Hospital-at-Home: Bruce Leff and Tacara Soones

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we are delighted to welcome, to the GeriPal podcast, Tacara Soones, who is a geriatrician. She trained at UCSF, for geriatrics fellowship. After that, she was faculty at Mount Sinai for a number of years, and now is associate professor at MD Anderson, in Texas, and is the lead of the hospital-at-home program there, called Care and Monitoring at Home. Tacara, welcome to GeriPal.

Tacara: Thank you so much for having me.

Alex: And we’re delighted to welcome Bruce Leff, who is also a geriatrician, and professor of medicine, and director of the Center for Transformative Geriatric Research, and has been studying hospital-at-home since the mid-nineties. He’s at Johns Hopkins, in Baltimore, Maryland. Welcome to the GeriPal podcast, Bruce.

Bruce: Great to be here, guys.

Eric: I’m not sure how hospital-at-home slipped through 300 podcasts, and this is our first one, but I’m super excited, because we’re going to be talking about hospital-at-home today. But before we do, Bruce, do you have the song request?

Bruce: I would love to hear Homeward Bound by Paul Simon. Great tune, very much on point.

Eric: Yeah. I usually ask more about why you chose that song, but this seems very on point.

Alex: (Singing).

That was fun. A lot of fast court changes there. That’s good.

Bruce: Well done.

Alex: Good challenge. I love it. Thank you. Thanks, Bruce.

Eric: Okay. We are going to take our time machine. We’re going to go back three decades, to the early nineties, or somewhere in the nineties. Bruce, how did you start getting interested in hospital-at-home at that time?

Bruce: Yeah. It’s a great question. Thanks for pitching it. I trained at Hopkins. We had, since the late seventies, a home-based primary care program. That’s focused on older adults who are too frail to get into clinic. And we would provide ongoing longitudinal care to them in the home, much like the Mount Sinai Visiting Doctors programs, and other programs like that. In that clinical experience, we saw a lot of older adults who would develop acute illness, often exacerbations of their chronic conditions. And it was not uncommon for them to, absolutely, refuse to go to the hospital. I remember, as a resident, taking care of folks with MI at home, pneumonia at home, COPD exacerbations at home, because they would absolutely refuse to go to the hospital, because they had been, in their minds, poorly treated, or had bad experiences there. On the flip side, I think, as geriatricians, I know, for myself, one of the more difficult clinical decisions I face, on an irregularly regular basis, is when I’m seeing people in clinic, or in the home, they are acutely ill.

I think I could get them to hospital, to treat an acute illness. And I wonder whether sending them to the hospital would, actually, cause them more harm than good. The pneumonia could get treated, but I think geriatricians, actually, were well aware of iatrogenic complications of care and quality gaps, even well before the IOM reports of the late 1990s and the like. Delirium and functional decline, and everything that we now call the hospital-associated disability syndrome, which your colleague, Ken Covinsky, popularized in a great JAMA piece. Those were some of the things that got us to think about hospital-at-home, back in the late eighties, early nineties. And then, I started working on it when my mentor, John Burton, convinced the Hartford Foundation program officer, Donna Regenstreif, to start to fund that, and to think about, actually, developing that model. That all started back in the mid-nineties. And I could certainly talk about the details of that. But that’s where the idea, really, germinated from.

Eric: Maybe you can just go through some of… How did we get to where we are now? What were some of the big changes that led us to where we are now? We can talk about where we are now afterwards.

Bruce: Sure. When we started working on this, the first questions we faced were, who and what to treat in hospital-at-home? We relied on our clinical experience as geriatricians, that home-based primary care experience. And then, we did a lot of claims work, looking at common reasons older adults get hospitalized. And we cross-tab that with thinking about the kinds of things we thought we could deliver in the home-based, in our experience. Initially, we focused on four conditions, community-acquired pneumonia, exacerbations of heart failure, exacerbations of COPD and cellulitis. And we then did a bunch of work to develop medical criteria, to choose the right patients for hospital-at-home. This is not, really, the most straightforward thing. You need to have people who absolutely meet threshold criteria for acute hospitalization, but they can’t be so sick that they need an ICU, can’t be so sick that they would need a very high intensity, high-tech-oriented procedure, would not be so sick that they would be clinically unstable, and the kind of person who you admit at noon, and you’re worried that, by 3:00 in the afternoon, they’re going to be in the intensive care unit.

