the recurrent operational cost of HH is significant, and not much less than traditional BAM care, and a slightly longer length of stay is also noted in practice (reflecting the research), there are 2 significant efficiencies that still attract hospital systems:

1. Given the above described problem with bed capacity with boarding problems in ED, HH can be a solution to expand their inpatient bed base with much reduced capital costs and
2. The lower rate of 30 day readmissions post-discharge from HH which has been described in research has also been confirmed in practice. This avoids significant penalties to hospitals and results in significant cost savings to providers and the health system in general

Around 300 hospitals have been approved to deliver HH in the USA under the waiver requirements, but only just over 120 have actually established HH programs. Those 120 are not typical: they are, in general, much larger urban academic not-for-profit hospital systems, some of which had existing small programs before the waiver. For example, there are only 6 hospital systems in the entire New York state providing HH. Only 2% of the active HH programs are in for-profit hospital systems, which is much lower than the representative national level. Of those hospitals with active HH programs, only 5 have reached a daily census above 20 patients. Of the most active hospital systems in HH, 2 were in Massachusetts: Massachusetts General Brigham which deliver HH across the 5 campuses of their system, and University of Massachusetts Hospital which has 4 campuses.

Both these systems have invested heavily in capital, operating budget, and executive commitment to the development and expansion of HH. In particular MGB is investing with an aim to create a 200 bed HH within its 3000-bed system.

Most HH is provided by the health systems themselves. In some cases, they partner with outside providers – the range of involvement varies from implementation and operational advice only, or for certain components of care, and in a few instances they outsource the HH completely. Again, it should be noted that very few systems are delivering HH services at any scale so far. The 2 systems referenced earlier, MGB and UMass both provide the HH service internally. They both have committed senior executive and physician involvement in HH.

Thus progress so far in scaling HH programs has been slow: after initial enthusiasm, the reality that HH is actually a difficult cultural, clinical, logistic, and financial intervention is being understood. Dissemination and growth require more effort and time than originally thought, even with adequate funding.

I note anecdotally that Medically Home, an early mover and major third-party provider of HH services to US hospital systems, has recently undergone a reduction in size and staffing, This is presumably due to pressure on slow progress to achieving scale into HH.

While there is obvious caution among health system and hospital providers, there is still serious thought being given to introducing HH. It is also clear that, when they occur, the efforts are likely to be at a much higher level of investment and commitment than Australia’s.

Some health systems have indeed agreed to accept HH patients even if not funded in order to assist with bed access and to improve the general awareness of HH. This is referred to as “Payor Agnostic”, and is designed to increase exposure of HH within hospital systems, and also reflects the premium hospitals place on clearing backlogs of patients.

On the other hand, rural hospitals, and hospitals without bed pressures will still be concerned with filling BAM hospital beds and HH is less likely to be adopted by them, unless there are trade-offs. Rural hospitals faced with closure, for example, may turn to HH as a way of retaining local acute health services. Whether they are cost efficient is currently the focus of an RCT by Dr Levine at Ariadne.

 

 

Observing MGB Home Hospital

The MGB Home Hospital (HH) is the best resourced HH system I have ever seen. It has grown significantly from a service initiated in a pilot RCT to a functioning service within a major US hospital system.

The following observations are based on my visits during May-June 2024, and set in the context of my knowledge of systems in Australia and around the world. I note that the census was relatively low during my stay, which I have ignored. Peaks and troughs are normal, and there’s nothing like a visitor to decrease the census.

In general terms, the patients treated in the MGB HH service meet the criteria for acute substitution that is at the core of the HH definition. MGB should be congratulated for keeping to both the spirit and the letter of the regulations around HH applicability. At the patient level, the interventions were familiar.

Australia does not have advanced practice providers (APPs) which include physician assistants (PAs) and nurse practitioners as APPs in the system.

Australian hospitals also do not have objective inpatient admission criteria applied by funders.

The aim of managing HH for a cluster of hospitals is not unique, but the extent of executive input and staffing ahead of demand is impressive.

