August/September 2011 Issue ◂ Previous Article (/publications/newsletters/quality-matters/2011/august-september-2011/in-focus) | Next Article(/publications/newsletters/quality-matters/2011/august-september-2011/news-briefs) Quality Matters offers reports on emerging models and trends in health care quality improvement and interviews with leaders in the field. Hospital at Home Program in New Mexico Improves Care Quality and Patient Satisfaction While Reducing Costs Summary: An integrated delivery system in Albuquerque, New Mexico, has been able to better meet the needs of its patient population by offering those who need acute care and meet specific criteria the option of being treated in their homes instead of the hospital. The program has reduced the average length of stay and cost of care and improved patient satisfaction. By Vida Foubister Issue U.S. hospitals face bed shortages that are expected to intensify as the population ages. To ensure access to care, health care system leaders have begun to look for creative ways to care for patients. "Hospital at Home," a program designed to provide acute care services in the homes of patients who might otherwise be hospitalized, has been demonstrated to increase the quality of care patients receive, improve their satisfaction, and reduce the cost of hospital care by at least 30 percent. [1] Despite its promise, broader adoption of the model by health systems across the country has been limited by payment policies that restrict reimbursement to care provided in the hospital setting. This case study profiles the work of one health system that launched a Hospital at Home program with the support of its health plan. Organization and Leadership Presbyterian Healthcare Services (http://www.phs.org/ (http://www.phs.org/)) (PHS) is an integrated delivery system based in Albuquerque that provides care to more than 750,000 patients throughout New Mexico. Presbyterian's network includes eight hospitals, a medical group with 34 locations statewide, home care services, and inpatient and outpatient hospice programs. Its managed care organization, Presbyterian Health Plan, provides commercial health insurance, Medicaid, and Medicare products to more than 500,000 members. The Hospital at Home program was developed by leaders of Presbyterian Home Healthcare, the health system's home care and Hospital at Home Program in New Mexico Improves Care Quality and Pat... http://www.commonwealthfund.org/publications/newsletters/quality-matte... 1 of 5 12/19/2014 10:42 AM hospice agency, who include Lesley Cryer, R.N., the agency's executive director; Karen Thompson, clinical director of special programs and Hospital at Home; and Scott Shannon, M.B.A., director of finance. They worked with Bruce Leff, M.D., professor of medicine at Johns Hopkins University School of Medicine (Johns Hopkins), who developed the Hospital at Home model. The system's executive and senior vice presidents were also ...

1. August/September 2011 Issue
◂ Previous Article (/publications/newsletters/quality-
matters/2011/august-september-2011/in-focus)
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Quality Matters offers reports on emerging models and trends in
health care quality improvement and interviews
with leaders in the field.
Hospital at Home Program in New Mexico Improves Care
Quality and Patient
Satisfaction While Reducing Costs
Summary: An integrated delivery system in Albuquerque, New
Mexico, has been able to better meet the needs of its patient
population by offering those who need acute care and meet
specific criteria the option of being treated in their homes
instead of
the hospital. The program has reduced the average length of
stay and cost of care and improved patient satisfaction.
By Vida Foubister
Issue
U.S. hospitals face bed shortages that are expected to intensify

2. as the population ages. To ensure access to care, health care
system
leaders have begun to look for creative ways to care for
patients. "Hospital at Home," a program designed to provide
acute care
services in the homes of patients who might otherwise be
hospitalized, has been demonstrated to increase the quality of
care
patients receive, improve their satisfaction, and reduce the cost
of hospital care by at least 30 percent. [1] Despite its promise,
broader adoption of the model by health systems across the
country has been limited by payment policies that restrict
reimbursement to care provided in the hospital setting. This
case study profiles the work of one health system that launched
a
Hospital at Home program with the support of its health plan.
Organization and Leadership
Presbyterian Healthcare Services (http://www.phs.org/
(http://www.phs.org/)) (PHS) is an integrated delivery system
based in
Albuquerque that provides care to more than 750,000 patients
throughout New Mexico. Presbyterian's network includes eight
hospitals, a medical group with 34 locations statewide, home
care services, and inpatient and outpatient hospice programs. Its
managed care organization, Presbyterian Health Plan, provides