We developed those criteria, did some validation studies, and thought we had some ways to choose the right people. We did some early studies of acceptability of the model. With the criteria we developed, we would find people in the hospital, who had just been admitted. This was about like 1995, 1996. To go back to then, this is before anyone ever heard the word “Hospitalist.” This is before the Affordable Care Act. This is before value-based care, all of that. We would find these people in the hospital, and we said, “What would you have thought if someone had come up to you in the emergency room yesterday, and said, ‘Hey, instead of going upstairs, you could go home.’ And these people you’ve never met, in a care model you’ve never heard of, will come to your home and do the hospital care at home. Would you accept?” And to our amazement, a large proportion of folks said, “Yes, I would do that.” And we would describe, at least, our vision for the model, nursing and doctor visits in the home, IV medicines and fluids in the home, oxygen and respiratory therapies.

We could do EKGs and x-rays, and ultrasounds at home. And people said, “Sure, I want to do that.” With that, we said, “Okay. Let’s, actually, try and do this thing.” We put together a clinical pilot study. And it took us a full year to get that through the IRB. Hopkins IRB, staffed with all these brilliant, hyper subspecialists who, especially back then, could not imagine hospital care being provided anywhere except the bricks and mortar of the hospital. It took us a year to get that through. They put some really interesting restrictions on us, which… Probably not worth going into now. But we ended up doing, basically, a case series of… I think it was 18 or 20 patients or so. And, by and large, people’s heads did not explode. And we took care of them at home. They did just fine. Good care experience, lower costs. We were, actually, able to do the delivery of care in the home.

Eric: And then, three decades later, we are where we are now. We can talk about why we are where we are. But I’d love to turn to you, Tacara. You did fellowship with us. We don’t have hospital-at-home. We have home-based primary care. How did you get interested in hospital-at-home?

Tacara: Right. After I finished a fellowship at UCSF, I went to UCSF East, otherwise known as Mount Sinai. [laughter]

Eric: We call it a satellite campus over there.

Tacara: Exactly. Small satellite campus. And had the opportunity to work with Al Siu and Bruce Leff, on Mount Sinai’s hospital-at-home program. It was a fantastic opportunity for us to understand what this would look like under Medicare. I think Bruce can speak to that, I think, 30-year gap in finances. And then, maybe, I’ll talk a little after that, about what we did at Mount Sinai. Yeah,

Eric: Yeah. But let me ask, why, personally, did you get interested in this? There’s so many things you could have done.

Tacara: I love thinking about models of care. How can we take our healthcare system, and really break it, and do it better for older adults who may not fit within, or may not have the conveniences of going into the clinic, or going to the hospital, all these things that we think about. How we deliver care for many of our patients, it’s not convenient, and not patient-centered. Hospital-at-home, for me, was an opportunity to think about how we can do this better.

Alex: Yeah. Can I ask, Tacara, when you think about hospital-at-home, and what are the benefits, from your perspective, what do you think of? And then, what are you hearing from patients who want the hospital-at-home? And those may be the same. They may be different. I’m not sure.

Tacara: Right. What really stands out to me, from my experience at Mount Sinai, was our patients, who we admitted, who had advanced cancer. These are folks who, in general, I think, for our early iterations of hospital-at-home, would not have been considered eligible. They would’ve been too sick, and too likely to pass away during their acute care episode. But as we talked to patients and providers, there was, really, this need for patients who wanted services, like IV antibiotics and IV fluids, but wanted to be able to spend that time at home, with their family, even if it meant it was their last days or weeks. The patients that, I think, most benefited from it were those individuals who, as I said, maybe, had a pneumonia, and needed IV antibiotics, but wanted to do that… If they could get better in the comfort of their own homes, that were not interested in passing away in the hospital. What we’re hearing is just how important it is to be at home, with the people that you care about.

Alex: Interesting. Maybe it wasn’t a slip of the tongue there, a lot of thread of hospice in there. And yet, the goals are different. And the treatments are different than what hospice might provide in the home setting.

Tacara: Exactly.

Alex: Interesting.

Eric: Let me ask some practicalities, because I’ve got a lot of questions about the practicalities. Bruce, you alluded to who is the right patient for this. Tacara is talking about that a little bit now. Again, probably every hospital-at-home program is slightly different, but in general, who is the right candidate for a hospital-at-home?

Bruce: No. Great question. A few ways to approach, thinking about that. One is, again, must meet threshold criteria to need to be in the hospital. You don’t want to throw hospital-at-home care at someone who could leave the emergency department with, say, a prescription for an oral antibiotic, for an infection.

Eric: So, you got to be sick enough, but not so, so sick.