MGB have combined the HH activities of the 5 hospitals in their conglomerate into a single service. Each campus has staff on site, and services are delivered geographically. However, at executive level it is a free standing entity with approximately 10 executives administering the service: CEO; Director Medicine; Director Nursing; Director Pharmacy; APA and paramedic director; Finance; Business Development; Quality, Surgery and a 0.3EFT doctor as Research and Development Director (Dr. Levine). While some of these positions are fractional, many are fulltime. They are not answerable to another hospital Division but have direct reporting lines to the organisation C suite.  The HH is in the top 5 priorities for the MGB executive as a whole. My impression is that MGB have approached the development of HH as it would the purchase of a new hospital – it has not been relegated to another side project with relatively low commitment.

Home Hospital is organised within the hospital as a distinct operational service of itself with direct C suite reporting. It is not part of another Division, nor is it combined with other post discharge, chronic disease, or miscellaneous home-based services. This is consistent with the view that the optimum method for introducing and driving genuine substitution and integration of HH is within the acute system. This aligns with my experience - hospitals that relegate HH to an organisational structure that includes non-acute or post discharge home based services fail to achieve any meaningful impact of their HH.

The most accurate description of the service management structure is that it is being treated as a new distinct hospital entity within the hospital system of MGB.

 

 

Clinical

The clinical services are provided by: HH doctors; HH Physician Assistants; HH nurse practitioners; HH nurses; HH paramedics; and non clinical services by personal carers.

The full range of other hospital services are available to HH patients from MGB: pathology; radiology; allied health; meals; transport; medical records; and pharmacy.

At present, the main conditions treated in HH are cardiac failure, COAD exacerbations, cellulitis, pneumonia, urosepsis, Covid and few others. The scope of practice is common across other US HH services, and sits within general medicine. It seems more limited than my experience in Australia. In particular, post surgical care and surgical complications do not form part of most HH activity at present. Serious infections requiring longer term antibiotic therapy tend not to be admitted because they receive “outpatient home infusion” services. Oncology related conditions are also not yet commonly admitted. Almost all patients, at present, come from the general medical or cardiology services.

In general, the length of stay for MGB HH is shorter than Australian HH.

Oxygen is routinely administered by HH. HH holds many oxygen concentrators and these are adequate for the kind of interventions required. The practice of admitting and treating patients with relative hypoxia and tachypnoea is higher than my experience, and it was one of the few differences in clinical approach. I was reassured by the positive experience of US HH clinicians in managing these patients. However, it needs to be recognised, as below, that the level of clinical input and surveillance for HH patients is higher than in Australia.

On the other hand, I found that the clinical scope of patient conditions was narrower than that in my experience. At present, the HH is a general medical service and it reflected the typical demographic of that discipline, rather than a collection of referrals from subspecialties. Although the conditions were slightly narrower, the general condition of patients could be frailer. This was able to be managed because of twice daily nursing visits, rapid and extensive carer support, and rapid after hours visit support.

Admitting hours are generally restricted at present: usually only till 4-6pm. Expanding those hours would help increase referrals, especially from ED, and many systems are working towards that goal.

Doctors are directly employed in the program. They are organised by an Executive Medical Director of HH. They undertake either admitting roles, or on the road visits in rotation, and additionally are on call overnight. Most are hospitalists, ED physicians or general medical internists. Most are part time although there are fulltime staff. Some of the physician visit roles are undertaken by Physician Assistants, who, while operating independently with patients, will still refer to doctors with concerns. In general, the proportion of HH patients who receive a face to face visit by doctors or APs each day appears to be broadly in line with those at my HITH i.e roughly a third to half of all patents. The others are consulted by telephone/video usually while the nurse is in attendance. David Levine at MGB conducted an RCT of face to face doctor visits vs virtual visits, and found significantly more problems with a purely virtual medical review including more frequent unscheduled medical visits, more unplanned returns to hospital, more adverse events and longer nursing/paramedic visits.

