Pandemic boosts ‘hospital home care’ model

BOSTON — Last week, Bud Waite reported to the Emergency Department at Brigham and Women’s Hospital with swelling in his legs, a complication of long-standing heart disease. The World War II veteran, who turns 96 later this week, needed hospital care, doctors determined.

But his medical issue wasn’t so critical that he had to actually be IN the hospital. Instead, doctors arranged to have the hospital come to him.

Hospital Home Care isn’t entirely new. But the pandemic made it more relevant than ever. In the spring of 2020, during the first surge, Brigham and Women’s cared for 65 patients through hospital home care. That not only freed up beds for COVID patients, it saved money.

“There’s about a 38% cost reduction when you deliver this care at home compared to the hospital,” said Dr. David Levine, the medical director of strategy and innovation for Brigham and Women’s Home Hospital.

Levine once did home visits as a high school chemistry teacher in Chicago. He never forgot the effectiveness of those visits to students’ homes and, after becoming a doctor, sought to integrate those experiences into hospital care. The result is a small, but growing program at Brigham and Women’s that operates within about a 10-mile radius of the hospital and its partner, Faulkner Hospital, and involves, at any given time, 15 patients.

Each patient is visited by a doctor once a day and a nurse twice a day. Patients are also remotely monitored 24-hours a day. Of course, not every medical condition is suitable for home hospital care. The general rule of thumb for inclusion: acute but not critical.

“Patients with cellulitis, UTIs, pneumonia, patients with heart failure, exacerbations of COPD and asthma,” Levine said. “Really what we like to think of as the bread-and-butter of general internal medicine can often very effectively be taken care of at home.”

However, those conditions do not automatically make a patient eligible for at-home care.

“It’s really an interdisciplinary discussion involving the emergency department team if the patient is in the emergency room,” Levine said. “We involve the whole team up on the floor if the patient is on the floor at the time of transfer to home hospital. And we have a whole set of inclusion and exclusion criteria we make sure the patient fits. That they’re not so sick that they’re going to end up in the ICU, but they’re sick enough that they’re still going to need hospital-level care.”

During the height of the pandemic, and before vaccines were available, it was obvious why hospitals could be dangerous places for patients. But even in the best of times, hospitals can be hazardous to human health.

“When a patient walks into an average American hospital, one in 10 times some sort of an adverse event is going to happen,” Levine said.

For one thing, there’s the risk of hospital-borne infections, which can be stubborn, sometimes impossible to treat. And then there are the smaller things that hinder healing: the loud roommate, the middle-of-the-night vitals checks, the constant beeps and buzzes of monitoring devices. No surprise, then, that studies have shown higher patient satisfaction when getting hospital care at home than in hospitals, Levine said.

Dr. Caroline Yang, who is taking care of Bud Waite, suggested that home hospital care creates a more holistic dynamic between patients and providers.

“I think by going home with the patient you get to see what their living situation is, who their family supports are, do they have stairs, what their kitchen looks like, what kind of food do they have - really get into the patient’s life,” she said. “And understanding how they live and maybe get a better sense of why they presented with the condition that they have and what factors made them sick, [that] then helps us really address and cater our care to something that will last beyond the hospitalization.”

Registered Nurse Nahall Rad, the other half of the team caring for Waite, has been working in hospital home care for three years.

“I’m able to build a stronger relationship not only with the patient but the family, and that allows me to deliver a higher level of care,” Rad said.

When told he was getting well enough to discharge from hospital care, Bud Waite was kind of sorry to hear it.

“This is a great plan,” Waite said. “I would like to be able to keep on it. But I guess I can’t be on it forever.”

“We also feel saddened to be leaving them, and in a way that’s a positive in that we’ve been able to fix their immediate acute issues and deliver a hospital-level of care to the home,” Rad said. “And we hope to see them out in the community but not in our emergency room.”

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