Bruce: You got to be sick enough, but not ICU. And I would say that, over the last 30 years, the ability to take more acutely ill patients, to go deeper into the acuity, has increased quite a bit. And I think part of that is because technology has improved. And NeverTech is a solution, but thinking about technology as a tool to do better monitoring in the home. When we first did our first clinical pilot, there was no technology. I had a first-generation cell phone. Not one of those big block things, but one of those things that you carried in a backpack. And we thought it was a miracle, because you would be untethered. And you would push a button, you’d get a dial tone, and you would make a call. And a pager that just went “Beep.” There’s no display. It just went “Beep.” And that was the technology.

Eric: I just have a picture of you, like Gordon Gekko, with that big phone.

Bruce: No, no, no, no, no. That was the next generation.

Eric: This was before that.

Bruce: That was the next generation.

Eric: This is like Ghostbusters, but it’s a phone.

Bruce: This is, Ghostbusters, basically, a ham radio. The technology has made it possible to take people who are sicker. The other way to think about who’s eligible… I talked about coming at this from a diagnosis point of view, people with certain conditions that you need to be hospitalized for. And that is, definitely, one way to approach it. When we did the Center for Medicare and Medicaid Innovation study at Sinai, that Tacara helped lead, we had a realization, that you can also think about, what you take into hospital-at-home is based on the competencies of that particular hospital-at-home model, an example. If your hospital-at-home model can do heart monitoring, and deliver IV antibiotics, and do ultrasounds and EKGs, and basically, you have the capability to treat infections at home, does it really matter if the infection is community-acquired pneumonia versus, say, diverticulitis, or complicated urinary tract infection, or pyelonephritis? It really doesn’t matter all that much. There are some subtleties there.

But basically, at the end of the day, those are people who are being observed and getting IV antibiotics. You can broaden the scope of diagnoses. And in that demonstration at Sinai, we went from the initial [inaudible 00:14:52] to about, I don’t know, Tacara, what was it, 50 or 60, or 70 DRGs. And now, that has been expanded even further, as programs get more competent, and have better ability to keep eyes on the patient, and know what’s going on, and coordinate the logistics and supply chain to support the model. Just one last comment there. The other piece of choosing the right people is also to think about the home environment. You are delivering care in someone’s home environment. That environment needs to be appropriate to deliver acute care in the home. Meaning, you need a roof, you need doors and windows, you need heat in winter, in certain places. You certainly need air conditioning in Houston. It sounds like you’re needing it more in San Francisco of late. You need running water, you need a functional bathroom. It needs to be… Not clean like an operating room, but it can’t be mired in absolute filth.

Eric: Do you need a caregiver?

Bruce: No, you don’t necessarily need a caregiver. There’s a lot of interest lately, in the role of caregivers in hospital-at-home. And that’s a totally, totally appropriate question. High-level review of the evidence would tell you that patient and family member, and caregiver experience in hospital-at-home is better than when their loved one is in the hospital. We did our initial pilot study. Then we did a larger study in several Medicare Advantage Plans in the VA. We never required a caregiver. And part of this came from early conversations with CMS, when we went to them in the late nineties and said, “Give us a payment model for hospital-at-home, and fee-for-service Medicare.” And they said, “This is really interesting. By the year 2000, everyone will be in a Medicare managed care plan.” Back then, they were called Medicare Plus Choice. We weren’t even up to Medicare Advantage. And they said, “This is really interesting, but all you’re really doing here is transferring the burden of care from hospital staff to family members.”

And we took that advice very seriously. In our larger studies, before the study that Tacara helped lead, we never required family members to be present, or do work. Think about the cost of an input of a home health aide for 24 hours, compared with the hotel stay of a hospital. It probably costs between two and three grand a day, your bill in the hospital. Home health aide at 25 to 50 bucks an hour is, actually, a very inexpensive, and well-worth input for people who need help with ADLs and the like. However, different programs take different attitudes towards requirements for family members, enlisting them in care, training them. It’s, actually, an area we’re doing a lot of research in right now, and appropriately so.

Eric: Yeah. And Tacara, can you walk me through, what does this process look like? Are people getting into hospital-at-home via a clinic, or is it all through the ED? What actually happens? What does it look like once they’re at home?

Tacara: Mm-hmm. It depends on the program. There are, actually, multiple places where patients can be enrolled. There are some programs that take patients directly from home, into hospital-at-home. They can do their first home visit, decide if somebody meets Milliman inpatient criteria. And then, the patient can bypass the emergency room entirely. At our program, we actually require that folks come into the emergency room and have their initial assessment. And that’s more standard. And we complete their hospital stay at home. Patients will come into the ER, they bypass the inpatient experience entirely, and go straight home. There are other programs that do what’s called an early discharge hospital-at-home. A patient may be in the hospital for a couple of days, get stabilized, get blood products, IV antibiotics, and what have you, and then finish the rest of their hospital course at home.