Staffing shortages have necessitated a reliance on alternative providers to deliver HH: for medical care these include Physician Assistants and Nurse Practitioners, and for nursing care this includes paramedics. In the case of MGB for example all these groups are used.

Paramedics operate as nurses in the HH program. In the US, paramedics are less costly to employ than nurses. They were initially introduced to MGH to manage the Home Hospital Emergency Department RCT which is still current. This is an RCT where primary care can enrol patients to either self transfer to ER or to a paramedic home intervention. The RCT has a very low uptake at present. However, this takes only a small part of their work now, as they folded their role into Home Hospital proper.

In essence the paramedics undertake the nursing roles:

1. They use fully stocked vehicles with prn medication (including ambulance level medication and narcotics), oxygen, full ECG, etc
2. They visit patients and administer IV medication and supervise, dispense and record oral medication. Once again, they will give patients scheduled medication for the bd visits and arrange for oral medication that needs to be given pre or post a visit
3. They will communicate with the doctor or APPC by video if required
4. They record their vitals and progress notes in EPIC on their return
5. They also staff the HH after hours. They are able to: do unscheduled urgent visits; later visits for tds or qid IV dosing if required; or potentially late admissions that need a visit after 6pm. There are usually 2 paramedics and vehicles available overnight every night

However, these vehicles and paramedics cannot transport a patient back to the hospital in the event of an escalation – this is done by the 911 ambulance.

It appears paramedics are more flexible than nursing staff. In the event of overflow, or unscheduled urgent visits during the day or night, they are often called upon.

The paramedic office also is the central scheduling service for nursing and paramedic visits. This involves a despatcher and a nurse who direct the patients to be seen each day.

This is relatively new function for paramedics in US and the paramedic exec team is keen to expand and find new applications as “Community” paramedics. However, accreditation, scope of practice and certification is a major issue, and I expect at a higher level nurses may have a negative view of their expanding role, given that they do not perform that role within the BAM hospital.

 

 

Remote Patient Monitoring

HH in the US is not required by regulation to supply Remote Patient Monitoring for HH patients.

As everywhere around the world, RPM vendors usually do not want to supply just the hardware, they integrate monitoring into the package. This means that the monitoring company screens any alarms or deviations. Generally, they call the patient first, then the HH. In this way, they are forcing HH into the chronic disease management/long term patient monitoring business model that they have always targeted.

This package makes the service extremely expensive.

At MGB, 3 separate monitors are used: a falls pendant, a BP/HR/oximetry/RR/temperature cuff worn tightly around the upper arm and a telemetry patch. The setup is restricting to the patient, difficult, time consuming and requires a hotspot (patients’ own wifi is not allowed to be accessed); the temperature and heart rate monitors are usually inaccurate, and each of the 3 separate instruments have a habit of disconnecting. Universal systems such as Bioformis have the benefit of a single adhesive patch but it also has stickiness and connectivity issues. All systems are expensive. The most common intervention is tachypnoea, usually from patients walking upstairs. The monitoring is actively used in only about 25% of patients.

In the case of managing CCF, which forms a big component of HH work for MGB, it usually helps by detecting rapid AF.

Overall, my impression was that the RPM was not critical to the conduct or success of HH.

 

 

Patient screening

The screening of HH potential admissions at MGB is guided through programming of the EPIC inpatient database, to include (or exclude) certain broad categories of patients for a desk screen suitability for HH. This alerts the HH navigators to assess certain patients on the wards or in ED. While helpful, however, this is not a high yielding device. However, it is assisting both HH and general hospital staff to become educated around the role of HH. There is heavy reliance on EPIC and its ability to be modified for all HH functions, including audit and research, is impressive. It is on the basis of this that programs using AI to detect HH patients are being proposed, although the comment on the yield of such results would remain low.

Nevertheless, HH is currently staffed enough to accommodate lower yields.