3. commercial health insurance, Medicaid, and Medicare products
to
more than 500,000 members.
The Hospital at Home program was developed by leaders of
Presbyterian Home Healthcare, the health system's home care
and
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hospice agency, who include Lesley Cryer, R.N., the agency's
executive director; Karen Thompson, clinical director of special
programs and Hospital at Home; and Scott Shannon, M.B.A.,
director of finance. They worked with Bruce Leff, M.D.,
professor
of medicine at Johns Hopkins University School of Medicine
(Johns Hopkins), who developed the Hospital at Home model.
The
system's executive and senior vice presidents were also engaged
in the development of the program.
Objective
Presbyterian Healthcare Services introduced its Hospital at
Home program to achieve better clinical outcomes, increase

4. patient
satisfaction, and reduce costs. The program was also expected
to address the hospital's need for increased capacity, a need that
will persist after the opening of its new hospital in October.
(The emergency department of this facility has already opened
and is
admitting patients to the Hospital at Home program). Demand in
the area has increased both with local hospital closures and the
growing number of patients with chronic disease—a population
health system leaders project will double by 2030.
The health system's Hospital at Home program, implemented in
October 2008, is based on a care model developed at Johns
Hopkins. Through that program, clinicians evaluate patients
arriving at the emergency department who require admission for
community-acquired pneumonia, exacerbation of chronic heart
failure, exacerbation of chronic obstructive pulmonary disease,
cellulitis, and other conditions to determine whether their
illnesses could be treated at home.
Those who meet specific criteria for home treatment are given
the option of being admitted to the program. If they agree, the
patients are then transported home with any necessary
medications and equipment; a nurse arrives at the home within
one hour to
ensure continuity of care for patients who have arrived at the
hospital with acute care-level medical needs; and the nurse and

5. other clinical staff, including physicians, make subsequent
visits as need. Upon discharge from Hospital at Home, the nurse
gives
patients follow-up instructions and sends detailed information
to their primary care physician. At Johns Hopkins, where the
Hospital at Home program was developed, it resulted in
measurably improved outcomes, reduced iatrogenic
complications,
increased patient and family satisfaction, and lower costs of
care.
Targeted Population
Presbyterian currently offers the Hospital at Home program to
three populations of patients who live in the Albuquerque area:
those arriving at the emergency departments of Presbyterian
Hospital, Kaseman Hospital, and Rio Rancho Hospital; those
who are
referred from physician offices, urgent care, and the health
system's home health agency; and patients who are transferred
to the
program from the hospital. The latter category includes patients
who have transitioned from the intensive care unit to a step-
down
unit.
To enroll in the program, patients must meet the following
criteria:

6. They are being treated for chronic heart failure (CHF), chronic
obstructive pulmonary disease (COPD), community-
acquired pneumonia (CAP), cellulitis, complex urinary tract
infection (UTI), dehydration, nausea and vomiting, deep vein
thrombosis (DVT), and stable pulmonary embolism (PE).
1.
They are determined to be sick enough to be hospitalized but do
not need the intensive care unit (ICU), a determination
made using research-based criteria from Johns Hopkins for the
first four disease categories and criteria that Presbyterian and
Johns Hopkins developed together for the others. These
determinations meet criteria for hospitalization established by
Milliman and Interqual.
2.
They live close enough to the three Albuquerque hospitals
participating in the program to be able to return to the
emergency
department within 30 minutes, if needed.
3.
1 (#1)
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The patient is covered by Presbyterian Health Plan or chooses
to pay for the Hospital at Home service, as the program is not
covered by other payers.
4.
Process of Change
Presbyterian began in 2007 by convening 12 multidisciplinary
teams and giving each a charter with specific deliverables and a
timeline for achieving them. The teams spent the first nine
months of 2008 creating the processes necessary to roll out the
model,
with each team focused on one of the following areas:
marketing/communication, pharmacy, emergency department,
physician
care, quality, billing/financial, vendor contracting, clinical
nursing, intake and scheduling, human resources, legal, and
documentation/coding.
One obstacle the human resources team encountered was hiring
a lead physician for the program. "We went through three
rounds