Each one of those programs, usually, has a different payment mechanism, which is also how you think about… Where somebody enters in the hospital-at-home process. But then, once somebody’s at home, many of the programs are really attempting to be standardized. If you enroll in a hospital-at-home program through MD Anderson, or through Mount Sinai, or through Hopkins, you should… The same way that if you go to the hospital, you know you’re getting certain services. You’re getting nursing visits, you’re getting IV fluids, antibiotics, et cetera. There’s definitely a move towards standardizing that care as well, in the hospital-at-home side. For the most part, programs are doing, twice a day, nursing visits. They’re doing, once a day, either MD, or MP, or nurse practitioner visits in the home as well.

Eric: Virtual or in person, for the MD?

Tacara: Sometimes in person, although there are programs that are doing those virtually. And I think that there’s more data coming out about whether or not those outcomes are equivalent. But there’s heterogeneity, I think, in how to meet our patient’s needs, depending on the resources that a particular healthcare system has, and their patient needs.

Bruce: I think it’s a great segue, also, to think about payment. Tacara was, I think, alluding, also, to something that’s had a tremendous impact on the field. And that is the Center for Medicare & Medicaid Services’ Acute Hospital Care at Home waiver program. That started in November of 2020. Go back in your mind, November of 2020, COVID is at its peak, we don’t have vaccines quite yet. Hospitals are getting very filled, like Sinai was taking care of people in Central Park, in tents. Mass General, basically, became one big ICU. And systems were thinking about how do we create capacity, basically, flex capacity, in the context of what’s going on with the pandemic. CMS recognized that. And Seema Verma pushed very hard and got the Acute Hospital Care at Home waiver put into place. This waiver is a hospital-based waiver. Hospitals apply to CMS, and attest to the fact that they can meet hospital-at-home requirements for care. And what the waiver did is, it waived only the requirement for hospitals to provide 24/7 onsite nursing.

All the other Medicare conditions of participation apply to hospital-at-home patients under this waiver. And if those patients are taken care of under the waiver, in a CMS-approved hospital, the hospital will get a full diagnosis-related group, DRG payment, for a patient that’s taken care of in hospital-at-home, the exact same payment that that hospital would’ve gotten, had the patient been taken care of in a hospital bed. That caused an explosion of hospital-at-home interest. I, and Al Siu, and David Levine, and Linda Decherrie, were involved in that process, helping to give input, to CMS, on developing that waiver among other stakeholders. And I think, if you had asked us the day before that went into place, how many hospitals would apply and get the waiver, I think the over-under might’ve been somewhere in the 40 to 50 range. And in fact, as of now, there are almost 300 hospitals in the country, with that waiver.

Eric: And do you think the waiver will still… Will it remain?

Bruce: That’s a great, great question. The waiver was, initially, tied to the public health emergency, meaning that it was a bit like Cinderella, when the public health emergency would’ve been declared over, the waiver would’ve gone away. Like the clock striking midnight and, Cinderella, her gown turns back into rags, and the Coach turns back into a pumpkin, which is why I think we were very surprised about all the initial enthusiasm, all these hospitals going in for the waiver. They had to make a substantial investment to build a program, never certain that the payment would survive. Back then, people said, “Okay, it’s going to go on for another six months.” And then another few months, and then another few months. And it went on for a while. And then, it did, finally, come to an end, but the hospital-at-home community was able to educate policymakers. And in the omnibus bill that was last passed, the waiver was extended through the end of 2024.

And CMS is now obligated to report to congress in September of 2024, about a year from now, on their experience with the waiver. And hopefully, we’ll be able to either extend the waiver, get a permanent payment into Medicare, but there’s a lot of conversation about what the correct approach is to that. CMS released some initial data on their experience with the waiver. They gave some very high level results on about the first 1,800 folks who were treated in the waiver. Very excellent results. And they are in the process now, I think, trying to get data out, on about the first 10,000 or so people treated under the waiver. What we hear is, they’ve been, favorably, impressed with the experience so far. Under that waiver, the payment only comes if the patient starts their care in the emergency room, or, as Tacara said, this notion of people transferring, out of a hospital bed, into the bed at home, into the hospital bed at home, to complete their hospital stay. And you get the DRG.

Eric: From a hospital perspective, it seems a little bit like a… I wouldn’t say “Cash cow,” but it seems like you don’t have the facility fees. There’s less staffing needs. This feels like, if you’re paying the same amount for hospital a home, versus a hospital bed-

Bruce: Yeah. The numbers don’t quite work out that way. It’s, really, not a cash cow.