The screening process itself bears many similarities to those I am familiar with, right down to the brochures. The major difference is that the acceptable level of patient independence can be lower, and family support lower, because the HH has access to more personal care attendants, as mentioned previously.

EPIC can be accessed remotely which adds a significant level of function to HH staff during their physical home visits.

 

 

More on Executive Organisation

The US regulatory structure imposed by CMS mandates a much higher baseline level of HH resourcing in infrastructure, staffing, service organisation and delivery, than Australia’s, and perhaps as a result there is also stronger executive consideration involved in delivering HH at any scale.

Many US hospital systems have multiple hospitals in a city or region. Multicampus health systems have some advantages in reaching scale in HH numbers. MGB have 5 separate campuses, however there is always difficulty in integrating multiple hospitals into a single HH structure. Each campus of MGB holds HH staffing including pharmacy, but the Executive is central, and the despatch service is central (due to overlapping geographies)..

UMass has 4 campuses but deliver all services from the single central site (like Epworth). This is more efficient according to them. They also have invested in C suite level resources with direct reporting by the Director of HH to the Director of Medical Services to the CEO. After 3 years of operation, They have reached a daily patient census of around 21 patients over 3 years and expect to grow further. They will not accept payor discounts from private insurance.

Again, it appears that the successful organisations have created stand alone executives for HH with direct reporting lines: HH is not a subsidiary of another hospital service line, and is not co-located or combined with other non-acute services.

 

 

Patient Satisfaction

Every US provider has reported the high levels of patient satisfaction with top box scores at UMass of 85-90%. At UMass their BAM top box score is 70-75%. The American hospital public has, so far, demonstrated the widespread acceptance of hospital system linked HH as found elsewhere in the world.

 

 

Surgery

Post surgical care is very uncommon in MGB HH and other HH services.

However, MGB is unique in appointing a surgeon, Dr. Denise Gee, a bariatric surgeon, to the HH executive team. In my experience, she is the only surgeon with a HH appointment in the world.

MGB use HH for post sleeve gastrectomies: mostly home Day +1 with IV fluid, observations and analgesia for 2 days.

HH not being used much by other surgeons at present

Adoption by surgeons will require different approach i.e RCT may not be as influential as peer acceptance.

Structure of Surgical HH may differ from normal HH: attendings not likely to visit or even do video calls. The wider application may need a Surgical Fellow level HH doctor in the structure to deal with surgical issues prior to escalation back to attending, as the general medical hospitalists are not as comfortable with managing issues

Such doctors could be drawn from the many Surg Fellows doing PhDs during their research years.

 

 

Nursing Staffing

In addition to the nurses (or paramedics) required to deliver 2 nursing visits to patients each day, the following nursing roles are in place at each hospital base at MGB :

            Admitter

            RN Navigator

            Co-ordinator AM

            Co-ordinator PM

Charge

            Case Manager

 

Overall, I estimate that the staffing for MGB HH is approximately 3-4 times (300-400%) that for Australian HH per day of patient admission. While they are clear that they are staffing for target demand, rather than current demand, even if that target was met the staffing would be significantly more than any Australian HH. This both has significant advantages and disadvantages. Their responsiveness is excellent, in particular the ability to screen, assess and transfer a patient home from the ward within hours of referral and assessment.

The only disadvantage of this approach is the burden it places on HH to ultimately demonstrate financial viability – it would be indeed a tragedy if the whole HH concept was deemed financially non-viable because it had set in place high levels of staffing that could not be modified.

The above list does not include a despatcher at the ambulance centre and a Nurse Despatcher who allocates and documents visits each morning based on geography. That list also does not include “nocturnists”.

 

 

Nocturnists

The coverage of care for HH patients at MGB HH after hours is extensive and appropriate to the care of acute general medical patients at the scale of MGB.

At MGB it comprises: doctor on call; APP (usually physician assistant) who takes the calls; and 2 paramedics available to actually attend the patient.

This ensures a rapid response to situations (mandated 30 minutes response), and also supports the admission of patients who are more acutely unwell than their Australian counterparts, particularly those with cardiac failure and exacerbations of COPD.

