Why A ‘complete Shift’ Of Paradigm Is The Most Challenging And Promising Aspect Of Hospital-at-home

The hospital-at-home (HaH) model of care has gained significant momentum in recent years and is transforming how care is delivered to patients. This model enhances patient satisfaction and clinical outcomes by providing reliable, high-quality acute care in the comfort of patients’ homes. Additionally, technological advancements are revolutionizing health care, enabling patients to receive excellent services at home rather than in hospitals.

However, the model also represents a “complete shift” from the typical model of U.S. health care, which means that change management is crucial and may be the biggest challenge in expanding the HaH model.

That’s according to Dr. Stephen Dorner, chief clinical and innovation officer at Boston’s Mass General Brigham (MGB) Healthcare at Home, who spoke with Home Health Care News about the future of the HaH model, the impact of technology on this approach and more.

The conversation is below, edited for length and clarity.

HHCN: What key trends are you observing in the HaH space as we approach 2025, and how have these trends evolved during the past few years?

Dorner: There is tremendous enthusiasm in the health care space. The individuals working in this field are incredibly mission-driven and dedicated to solving many of the problems within the existing health care system.

During the last 50 years, we have built a health care system focused on facilities, primarily bringing patients to these locations to receive the care they need. However, we have not achieved true integration.

Patients often visit one clinic for a specific service, a hospital for emergency care and yet another facility for urgent care, all of which differ from their primary care provider’s office or post-acute care. Many see the home as an opportunity to create the seamless care continuum that is often discussed, though the current health care system is highly fragmented.

This enthusiasm is translating into significant interest and energy from individuals who want to continue addressing challenges in health care, such as capacity, finances, quality and patient satisfaction. They aim to change the paradigm of how and where care is delivered. As a result, there is constant innovation, with new entrants in the care delivery model, traditional hospitals evolving and an increasing number of hospitals participating in federal waivers. Additionally, many health care providers are now contracting for home hospital care, while tech companies seek to enable care delivery through modular and portable technologies used in the home setting.

Looking ahead to 2025 and beyond, the goal is to leverage the extensive data being collected through these technological modalities and across the various stakeholders in the space. This will allow for a shift from a reactive to a proactive and predictive perspective in health care. By using artificial intelligence (AI) and other tools, we can anticipate patients’ care needs and intervene in their homes, preventing situations that require facility-based care and helping them heal and improve within their home environments.

What specific technologies do you foresee playing a critical role in enhancing care capabilities at home?

When discussing health care at home, many people immediately think of remote patient monitoring, but there is so much more to consider beyond just monitoring vital signs. One important aspect is the need to assess individuals’ mobility and anticipate their mobility support needs, which will become increasingly significant in the future.

We can also expect advancements in portable mobile diagnostics, which encompass imaging, pathology and lab samples. More point-of-care testing will become available at patients’ homes, providing real-time results. This immediacy allows for actionable insights and eliminates the need to transport samples back to traditional health care facilities.

Another important development is in medication delivery. We need to move beyond the standard pill box that most people associate with home medication management. Instead, we should adopt more sophisticated and secure systems for medication management and dispensing within patients’ homes. These systems could be integrated with medical records, allowing health care providers to adjust medication dosages remotely. For example, a smart pill box could automatically identify whether a patient should take one pill or two without the provider needing to be present.

Overall, technological advancements will significantly enhance care delivery in the home, making it more sophisticated, robust and safe as we expand the types of support we offer.

What challenges do you anticipate in integrating new technologies into existing health care frameworks for home care?

Our existing frameworks were not designed with HaH care in mind. Consequently, this significant paradigm shift will inevitably encounter challenges and growing pains as it adapts to a space for which it was not originally intended.

A critical factor in moving forward is the signal and framework provided by Congress to foster advancements in this area. Many individuals are eager to invest in this space, which is filled with ideas, energy and momentum. However, they need assurance that there is a viable path for their investments. The congressional extension of the federal waiver for HaH is essential for enabling this and creating the necessary runway for technological advancements. This support will help stakeholders navigate the adjustments needed to integrate technologies into this innovative care environment.

I am confident that Congress recognizes the substantial bipartisan support observed during the recent continuing resolution negotiations. As they reconsider this issue before its expiration in March, I anticipate a longer waiver extension that will provide the necessary runway for new market entrants and encourage more significant investments in this space in the future.

How do you see the role of data and AI evolving in the HaH model?

We’ve never had as much data in health care as we do today. The long-standing adage “garbage in, garbage out” reflects the challenges of data, AI and predictive modeling. However, we are beginning to see significant changes, especially in the fidelity and sophistication of the data we collect at home and what it can produce through analysis.

When discussing AI and data in the home-based health care space, there are two key aspects to consider. One is less commonly emphasized: the identification of patients who should receive care at home. Being able to accurately identify the right cases and match them to the appropriate care settings is crucial. This is somewhat analogous to discussions about the use of ambulatory surgical centers, where decisions need to be made about which cases can be safely treated in these centers versus those that require hospitalization due to the likelihood of needing inpatient care or an overnight stay.