Eric: Yeah. I imagine, every hospital would be doing it if it was.

Bruce: Just to push back on that a little bit, it does take substantial investment to get this thing up and going. Because the thing is, you do not want to do this using post-it notes and a little bit of scotch tape. You’re building out a true hospital ward outside of the hospital. And some things are, actually, more expensive to provide in the home, right?

Eric: Like imaging and labs.

Bruce: Actually, not so much that stuff. If someone needs imaging, if someone needs an MR, or CT, you bring them back to the hospital, so there’s some transport costs there. Just think about something like a nurse visit, a nursing visit, or a physical therapy visit. In the hospital, a physical therapist goes into one room, comes out in the hall, walks into the next room, providing the single… Physical therapy visit, actually, costs more in terms of time of provider. It takes a bit to get these things up and going. If there were more certainty about the longevity of the payment, I think you would see many more hospitals coming in on this. But we were really impressed with the interest that came with the waiver.

Eric: And Tacara, from your perspective, at a cancer center, what does it look like there?

Tacara: It’s quite different. MD Anderson is PPS exempt, or DRG exempt. We’re not paid, as part of a DRG, for any particular diagnosis. Our math and our model looks quite different. Another way of thinking about that is, for each day somebody’s in the hospital, we bill for that day in the hospital. We are not eligible to apply for the Medicare waiver for our program. We are working with a vendor that is contracting with specific commercial payers to be able to provide this at home, so they have a single Medicare Advantage Plan. The finances, for us…

Our goal is, really, to break even, or even lose a little bit of money, that’s okay, with the goal being that this is very patient-centered. And we know that folks who are… Within the first year of diagnosis of cancer, about 65% of patients are admitted to the hospital at some point in time. For our patients, it really is much more patient-centered to able to do symptom management, and to do IV antibiotics, and all those things at home, instead of having them come in. And then, that allows us to use those beds for things like stem cell transplants that we can’t do at home.

Eric: Going into, now, the data, what does the data show? What do the studies show, as far as the benefits of hospital-at-home?

Bruce: Yeah. Actually, hospital-at-home is probably one of, if not, the most studied health service delivery innovations of the last 40 or 50 years. They’re actually randomized, controlled trials of hospital-at-home that were started in the late 1970s. The first one in the UK done for MI, believe it or not, done by Archie Cochrane of the Cochrane collaborative.

Eric: Is that a review on hospital-at-home?

Bruce: There are multiple Cochrane reviews of hospital-at-home. But the funny story on Archie Cochrane was that he did this study of MI, and he presented the data to cardiologists. And he flipped the column headings purposely, and presented the hospital-at-home data as the hospital data, in the initial view to the cardiologist, making it look like hospital-at-home was terrible compared to the alternative. And then, he puts up the data, the cardiologist starts screaming, and going nuts, “You’ve got to close this down.” And then, he says, “Oops, sorry, let me put up the right slide, with the correct column headings.” And he said, “The room just went silent.” It’s a great story.

Eric: That was a great story.

Bruce: I’m happy to send that to you. It’s a great little story. It’s been studied in dozens and dozens of randomized controlled trials since the late 1970s, multiple meta-analyses and systematic reviews. And the net-net-net is that, at its very worst, it’s equal to hospital care. But most studies actually show, and a lot of systematic reviews show, that it’s actually superior to hospital care in terms of patient and caregiver experience, in terms of satisfaction with care, in terms of costs, in terms of reductions in important complications, especially for older adults. And some show better functional outcomes. And it’s, overall, a very positive literature. There was one meta from… I think it was close to 80, 70 studies that looked at the international literature, close to 70 studies, and showed a 25% reduction in mortality at six months, better, if you’re at home, than the hospital.

All of us are geriatricians. I think we have a bird’s eye view into the challenges of hospital environment for older adults. I think it’s not hard to visualize that. In our study that we did in Medicare Advantage in the VA, we found a 75% reduction in incident delirium, very carefully measured. Overall, a very robust and positive literature. We’ve had some studies in the US. David Levine has led some great work, and Mass General Brigham, including RCTs. The work that Tacara helped with, leading at Mount Sinai, showed the same kind of results. It’s a very consistent set of results across multiple continents, across multiple decades.

Eric: Tell me about what you did, Tacara.