They have adopted a high quality and risk averse approach to after hours care, something that in Australia after 30 years has been generally ignored to our (and or patients’ and our Emergency Departments’) detriment. It remains reassuring that when executive systems are serious about HH, these interventions are taken seriously and are capable of introduction.

 

 

The HH Business Case at MGB

The CFO of MGB is a Strategy CFO: i.e he is not an accountant. The intention of such a position is that the CFO office understands and reflects clinical priorities and realities in the difficult decision making required around allocation of capital and expenditure.

His view is that the “Business Case” should be expressed in terms of outcomes other than simply P&L, and the most important of these is capacity creation, reduced readmissions, and improved patient satisfaction.

He is happy to accept no cost reduction in operational costs. MGB is staffing ahead of demand, so that in this way there are no refusals based on lack of capacity, so all the spikes in referral and admissions can be accepted. Spike capacity is a problem for Epworth HH.

As a result, the resourcing is impressive and beyond anything I have seen in HH.

Importantly, the pressure to meet targets is not just left to the HH but is part of the ownership and strategy of the overall hospital systems’ executive. It is in the Exec scorecard/ top strategy/bonus target. Also, it is accepted by everyone that the pressure to increase activity is not extended to gaming or reducing admission thresholds. I saw or heard no evidence that management pressure to increase activity was addressed simply by shifting inclusion criteria, which they cannot do anyway. There is, however, a strong drive to increase admissions, and there has been some resistance among some nursing staff at the speed of that drive. Some of this reaction may have resulted from the fact that many of the executives do not have a grounding in HH, a similar situation in Australia.

Having said that, aside from clinical staffing, they have established an entire executive division, analogous to a small hospital’s executive, to manage the growth and operation of HH. It isn’t just the scale of this team that is important – it is that they are not a subsidiary of another hospital Division or department. They hold much greater control over their own destiny.

 

 

Pharmacy

Pharmacy is proving difficult to manage in HH due to a mix of regulation and risk aversion. The requirement for hospitals to manage all the patients’ medication and to prescribe, dispense and record all oral medication (including pre-existing oral medication) causes a great deal of waste. It also is making the dispensing of oral narcotic very difficult, denying patients access to such medication for analgesia.

Thus medication is prescribed on EPIC and nursing staff bring out each patients daily medication in separate dose bags and either directly administer them, or leave out of time doses labelled for later, and then record such dosing with bar codes. It is unwieldy, impractical, onerous and frankly ridiculous. It prolongs the nursing visit by approximately 10-15 minutes, and I suspect the effort in pharmacy would be incredibly time consuming.

The Director of Pharmacy on the MGB HH executive agrees with my observation that most companies have not designed innovative dispensing interventions or technologies with HH in mind. They are all structured toward long term care and as such are usually of very limited value to HH care.

 

 

Novel Applications

The expectation of HH growth is also generating novel ideas for applications. Ariadne is heavily involved in seeking funding for RCTs of new interventions, and has been successful in several projects.

Rural HH has been investigated in a RCT by Dr David Levine which has just concluded, and is in the analysis stage. Some of those services are continuing in an effort to improve the delivery of any hospital services to patients in rural areas, perhaps offering a model for the survival of rural inpatient services. However the RCT uses the rural hospitals’ current medical teams to deliver the HH services.

Post acute rehab HH services are currently under investigation in a RCT at MGB. It has just commenced recruitment: again, the baseline level of service far exceeds any input that would be possible within the Australian setting - for example the availability of 24 hour live in personal care.

A RCT of acute psychiatric HH for voluntary admissions is funded and still in the planning and simulation stages.

Finally, out-of-box ideas like drone delivery of medication and supplies are also being actively investigated to implementation trial stage. Proof of concept flights are beginning this summer.

Paediatric hospitals are expressing interest in HH, but as yet have not commenced such programs. I expect these may also commence in either pilot programs or trials.

