Focus: Hospital-At-Home Is The New Trend In Healthcare

When Martin Fernandez came into Mount Sinai Hospital's emergency room one re-cent afternoon, with high fever and excruciating abdominal pain, he and his family were asked an unexpected question.

Fernandez, 82, would have to be officially admitted to receive intravenous antibiotics for his urinary tract infection. But he could stay at Mount Sinai, or he could receive treatment at home.

If he chose to be hospitalized at home, doctors and nurses would visit daily. He would receive lab draws and intravenous medications, even X-rays or ultrasound scans if he needed them. The costs would be no greater than if he were physically in hospital. In three or four days, he would be discharged -and he would not have to go anywhere.

For Fernandez, a retired house painter from Venezuela who lives with his wife on Manhattan's Upper West Side, the choice was clear. He was hospitalized at his daughter's apartment, just a couple blocks away , a few hours later.

He had a urinary catheter, but Fernandez could still wear his own clothes during the day and his pajamas at night. His wife and his daughter cooked him meals of arepas, vegetables and black beans and served them to him in bed.

Under pressure to reduce costs while improving quality , a handful of hospital systems have embarked on an unusual experiment: they are taking the house call to the extreme, offering hospital-level treatment at home to patients like Fernandez.

Back in the late 1980s, as part of his primary care training at the Johns Hopkins University School of Medicine, Dr Bruce Leff noticed that for many patients hospitals were a scary proposition.

So Leff and his colleagues had an idea. What if patients could be hospitalized in their own beds?

The first task was to determine which common conditions required admission but could be treated with technologies placed in the home. Leff and his colleagues settled on four diagnoses: heart failure, exacerbations of emphysema, certain types of pneumonia, and cellulitis, a bacterial skin infection.

With a grant from the John A Hartford Foundation, Leff and his team offered outpatient hospi tal-level care to nearly 150 patients with these four diagnoses who would otherwise have been treated at one of three hospitals and compared those patients with a similar group who were hospitalized in the usual way . They called their program `Hospital at Home'.

The findings, published in The Annals of Internal Medicine, were promising. Offered the opportunity, most patients agreed to be treated at home. They were hospitalized for shorter periods, and their treatments cost less. They were less likely to develop delirium or to receive sedative medications, and no more likely to return to the emergency room or be readmitted.

But even with the most careful admitting criteria, the unexpected happens. Home-hospital providers have had to move patients to the hospital for worsening conditions. Still, it is an infrequent occurrence: only 2.5% of these patients must be moved into the traditional hospital.