It’s essential to determine what types of cases can be successfully transitioned from the hospital to home care, considering the lower chances of these patients needing to return to a traditional hospital setting. By analyzing patient populations and developing algorithms that proactively identify those who can safely receive care at home, we can make important strides in this area, which has not received as much attention but has tremendous market interest.

The data collected from patients in their homes naturally captures more attention. We need to understand which patients succeed at home, their vital signs, mobility levels and fall risks. AI models will be instrumental in identifying these patients and providing feedback to health care facilities, helping to determine who may fare better at home and who may struggle. Furthermore, this information will allow us to anticipate patients’ needs more effectively, enabling earlier interventions in a proactive manner, as previously discussed.

As data becomes more abundant, how will this transparency affect research and the establishment of best practices in home care?

The pool of participants in this space has certainly deepened. When the Centers for Medicare & Medicaid [Services] waiver was first launched in November 2020, only six hospitals operated under the federal waiver. Now, that number has grown to more than 370. This increase means more operators are engaged in delivering this care model. As data becomes available from all these participants, we have a greater opportunity to identify trends and determine what works and what doesn’t. This will help us establish best practices.

At MGB, we have been fortunate to have thousands of patients who have trusted us with the transition of care into home-based settings. We are excited to continue contributing to the dialogue surrounding this topic. As an integrated academic medical system, we aim to use the information we’ve collected to inform discussions and debates about best practices as this field evolves moving forward.

How does the HaH model improve patient satisfaction, and what metrics are you using to measure its impact?

There is an ongoing meeting about a national patient survey with NRC Health that we are looking to deploy in the home-based care space. This is an important issue because our hospitals are overcrowded. As an emergency room doctor who practices clinically every week, one of the first things I hear from patients is, “How soon can I go home?” When I explain that they need additional care but then inform them they will have to wait in a hallway for a bed, their satisfaction plummets, and their trust in the care they will receive diminishes. We know that the quality of care they receive under such conditions is also compromised.

Caring for more patients in their own homes allows the clinician to give undivided attention to the patient at the bedside without the distractions of alarms or calls for assistance from down the hallway. This can significantly improve the quality of care. Who wouldn’t prefer to recover in their own bed, surrounded by loved ones and familiar objects, rather than in a sterile hospital environment? This comfort contributes to better outcomes and overall satisfaction with care.

Following the COVID-19 pandemic, many health care workers felt exhausted and burned out, and some considered leaving the field altogether. However, many who joined our HaH program discovered greater satisfaction in their clinical roles than in their previous experiences. This renewed sense of purpose helped them stay in the health care workforce.

[The HaH model] is tremendously beneficial not only for patients who are satisfied with the care they receive but also for clinicians who appreciate the deeper relationships they can foster with their patients. It reinvigorates the mission-driven spirit that motivated many of us to pursue careers in health care in the first place.

What are some common barriers health care institutions face when implementing the HaH model?

It’s a complete shift. Clinicians did not go to medical school, nursing school or physician assistant school to learn how to deliver care in this way. Our hospitals and clinics weren’t built with this approach in mind, which means there is a tremendous amount of change management required to adopt this novel care model. We need to ensure that patients, clinicians and health care systems all adapt to make this model a mainstream part of care.

I believe this is the biggest challenge for many as they venture into this space. However, once they take the leap and begin to see the benefits, the process becomes much easier. That said, technological barriers, regulatory uncertainty and financial instability can create hesitation for individuals considering this shift. These factors make it more challenging for them to fully commit, even though we know that doing so would greatly benefit their patients.

Looking ahead, what are your predictions for the growth and sustainability of the HaH model in the next five years?

The most important factor depends on what Congress decides regarding the five-year extension. If they provide that five-year runway for patients, hospitals and the market, it would be game-changing. Without it, I believe there will be a significant outcry from both health care providers and patients. We simply cannot meet patients’ care needs with the current number of beds in our brick-and-mortar hospitals. Additionally, we are unable to build new facilities quickly enough to address those care needs.

We can’t keep relying on the same approaches of the past and expect different results. The status quo has led to long wait times and many patients with unmet care needs, resulting in lower quality of care and decreased patient satisfaction. When quality and satisfaction decline, financial performance also suffers, making care delivery even more expensive, which only adds to the problem.

This is where HaH care becomes crucial. It offers a novel solution to our issues. I believe it provides an exit strategy to help us break the cycle and develop new solutions for the future.

What advice would you give to health care providers who are hesitant about adopting the HaH model or using new technologies in their practice?

I would encourage them to seize the opportunity. There is a tremendous amount of collaboration in this field that is refreshing on many levels, from sharing best practices to troubleshooting various barriers that individuals face. The mission-driven enthusiasm and excitement of those who are genuinely committed to fulfilling the quintuple aim of health care are evident. Health care is not just about quality, costs, capacity and satisfaction; it addresses many different challenges we encounter.

Additionally, there’s nothing more rewarding than hearing a patient share how they could return home to be with their granddaughter, dog and spouse. Patients who have benefited from this care model share these stories with us every day. Their experiences inspire us to get up and continue our work, pushing through barriers to make this care available to even more patients.

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