 

 

Lessons for Australian HITH

In many ways, some Australian HHs are ahead of the US in the adoption, integration, funding and delivery of HITH. As mentioned earlier however, the impact of the Australian experience is diluted by the lack of research and publication output.

However, there are lessons from the Boston experience for any major hospital system in Australia seeking to expand its HITH services to meet the requirements of a major service between 50-100 patients. The benefits mooted by the US also apply here: expanded inpatient bed supply by HH; addressing ED boarding; lower 30 day readmission rates; better patient satisfaction; and better use of evolving technology. But MGB has demonstrated a level of financial infrastructure, clinical input and executive commitment that far exceeds that in Australia.

There is no doubt (in my mind) that the reimbursement policy initiated in Victoria 30 years ago to fund HH on equivalent terms to other inpatient care has driven similar HH policy in the US, even if they do not immediately recognise that fact.

The problem, however, is that since that time, state (and federal) health departments in Australia continue a laissez fare approach to HH policy review which ironically may contribute to hampering HH development. This is sadly coupled with private insurers adopting sub optimal and subacute definitions of HH in order to involve themselves as providers, which is also a threat to HH development in the private sector.

In the case of public HITH, the irony remains that HITH is inadequately managed at a senior hospital executive level. Although reimbursement is excellent, expenditures are clamped resulting in insufficient coverage to undertake the task of genuine clinical substitution which would ultimately benefit the whole hospital. Executive pressure to increase patient numbers can manifest as forcing units to accept subacute or non-acute patients, relying on on-site clinics, or keeping them longer. The process of seeking appropriate levels of medical and nursing input, after hours cover, access to paid personal carers, meals etc falls to the unit themselves, and HITH units remain the least powerful clinical units within the hospital pecking order. My observations in Boston elevate the view that HITH should not be held within another Division or Department’s responsibility. The problem with integrating HITH into other hospital divisions is that the middle managers at that level have no experience of HITH – they have their entire clinical histories (and arguably their loyalties and biases) based in their BAM hospital experience be it ICU, CCU, surgery, ED, non-HH wards etc. HITH is a well resourced but organisational weakling they feel free to ignore, or worse to manipulate. This holds back the development of what is still an innovative yet difficult clinical service to implement properly. The solution I observed at MGB (and heard described at U Mass) is to give it free standing prominence within the executive even if it means increasing reports to CEOs. If CEOs want genuine solutions for their demand problems they should arm those solutions and not allow them to be held hostage.

While non-US (and US!) policy makers criticise the level of bureaucracy in US funding, the clarity of the terms of engagement for HH, and the reluctance of some hospital systems to become involved, is actually beneficial to ultimate HH uptake. It will ensure that only the serious providers will get involved initially and create significant HH models of service that can deliver genuine acute care, and these will hopefully be duplicated and further convince funders to retain support for HH.

There are some lessons to be learnt from the regulated conditions of the waiver, with just a couple of exceptions. The regulations around medication dispensing and the disallowance of all direct admits to HH are unfortunate, and certainly should be reviewed to allow direct admission of patients in Residential Aged Care. The dividing line between how much hospital should be taken home is delicate.

HH is currently under-regulated and under-defined in Australia. The background effort that has occurred in the US with regard to consultation, research and analysis of HH that precedes (and runs concurrently with changes to) the regulations ensure that there is some education of senior policy planners. The lack of agreement in Australia about, for example, number of nursing and medical visits and after hours cover, is to the detriment of HH developments. Those issues should be regulated along the same lines as the CMS waiver rules. Perhaps the strict substitution definition of HH, recently adopted by the Australasian Society of HITH, needs to be regulated and directly linked to reimbursement in all states.

 

 

Concluding Remarks

If the US waiver for HH funding is extended in November this year, there will be a significant expansion of HH activity in the US, and I expect this will be followed by many large well funded research projects. These will find a home in the global literature and be influential. It is important that the context in which those studies are conducted and reported are understood, and hopefully this paper will assist in improving that background.