Creating access for hard-to-reach Medicare beneficiaries during the pandemic

The American health system must creatively use limited resources to meet the aging population’s needs. Every day, more than 10,000 seniors age into Medicare, and by 2030, one in five Americans will be 65 years or older. Brick-and-mortar hospitals lack the resources to meet those growing numbers.

To address inpatient bed capacity and workforce shortages during the PHE, three provider-aligned, nonprofit health plans innovated to expand existing acute-care-at-home services to reach at-risk and often rural seniors.

Presbyterian Health Plan in Albuquerque, New Mexico, and Security Health Plan in Marshfield, Wisconsin, used a Centers for Medicare and Medicaid Services (CMS) waiver to expand Medicare members’ access outside of hospitals. In Utah, SelectHealth built on existing home care efforts to begin offering at-home acute care services.

These unique Hospital at Home programs benefited local health systems and Medicare beneficiaries during the pandemic. The programs increased bed capacity and provided relief for frontline workers—while improving access and producing better health outcomes, higher patient satisfaction, fewer complications, and lower costs and readmissions.

These initiatives’ success supports the need for continued Hospital at Home programs nationwide and health plans’ key role investing in these care models for an underserved, at-risk population.

Existing infrastructure enabled nimble pandemic pivot
As COVID-19 spread, health plans with existing Hospital at Home infrastructure quickly expanded programs to provide additional access for high-risk seniors.

Presbyterian Health Plan has operated an at-home program in New Mexico, a state with one of the least hospital beds per capita, since 2008. The program admits patients needing non-intensive inpatient care for conditions such as pneumonia, congestive heart failure and chronic pulmonary disease. Patients must be otherwise stable if treated, not at significant risk for rapid deterioration and live within 25 miles of a Presbyterian hospital.

During the PHE, Presbyterian’s program admitted 74 new patients, 12 under the Medicare waiver. Emergency room clinicians and hospital care coordinators refer seniors for early discharge from brick-and-mortar settings or Hospital at Home admission. These seniors may not have received hospital-level care with inpatient beds at capacity. Services include visits from a provider, home health aide, care coordinator or social worker — as well as therapy, diagnostic testing and supplies.

In 2016, Security Health Plan became the nation’s first payer to implement 30-day home care for treating 150 traditionally inpatient conditions. Patients must live within 30 miles of the hospital and have strong cellular/Internet service and family support at home. During the acute phase, a Recovery Care Coordinator visits daily performing X-rays, EKGs and lab work; providing therapy, rehabilitation and nutrition counseling services; and delivering medical equipment. Once ready for discharge from the acute phase, the patient transitions to the monitoring phase, and the Recovery Care Coordinator assesses the patient’s health via phone calls and virtual interactions.

Security expanded this program under the waiver by providing the same inpatient level home care for Medicare patients, serving 39 patients between December 2020 and April 2021.

In 2019, SelectHealth and Intermountain launched Intermountain at Home to prevent or shorten hospital admissions and avoid readmissions through primary care, some hospital-level services and palliative care at home.

SelectHealth launched Hospital Level Care at Home in 2020 as an early discharge program for patients to finish hospitalization. However, when ICUs were at or above full capacity, Intermountain’s program freed up 10 to 12 beds per day though at-home treatment. In 2021, during the pandemic’s peak, the organizations’ emergency department diversion program for preventing hospitalizations resulted in over 60 percent of home admissions being emergency department patients.

Increased social distancing opportunities
Every day, one in 31 hospital patients has a health care-associated infection. During the pandemic, Hospital at Home programs offered care options with lowered risk for contracting COVID-19. Some organizations used their program to treat COVID-19 patients, while others reserved inpatient care for COVID-19 patients and used home programs to treat other conditions.

As Security/Marshfield health system’s inpatient beds reached capacity, the organization’s Completing Hospitalization at Home program treated COVID-19 patients. Patients either completed their inpatient stay from home or were admitted to the program from clinics or the ICU after stabilization.

Presbyterian used the Hospital at Home program to treat non-COVID-19 patients. By offloading brick-and-mortar hospital capacity, Presbyterian was able to provide its usual high standards of care to all at-home patients.

Intermountain’s program treated nearly 100 patients by the end of 2020. In 2021, the system admitted over five hundred patients. When the Omicron variant appeared, Intermountain fully used Hospital Level Care at Home as a COVID-19 program.

Better patient outcomes and satisfaction
Higher patient satisfaction correlates with better patient outcomes, and patients and their families tend to prefer the Hospital at Home programs over a hospital stay.

Compared to inpatient stays, Presbyterian at-home patients experience shorter average lengths of stay (3.3 days vs. 4.5 days); fewer readmissions (3.2 percent vs. 9 percent nationally); lower mortality rates (less than 1 percent vs. 1.5 percent for hospitalized Medicare patients); a fall rate of zero; and reductions in delirium, adverse drug events and other unintended consequences of inpatient hospitalizations. Patients maintained independence, leading to reductions in post-acute services, particularly skilled nursing facility use. Presbyterian reports a 96.8 percent patient satisfaction score (99th percentile rank/HCAHPS).

As with other Hospital at Home programs, Security’s patients recover quicker with lower risks of infection and fall incidence, and 44 percent fewer 30-day readmissions compared to the hospital setting. Home Recovery Care patients reported satisfaction rates of 90 percent.

More than 82 percent of patients in the Select/Intermountain program cite 5/5 satisfaction rates. None of the program’s patients have experienced serious safety events, and readmission rates have been 3 to 6 percent lower compared to trauma and community hospitals.

Reduced care costs
Hospital at Home programs consistently reduce costs for consumers and the health system.

Presbyterian provides lower-cost, high-quality care at home for Presbyterian Health Care patients without a patient co-pay. For those under the waiver, Presbyterian billed care for a standard inpatient hospital stay, without additional hospital room and board cost or charges for medications the patient was already taking at home. Relative to brick-and-mortar, Presbyterian estimates cost savings of 42 percent, including cost savings from the shared staffing model with Presbyterian’s Complete Care program, a population management initiative providing primary and urgent care services at home.

Without a brick-and-mortar stay, Intermountain bills Hospital Level Care at Home patients only for provider fees and home care by utilization, significantly lowering costs.

Security estimates cost savings of 15-30 percent by admitting patients with a reduced, bundled reimbursement rate, which includes medical visits, equipment, medications, labs, therapy and other necessary services.

Looking ahead: Hospital at Home for all
After widespread virtual care adoption during the PHE, consumers expect—and will demand—care anywhere. Presbyterian, Security and Select invested time and resources to build these patient-centered acute care in the home programs pre-pandemic, allowing them to pivot in the face of a pandemic and expand care access for at-risk seniors: all with better outcomes, shorter stays, lower costs and high patient satisfaction. Moreover, they reduce hospital strain by increasing bed capacity and alleviating staffing challenges. That is a model worth replicating.

Health systems nationwide can significantly benefit from a federal commitment to Hospital at Home programs. Permanent legislation can mandate cost savings and provide information sharing mechanisms. Value-focused, regional health plans advocate for making PHE flexibilities permanent and ensuring best practices and standards across the board.

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