Tacara: At Sinai, it was the CMMI award that Bruce alluded to earlier. The goal was to model hospital-at-home with a 30-day payment bundle, to be able to say, “Can we take care of patients in their home, for their acute hospital stay, and then follow them for an additional 30 days to prevent readmission?” And when you provide additional support in the home, when you’re available to patients, they call you. And you’re able to address a lot of those needs in the post follow-up, or post discharge period, that you wouldn’t be able to if you just sent somebody home. We all know this, who do house calls, but when you’re in the home with a patient, and you can see how they’re filling their pill bottles, or pouring the bottles into a bowl, and picking out the pink ones, you can do that kind of medication reconciliation and individual teaching in a really patient-oriented way in the home, in comparison to in the hospital, where everything is so controlled.

Alex: I wonder if-

Bruce: I think…

Alex: Go ahead, Bruce.

Bruce: No. Just to build onto Tacara’s point there, I think one thing that, sometimes, we don’t emphasize enough, and it’s a soft outcome, but I think clinical experience bears it out, is that when you’re taking care of someone in their home, whether it’s home-based primary care, or home-based palliative care, or hospital-at-home, I think it has the ability to improve trust between providers and patients, and family. And I think the main mechanism for that, or a mechanism for that, is that it changes the power equation. When I’m in someone’s home, I’m a guest in someone’s home…

I feel very different when I’m in someone’s home than when I’m standing in someone’s room in the hospital. You’re in someone’s home. You’re a guest. It’s impossible to escape. There’s no emergency hatch like grabbing your belt and saying, “Hey, I just got paged. I’ll be back in a little while.” Those kinds of things just don’t happen. Being in someone’s home, I feel like I… I am not particularly proud to say it, but I think I’m a better communicator. I take my time, a little bit more time. I’m a little bit less stressed, usually. And it’s just a different feel. Tacara, I don’t know if you have that kind of experience.

Tacara: I agree. But one thing this brings up for me is that question of equity. I distinctly remember being in the ER, trying to recruit patients for this program. And they would say, “Why me? What is it about my insurance, that does not cover me staying in this hospital?” You have to also build that trust for patients to be willing to come home with you. I wonder, Bruce, if you could speak a little bit to the questions that come up about equity in hospital-at-home. Is it a program for rich people, or poor people, or both?

Bruce: Yeah. And it is definitely both. I think there’s a misconception that people feel you have to live in the Presidio, or whatever those wonderful neighborhoods in San Francisco are, or on Park Avenue, or Central Park South, in New York City, to qualify for hospital-at-home. And, in fact, that’s not true. In the study that Tacara led, the CMMI demonstration study, we did a post hoc analysis, looking at outcomes related to housing and socioeconomic status. And 40% of the people in that study lived in New York City public housing. And overall, in the study, we had a… I think it was a 50% reduction in ED visits and readmissions. When we stratified that by Medicaid eligibility status, all of the… We saw the statistically significant benefit in the Medicaid eligible population. The difference was not statistically significant in the non-Medicaid eligible group. But I think Tacara is right. Sometimes, people might be a little suspicious.

I can remember one or two phone calls from health systems, over the years, saying, “Hey, we are interested in the hospital-at-home. And we want to do it only our Medicaid patients.” And I said, “Really? Really? Let’s talk through the optics on that.” Something goes wrong. And then, you’re going to be on the front page, with Medicaid patients given non-standard model, and experienced bad act. You don’t want that. You want this available to everyone. I think it’s possible that part of the advantage we saw in that Medicaid eligible population, which is a secondary data analysis and… Certainly, hypothesis generating, rather than hypothesis testing. Maybe it is developing trust. Maybe it is that ability to not only see, but start to address social determinants of health, which I think are much harder to do in the abstract, in the hospital, when people are very focused on moving people through, and getting them out to a SNIF, or just out of the hospital. But a lot more work to be done in that context. We’re doing some research on that now, in our continuing work.

Alex: I love the notion of hospital-at-home, and thinking back… Historically, my great-grandfather would do house calls. He, primarily, did house calls. He was a terrible driver. I have a painting, that he did, of… He crashed a car into a fence, and he’s walking away, towards the house, with his black medical bag, left the car there, on the snow drift, crashed into the fence.

Bruce: Where was this?

Alex: This was in New York. Yeah. We’re moving back to an earlier time, in a way, in which the locus of care wasn’t in these highly specialized hospitals. And we weren’t bringing the patients to us. We were going to them. That is beautiful. Just thinking about that individual experience, as you’re talking about Bruce. We’ve talked a lot about the data. Sometimes, the stories trump the data. I wonder if you could share… Appropriately anonymized for our listeners, if you have any stories of any patients in particular, and what it was like going into their home, and what it meant to them, to receive this care at home.

