In November, the Centers for Medicare and Medicaid Services took several new steps to help U.S. hospitals manage the crush of new patients as the COVID-19 crisis worsens. Among them were new allowances for telehealth and remote monitoring, for what CMS is calling the Acute Hospital Care at Home program.
Additionally, the agency expanded its Hospitals Without Walls initiative, with even more regulatory flexibility for ambulatory surgery centers to provide care as a “relief valve” to help overburdened hospitals.
Keeping patients at home
Simply put, home hospital involves delivering hospital-level care at home instead of in the hospital, said Dr. David Levine, assistant professor of medicine and medical director of strategy and innovation for Brigham Health Home Hospital at Brigham and Women’s Hospital.
“So, it’s a sick person who shows up at the emergency department, and instead of staying at the hospital and getting admitted and receiving all that hospital care, that person actually turns right around and goes home with a specialized home hospital team that delivers all the same care that they would have received in the hospital, but they get it at home,” Levine explained.
“And so you imagine this is a pretty amazing way to get your care,” he added. “We’ve got randomized control trials. We’ve done them at Brigham at Harvard. They’ve been done all across the country, all across the world. Actually, we’ve had randomized control trials showing that when patients get their care at home instead of in the hospital, they get readmitted less often. They like it more. And they end up moving a lot more and therefore preserving their strength.”
In addition to fewer readmissions and a better patient experience, the care costs less.
“We’ve actually shown in the U.S. in our most recent randomized control trial that care actually costs less, so there’s a societal benefit as well.”
Dr. David Levine, Brigham Health Home Hospital
“We’ve actually shown in the U.S. in our most recent randomized control trial that care actually costs less, so there’s a societal benefit, as well,” Levine said. “The CMS waiver is a really huge step forward. It’s what we’ve been waiting for some time now. Previously with Medicare, programs like mine had no way to bill for care. Now this is the opportunity to bill Medicare for home hospital-level care, and this is going to be offered all across the country.”
There is going to be a huge explosion of home hospital care; already there are 56 sites that have signed up in a month, he added.
Remote monitoring, wearable biosensors, AI and analytics
Boston-based Biofourmis, a vendor of digital therapeutics and virtual care that powers personalized predictive care, has codeveloped with Brigham and Women’s home hospital technology.
“From a technology standpoint, Biofourmis recognized several years ago that safely and effectively delivering inpatient-level care within patients’ homes was highly feasible, especially given the advances and increased adoption of remote monitoring, wearable biosensors, artificial intelligence-based analytics, and consumer technology such as mobile devices,” said Kuldeep Singh Rajput, CEO and founder of Biofourmis.
“During the past few years, we have been working with Brigham and Women’s Hospital to provide the remote monitoring technology for Brigham Health Home Hospital, a program they started in 2016,” he said. “Brigham conducted a randomized controlled trial of their home hospital program and published the results early in 2020 in the Annals of Internal Medicine.”
The study demonstrated improved outcomes, decreased costs and increased mobility in home hospital patients when compared with a control group that received usual care in the hospital.
Launching the new technology
Biofourmis launched the Biovitals Hospital@Home solution shortly after the CMS Acute Hospital Care at Home program was announced. This was an extension of CMS’ Hospitals Without Walls program announced in March, which provided broad regulatory flexibility that allowed hospitals to provide services in locations beyond their existing walls.
“When the CMS program was announced, Brigham already had years of experience with this care model, so they were one of only six health systems already approved by CMS to participate when the announcement was made right before Thanksgiving,” Rajput explained. “Since then, several other health systems have been approved for the waiver program, with CMS administrator Seema Verma regularly announcing them on Twitter.”
“Wearable biosensors continuously collect multiple physiological parameters from patients, and AI-based analytics are applied to that data across a wide range of complex chronic and acute conditions, including heart failure, chronic obstructive pulmonary disease, asthma and others.”
Kuldeep Singh Rajput, Biofourmis
Technology is an extremely important component of delivering hospital-level care in a patient’s home, enabling clinicians to remotely monitor patients as they deliver personalized high-quality care, he added.
“Wearable biosensors continuously collect multiple physiological parameters from patients, and AI-based analytics are applied to that data across a wide range of complex chronic and acute conditions, including heart failure, chronic obstructive pulmonary disease, asthma and others,” he said. “Hospital@Home is a modular solution that is easily customized to specific patient populations and conditions.”
Artificial intelligence and machine learning algorithms rapidly personalize the baseline for each patient, starting within the first several hours of monitoring. This approach provides clinical teams with a real-time look at a patient’s disease-trajectory that can enable them to detect, predict and prevent serious medical events before they occur by flagging any signs of decompensation that require intervention, Rajput said.
What clinicians expect
The idea from an operational standpoint is there are a lot of different things that need to be made portable and brought to the home because clinical staff expect all of these things in the hospital; there is no end-to-end software and hardware solution that does this right now, said Levine of Brigham Health Home Hospital.
“Our team, for example, uses something like eight or nine apps every day to manage our patients’ care,” he said. “Applications with different interfaces. And we use different monitoring sensors and different lab sensors and so on. And as you can imagine, that is clumsy. That is time-consuming. And frankly, it’s expensive as a result.”
So the idea was codevelopment of a system that would enable this care model in an easier fashion, he said.
Patients will receive 24/7 remote monitoring through the Hospital@Home solution for five to seven days. If needed, the monitoring period can be extended to up to 30 days. Biosensors will collect vital signs such as heart rate, respiratory rate, activity and other metrics that clinicians who are monitoring the patients can view from their dashboards.
Along with tracking sensor data, providers will communicate by text and video with patients through their mobile devices and complete clinically validated questionnaires on the Hospital@Home patient-facing app.
“The patients’ individualized biometric signature is dynamically updated and shared with the patient’s clinicians,” said Rajput. “Continuous analysis and refinement of the patient’s biosignature through machine learning can alert clinicians to signs of decompensation that in some cases may be flagged weeks before an event would have otherwise occurred without any intervention. When such a warning sign is detected, clinicians who round daily on patients can then perform any needed interventions to prevent a medical crisis.”
Preventing potential costly medical crises in this way can prevent readmissions and ED visits, which in turn lowers healthcare costs, he added.
Analytics offer actionable insights
“The analytics insight also can make home visits or virtual visits more efficient, because the clinicians entering the encounter have more actionable insight into how to accelerate recovery and shorten the admission based on the analytics data,” he said.
Brigham’s research has demonstrated that they can deliver hospital-level care in patients’ homes with lower readmission rates, more physical mobility and a positive patient experience. In Brigham’s randomized controlled trial of the home hospital program, they found the adjusted mean cost of the acute care episode was 38% lower for home hospital patients versus control patients treated in the hospital. In addition, only 7% of program patients were readmitted within 30 days, compared with 23% of hospital-admitted patients – more than a 70% improvement.
Home hospital patients had a median of three laboratory tests compared with 15 for hospital-admitted patients. Likewise, only 14% of home hospital patients required imaging studies, compared with 44% of hospital-admitted patients, and only 2% of the home patients required consultations with other physicians, compared with 31% of hospital-admitted patients.
Home patients only spent 12% of the day sedentary, compared with 23% of the hospital-admitted patients; and they only spent 18% of the day lying down, compared with 55% for hospital patients.