8. of interviewing before we found a Hospital at Home doctor,"
says Cryer. "It seemed way too risky to physicians who were
used to
working in a hospital setting." (The health system has since
hired two more physicians for Hospital at Home and is in the
process
of training them to work within the new model.)
While the clinical teams worked to build staff acceptance of the
model, the marketing and communications team was tasked with
building patient awareness and acceptance of treatment at home.
They developed a commercial featuring a patient receiving care
through Hospital at Home, which ran on television for three
months, and promoted the program through billboard
advertising.
However, they are finding that many patients are learning about
the program through word of mouth. Patient acceptance of the
program is high; about 90 percent of eligible patients agree to
be admitted.
Using this multidisciplinary process helped to create "incredible
buy-in for the program," says Cryer, as it created institution-
wide
awareness of the new care model. "It's really the only way we
were able to create this virtual hospital in a nine-month period."
The Care Model
Once admitted to the program, patients are transported home

9. and seen by a nurse within one hour, and are visited once every
day
by a physician. A registered nurse comes one to two times per
day, as does an aide. These visits are supplemented by
telemedicine-based video monitoring. Through shared staffing
arrangements with departments whose clinicians are cross-
trained in
hospice and home care, the program is able to provide patients
with round-the-clock physician and nursing coverage. Their care
follows specific pathways, which were developed initially by
Leff and have since been modified and expanded for the needs
of
Presbyterian's population.
If needed, Hospital at Home patients have access to social
workers; rehabilitation services, including occupational therapy,
physical therapy, and speech therapy; and nutritionists. In
addition, contracted vendors, with whom the system had
existing
relationships through its health plan, provide patients with any
necessary equipment, oxygen, medication, infusions, diagnostic
services, and transportation. Similar to the hospitalist model,
the Hospital at Home program discharges patients when they are
stabilized and the lead physician provides a detailed summary
of the patient's treatment to their primary care physician. In
some

10. cases, patients that continue to need care, albeit at a lower
level, are discharged to regular home care.
Quality Measurement
Concurrent with the development of the patient care services,
quality measures were created to enable Presbyterian to
evaluate
the outcomes of Hospital at Home patients and compare them
with those of patients admitted to its hospital facilities. These
outcomes include patient and family satisfaction, illness-
specific clinical quality measures, hospital readmission rates,
and total
cost.
Payment Model
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The rollout of the program depended heavily on the system's
ability to create a mechanism to pay for the service, as
Medicare
does not cover it.
The health system relied on its relationship with the

11. Presbyterian health plan to do so; the plan reimburses providers
using a
bundled rate that covers the full continuum of costs, including
physician fees and ancillary costs for services provided by
contracted vendors, such as oxygen or diagnostic tests.
Presbyterian is able to do this because a high percentage of its
patients are
covered by its health plan and only about 40 percent of its home
care patients are covered by Medicare, as opposed to 80 percent
to 90 percent of patients in most home care agencies nationally,
says Cryer.
In addition, the system agreed to be reimbursed at a discount of
the Medicare Prospective Payment System, which determines
payments based upon Medicare Severity-Diagnosis Related
Groups (MS-DRG), sweetening the pitch to its health plan, says
Shannon. Presbyterian had been tracking its costs per Hospital
at Home episode of care and those managing the contracting
were
confident that the discounted rate would enable the program to
break even. The health system chose to contract as this rate as it
believes the Hospital at Home care model benefits patients.
Results
Within the first year, the Hospital at Home program admitted
125 patients with CHF, COPD, CAP, or cellulitis. Because CAP
and