Bruce: Yeah, I can do that. I’ve been carrying around a slide, with a patient named Walter on it, for decades now. Walter is no longer with us, but he gave me permission, many, many years ago, to talk about his experience. Ex-best steel worker, lived in southeast Baltimore, lived in one of the Baltimore row homes, was in our home-based primary care program, and had COPD and heart failure, and the long list, and the many medicines. And despite being well-managed, or at least, in theory, well-managed, by well-meaning Hopkins geriatricians, would often end up in the hospital. And one day, we’re out on a house call, and he clearly has lobar community-acquired pneumonia. And he’s statting at about 89% on two liters already, because he was on chronic oxygen. And we said, “Walter, you need to go…” He need to go to the hospital.

And he looked at us, and he said, “I am so sick and tired. I’m so sick and tired of you geniuses from Hopkins. You’re great doctors. You run a crappy hotel. I’m not going to the hospital. This is your problem.” We did for him, we did hospital-at-home on a shoes string before we even had the model. But he was able to stay at home. He was able to stay with his cat. I used to admit him to the hospital. I’d make one of my fellows take his cat home. He did not become delirious. He did not get physically restrained, which had happened to him previously, in the hospital, in which was one of the most humiliating experiences of his life that he never stopped talking about. Every time we’d make a visit, he would talk about being physically restrained. For someone like that, getting the care at home was kind of genius. He loved it.

Alex: Just before we let it slip, made the fellow take home the cat.

Eric: I love that. That was back in the day.

Bruce: That would definitely be considered a macroaggression in 2023. I could not get away with that crap.

Eric: Tacara, any stories from you?

Tacara: I was just thinking about how allergic to cats I am. [laughter] I’m glad I wasn’t your fellow then. [laughter] I think I’d just like to go back to the technology piece, because I think that’s also part of what really enables us to, now, be in patients’ homes in a way that might not have been efficient or possible 10 to 15 years ago. We can do monitoring at home for patients. We can really manage that supply chain, so that it’s not a doctor with a backpack who goes in and draws the blood, and then has to take that sample back to the lab, and let somebody run it. Now, we have a way of managing all these people out in the field, to meet our patient’s needs. Because it’s technology-enabled, because the provider can look at the patient’s EMR on the computer in their lap, in a way that we wouldn’t have been able to do 20 years ago. I think that these two really go together, in a way, to allow us to do hospital-at-home.

Bruce: Yeah. Just to build on that, one thing we haven’t quite talked about is… We’re talking about hospital-at-home as something of a siloed model. And that’s appropriate. Tacara and I are pointy-headed health services researchers. Like a lot of folks who carry that card, we test isolated models under very special circumstances, and try and do trials, and prove that efficacy, and all of that. One thing that hospital-at-home, at least in my view, enables is the development of a fully-baked home-based care ecosystem. If you think about everything that can happen in the home, from long-term services and supports to home-based primary care, home-based palliative care, skilled home healthcare, mobile integrated health, skilled nursing facility, care-at-home, hospital-at-home, and a few other things in between. Once you build the system for hospital-at-home, the most acute, the most complicated stuff at home, all of that supply chain and logistics of Tacara was talking about, you actually can start to build a truly patient-centered care at home.

The patient’s at home. Today, it’s a primary care day. You know what? They got sick. Tomorrow, it’s a hospital-at-home day. The patient doesn’t move. The care moves around the patient. And as we develop total cost of care payment models, I think that’s where care will go. But at some level, hospital-at-home enables that system to exist, which requires logistics and data, and monitoring, and all of the pieces that tend, now, to get centralized within bricks and mortar. And we need hospitals. Believe me, tacara and I are not saying, “Tear down the hospitals.” And all of that. But there will not be enough hospitals. Period. Full stop. California’s a great example. You guys are busting at the seams. And no one is building hospitals.

Eric: Can you do a hospital-at-home in rural areas. Because that’s one area that we’re running out of hospitals in. They’re closing.

Bruce: Absolutely. You can do it in rural areas. David Levine, based at MGB, is doing a lot of work on that. He has a rural hospital-at-home collaborative. They’re doing all sorts of stuff. And he’s doing some randomized trials with that. But do you know what it costs to build a hospital bed, to capitalize a hospital bed?

Eric: $1 million, right, per bed?

Bruce: In California, it’s closer to five. Yeah. Remember, your hospitals have to be earthquake proof.

Eric: The building me and Alex are in right now is not earthquake proof. They don’t allow patients in here.

Bruce: Only junior faculty, right?

Tacara: And fellows.

Eric: Only senior faculty.

