As hospitalists caught on, so too can the hospital at home

As the industry debates what it will take for the hospital at home to succeed, a recent Health Affairs commentary drew parallels to the ascendance of the hospitalist – a concept that was similarly controversial when first introduced but now widely accepted as best practice.

The authors, Drs. Robert M. Zimbroff and Robert M. Wachter of the University of California San Francisco, noted the hospitalist and the hospital at home concepts first appeared in (separate) journal articles in 1996.

Both came with promises of better outcomes, lower costs, and higher patient satisfaction than traditional hospital stays. Within a decade, “the hospitalist model came to define inpatient medical care,” Zimbroff and Wachter wrote.

Meanwhile, it took a global pandemic with stay-at-home orders and supply chain disruptions to lift the regulatory burdens holding hospital at home back. That said, waivers through the Centers for Medicare & Medicaid Services’ Acute Care Hospital at Home program are due to expire at the end of the year. This is likely to shut out small hospitals unable to foot the bill for staff and infrastructure.

According to Zimbroff and Wachter, hospital at home advocates need to do two things to help the concept reach its potential: Define the role of clinical staff and make the business case. On both points, advocates can draw from the rise of the hospitalist.

The role: A general specialist in the home

Advocates for the hospitalist role emphasized the ability to provide 24/7 care at a time when primary care physicians (PCPs) typically made rounds in outpatient facilities. As “site-defined general specialists” with a narrower scope of practice than primary care, hospitalists were better positioned to provide high-value care within the hospital than PCPs.

In a sense, hospital at home physicians are “home hospitalists,” Zimbroff and Wachter suggested. They have a similar narrow scope of practice (the home) and require a unique set of skills (from interpreting biometric data to navigating home-based care). The term, they added, “reinforces both the special nature of the home-based location as well as the competencies – clinical and operational – of providing high-value acute care that hospitalists have honed.”

The framing of the hospitalist’s responsibilities, coupled with evidence of its effectiveness, helped hospital leaders understand the value of the role and invest in it. Critically, that investment included training, credentialing, and research. A similar mindset could help advance the cause of home hospitalists, Zimbroff and Wachter argued.

The business case: More beds for high-acuity care

Hospitalists stated their business case by proving two things. One was their ability to reduce costs and improve efficiency enough to cover the difference between their salary and the reimbursement rate for hospital care. The other was that the revenue PCPs would gain from additional outpatient volumes would make up for the revenue lost by no longer conducting inpatient rounds.

Hospital at home advocates need to make a similar argument, Zimbroff and Wachter said. An effective program would enable lower-acuity patients to be “discharged” to the home, as well as patients at a high risk of hospital-acquired infection. This would improve clinical outcomes – and, on the financial side, it would free inpatient beds for high-acuity cases that reimburse at higher rates.

That said, Zimbroff and Wachter pointed to a unique obstacle in the business case for the hospital at home: The supply chain. Effective care at home depends on the availability of medications, monitoring devices, and other medical equipment. Amid limited demand relative to hospital admissions, suppliers may find it difficult to support timely deliveries to patients’ homes.

 Brian Eastwood is a Boston-based writer with more than 10 years of experience covering healthcare IT and healthcare delivery. He also writes about enterprise IT, consumer technology, and corporate leadership.