12. COPD were found to be less prevalent in the summer months,
five more diagnoses—complex urinary tract infection,
dehydration,
nausea and vomiting, DVT, and stable PE—were added in
January 2010. Presbyterian worked with Hopkins to develop
enrollment
criteria for these new diagnoses and by July 2010, 261 patients
had been admitted to the program; this number reached 439 by
the
end of June 2011.
Though the implementation of Hospital at Home was not
without its challenges, the program appears to be a success. Its
performance indicators are all equal to or better than those
measured at the hospital facilities. In 2010, patient satisfaction,
as
measured by a Hospital at Home Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey developed
with
Press Ganey, was 94.5 percent. In the first six months of 2011,
among the 100 patients admitted to the Hospital at Home
program,
only one was readmitted to the hospital within 30 days for the
same diagnosis.
The program also has a lower average length of stay and lower
cost per episode than the hospital facilities. The average length
of

13. stay for Hospital at Home patients is 3.5 days; the length of stay
for comparable inpatient admissions is 5.4 days. And the
Hospital
at Home variable costs per stay are $1,000 to $2,000 less than
comparable inpatient costs per stay by diagnosis. These savings
ensue from lower costs for diagnostic testing—including labs
and radiology—and pharmacy; less clinical service
consumption;
cost avoidance due to prevention of complications and
rehospitalization; and flexibility in the staffing model.
All clinical outcomes are equal to or better than those found
among Presbyterian facility patients with 100 percent of
patients
meeting the indicators for: receipt of pneumonia and influenza
vaccination; antibiotics within six hours of diagnosis for CAP;
and
receipt of angiotensin-converting enzyme inhibitors (ACE
inhibitors) and angiotensin receptor blockers (ARB) for CHF.
Next Steps
Beginning in April, Presbyterian began work on a modified
Medical House Calls program, which uses physician home visits
to
increase the intensity of patient care in the home setting. "What
we're attempting to do is prevent patients from deteriorating so
much that they have to go into the hospital," Thompson says.

14. This, in turn, is expected to prevent the iatrogenic
complications—such as falls, delirium, infections, and exposure
to medication errors—that so often go hand in hand with
hospital
admissions for many of these patients.
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In addition to increasing the number of house calls, the system
also plans to increase physicians' presence with at-home
patients
through use of telemedicine, especially for patients discharged
from Hospital at Home and home care.
Implications
Presbyterian is committed to creating a community of early
adopters and, to that end, has worked with Johns Hopkins to
provide

15. guidance to about 30 organizations interested in establishing
similar programs. "Just having New Mexico able to do this isn't
going
to convince CMS to pay for it," says Cryer. The interested
groups tend to be other integrated health systems or systems
that own
hospitals, employ doctors, and/or have home care agencies.
Many of the organizations have close ties with a payer that
enable
them to negotiate innovative payment approaches.
Payment, however, remains a critical barrier. Presbyterian has
worked to create a replicable bundle of care that covers all
services,
with Hospital at Home as a standalone benefit with one co-
payment per admission. This, however, is only offered through
its own
health plan. Commercial payers have expressed interest in
purchasing the Hospital at Home service as a product, but
before these
health plans can offer it to their members, Presbyterian must
first test the bundled payment model that it has developed with
its
own health plan.
The model also depends heavily on strong connections with
physicians throughout a care system. Those leading Hospital at
Home

16. programs need to constantly remind emergency department
physicians, hospitalists, and primary and specialty care
practitioners in
the community to consider their services for patients requiring
acute-level care and must maintain close relationships with
caregivers to ensure their commitment to the program. "This is
such a new concept and no one has a reference point to it," says
Thompson. "We had to learn as we did it: 'What does a Hospital
at Home patient look like? How do you get them to look to
Hospital at Home as an alternative?' "
For further information, contact Lesley Cryer, R.N., executive
director of Presbyterian Home Healthcare at [email protected]
(mailto:[email protected]); Karen Thompson, clinical director of
special programs and Hospital at Home, [email protected]
(mailto:[email protected]); and Scott Shannon, M.B.A., director
of finance at [email protected] (mailto:[email protected]).
Note
B. Leff, L. Burton, S. L. Mader et al., "Hospital at Home:
Feasibility and Outcomes of a Program to Provide Hospital-
Level Care
at Home for Acutely Ill Older Patients," Annals of Internal
Medicine, Dec. 6, 2005 143(11):798–808.
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