Bruce: Only senior faculty, fellow. Only people we can sacrifice. I know we’re not allowed, THE geriatricians, to talk about the silver tsunami and all of that. However, there are a lot of older people coming down the track, who are going to need hospital-level care. We do not have the hospital beds for that.

Eric: Okay. Somebody’s listened to this podcast. They got really interested in hospital-at-home. It feels almost daunting because of everything that it has to do… I think about palliative care, but one of the best things that happened in palliative care was, CAPCE was created. And it served as a resource hub to how to, actually, develop a palliative care program. Is there something like that for a hospital-at-home?

Bruce: Yeah, for sure. There are several things like that for hospital-at-home. First, there’s the hospital-at-home users group. It’s not the sexiest name on the block, but Al Siu and David Levine, and Linda Decherrie and I run that. It’s funded by the John A. Hartford Foundation. And it is open source technical assistance material for hospital-at-home folks. We have, about, monthly webinars. We have posted gobs of technical assistance material in the spirit of CAPCE, hahusersgroup, all one word, .org.

Eric: We’ll have a link to that on our website.

Bruce: You also have the entry of a number of commercial hospital-at-home entities. And these have served health systems well. Because I think, at some level, many health systems are a little bit suspicious of academics who… They don’t get anything done in a certain timeframe. You’ve had these commercial entrants in the field, that collaborate with health systems, to help them build out their hospital home, often supplying the command center to coordinate logistics and supply chain, and all of the billing, and the back office stuff, which sounds kind of easy, but is really hard. And it’s really not a trivial thing.

A number of those entities exist. And a lot of health systems are collaborating with those entities to launch their programs. And then, there are some systems that will do it all on their own. And that’s fine too. But there are many more options now, than there were, even, five years ago, up until, I would say, the early 2010s. I think I was the only one in the country who could take those calls. And now, thankfully, I’m not. There are lots of folks who are getting up every day, thinking about hospital-at-home, which is terrific.

Alex: And Tacara, you, obviously, have a lot of history, and studied hospital-at-home. And you’re starting a program at MD Anderson. I wondered if you could share with our listeners, any lessons learned from starting up a hospital-at-home program at an institution.

Tacara: The hospital-at-home users group is, really, just a tremendous resource to get you started. And I think this is a community of folks who’s just really passionate about the model of care. You can email anyone, or call anyone to ask questions and learn. For somebody who is, generally, a bleeding heart, it’s been a little bit more challenging to think about the reimbursement and finance piece, but that’s really essential to what we’re doing. You can’t deliver care if you can’t reimburse people for the work that they’re doing. Really thinking through what that looks like for your institution is important, and understanding what need the program is supposed to meet for your specific institution, because they’re not all the same. There are some programs who are thinking about expanding bed capacity. There are programs, like ours, that think about this more as patient-centered, even though it will not have a substantial impact on bed capacity. There are many, many reasons for doing it. But I think, because of the tremendous operational and financial investment required to get started, it’s really important to be thoughtful about those steps in the beginning.

Eric: All right. In the last minute, last question for both of you. Magic wand, you can do anything that you want around hospital-at-home. Tacara, what are you going to use that magic wand on?

Tacara: I would use that magic wand for Bruce’s hospital platform reimbursement, so that you could think about where somebody is in their needs at home, and be able to pay for that agnostic to which type of care you’re providing.

Eric: Bruce?

Bruce: Yeah, I think, in the hospital-at-home context, I would like to see a long window on a payment. The DRG payment, I don’t think is the ideal long-term, value-based payment, as much as I hate the term “Value-based.” Right now, we’re in the middle of a two-year extension. I think systems need a longer runway to get some sense of permanence, although I do think that’s been factored into the market, as it were. I’d like to see, maybe, a five-year extension of the waiver, or something like that, so that we can then get the data that we need to come up with a more permanent, better payment approach. And remember, as Medicare Advantage penetration increases, that’s going to change how we think about this as well. I’ll stop there.

Eric: Tacara and Bruce, thank you for joining us. But before we add, Alex is going to give us a little bit more Homeward Bound.

Alex: I love this song. When I was in med school, this is about 20 something years ago, I spent a few months in India and Nepal. And towards the end of that, I remember I was in Kolkata, I was waiting for a train to take me to Delhi to fly home. I had this song, Homeward Bound, on repeat. I was so homesick at that point, so ready to be back. This just brings me right back to that train station in Kolkata. Thank you for this gift. Here’s a little bit more.

Alex: (Singing)

Eric: Bruce, Tacara, thank you for joining us on the GeriPal podcast.

Tacara: Thank you.

Bruce: Thanks guys. It was great to be here.

Eric: And thank you to all of our listeners for your continued support.