Hospital at home: A movement whose time has come

Each year, nearly a million Americans find out they have heart failure. This diagnosis isn't as quite as dire as the name sounds (see "What is heart failure?"). Still, it's one of the top three reasons older people are admitted to a hospital — and about half of these people return within six months. But what if you could receive the same high-level care for this common condition in the comfort of your own home?

Hospital at home isn't just a dream, but a well-researched concept that's been around for decades and already practiced in Australia and many European countries. Now, it's finally starting to take hold in the United States, thanks to a waiver from the federal government that currently allows Medicare to pay for the program.

A growing need

"The COVID-19 pandemic, along with the rising numbers of aging adults in this country, made it very obvious that we need to increase our capacity for providing hospital-level care," says emergency medicine physician Dr. Jared Conley, associate director of the Health Care Transformation Lab at Massachusetts General Hospital. Back in 2016, he and colleagues launched hospital-at-home programs there and at Brigham and Women's, another Harvard-affiliated hospital. Their early experience focused on treating people with a variety of medical conditions but especially worsening heart failure, which often accounted for one-third of hospitalizations, he says.

The hospital-at-home programs at the two Harvard hospitals were found to be just as safe and effective as in-hospital care, with equal or improved survival rates. People also preferred the at-home care and were less likely to require repeat hospitalizations. Another bonus: hospital-at-home care was about 30% to 40% less expensive, says Dr. Conley.

What is hospital at home?

Of course, some people are too ill and unstable to receive care at home. But many people who need less-intensive treatment are good candidates for hospital at home, where a doctor oversees your care visits once daily (sometimes via videoconferencing), along with nurses or paramedics who come to your home at least twice a day. If you have heart failure, you may have a video consultation with a cardiologist to fine-tune your treatment. Treating an episode of worsening heart failure usually requires intravenous medications that help remove fluid from the lungs and elsewhere in the body. In addition to setting up the apparatus to deliver those drugs, nurses or other care team members can draw blood and carry out other tests, including portable ultrasounds of the heart and chest x-rays, as needed. Health care team members will check your vital signs daily, but you'll also be constantly monitored via a small patch on your chest that measures your heart rate and rhythm, breathing rate, and activity. (It also features a sensor that determines if you've fallen.) All equipment is provided by the care team, including the tablet used for video visits and, if needed, a separate device to enable a fast, reliable Internet connection. "Home is a much better environment for healing — you sleep better, are less sedentary, and can have more social interaction with family and friends," Conley notes.

Future directions

Before the pandemic, there were no more than 20 hospital-at-home programs in the United States. "But once the Medicare waiver took effect, the care model increased almost exponentially," says Dr. Conley. Today, there are 260 hospitals in 37 states in various stages of starting or expanding their programs to provide at-home hospital-level care. In December 2022, Congress approved an extension of the waiver for another two years.

Heart failure cases are expected to rise significantly in coming years as America ages. "Instead of building more and more brick-and-mortar hospitals, which often require capital outlays of about $2 billion each, we have a unique opportunity to rethink the way we care for people. Our north star for patient care should be maximizing days spent healing safely in the comfort of our own homes," Dr. Conley says.

Image: © Phynart Studio/Getty Images