key: cord-0701239-gkn4vapc authors: Ouchi, Kei; Liu, Shan; Tonellato, Daniel; Keschner, Yonatan G.; Kennedy, Maura; Levine, David M. title: Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities date: 2021-07-21 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12517 sha: ffa8302d823c84186ce59655ab91da26f51dc6fa doc_id: 701239 cord_uid: gkn4vapc The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for “home hospital” services. A “home hospital” is the home‐based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital‐level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department. increasingly costly, accounting for about one third of total medical expenditures, and is a leading cause of patient debt. 17 The novel coronavirus disease 2019 (COVID- 19) pandemic further demonstrated the limited ability of hospitals to increase inpatient capacity to accommodate a surge in patient hospitalizations and acuity. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services (CMS) announced the acute hospital care at home waiver to reimburse for "home hospital" services. A "home hospital" is defined as home-based provision of acute services usually associated with the traditional inpatient hospital setting. 2 Prior work suggests that home hospital care can reduce cost, maintain quality and safety, and improve patient experience for select acutely ill adults who require traditional hospital-level care. [3] [4] [5] [6] [7] [8] [9] [10] [11] Although home hospital care is familiar in several developed countries, 18 only 2 randomized clinical trials have been conducted in the United States. 19, 20 The CMS's unprecedented announcement recognizes the benefits of home hospital services and has the potential to rapidly expand hospital capacity in the midst of the COVID-19 pandemic. More than 96 hospitals in the past 2 months have already been granted waivers. This announcement will likely trigger a wave of health systems investing to provide hospital-level care in patient homes in the next year. However, given the dearth of institutions currently offering this service from the ED, most emergency physicians are unfamiliar with the existing evidence in support of using home hospital services as a disposition option. With the anticipated rapid increase in dissemination of home hospital services across the United States, the urgent need exists to delineate the proven and potential benefits and future opportunities for research specific to emergency medicine. In this concept article, we discuss the benefits of home hospital care compared with traditional acute care, describe additional potential benefits specifically for older adults, and delineate important areas for emergency medicine-focused research. As one of the institutions that provided evidence for the CMS to develop the "home hospital" waiver with experience caring for >1000 patients on the home hospital service, the lead author solicited narrative inputs on this topic from our experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then, we sought to highlight information most relevant to the practice of emergency medicine. Variations within home hospital exist ( Figure 1) The experience of care is substantially better with home hospital service compared with traditional hospitalization. Qualitative results demonstrated the contributing reasons for better care experience: better environment to promote activity and sleep (eg, patient's own room with own bed, reduced ambient noise), better availability and ease of contact with the clinical team, more contact to family and friends (if desired), and more familiar and comfortable food for nutrition and psychological well-being. 27 In addition, patients randomized to home hospital service felt that the admissions process was a better experience compared with those who stayed in the traditional hospital. Home hospital service also improves the experience of care for patients transitioning to hospice care. For patients at the end of life, a structured approach to transition to hospice care in the ED is possible but remains difficult given the complexity of steps required. 28 Although emergency physicians are becoming more experienced with goals-of-care conversations, 29 There will be little change to the emergency physician's workflow. No restrictions on diagnosis exist for the CMS waiver. To provide examples, the CMS identified >60 diagnoses as appropriate for home hospitalization; common diagnoses include heart failure exacerbation, pneumo-nia, chronic obstructive pulmonary disease exacerbation, and cellulitis. Patients with COVID-19 infection may be safely cared for at home 31,32 ; thus, home hospital effectively expands the hospital capacity during this and future pandemics. The initial evaluation and treatment in the ED will remain the same; emergency physicians will evaluate and treat patients and determine an appropriate disposition. When considering hospital admission, emergency physicians will consider the appropriateness of home hospitalization as an alternative in collaboration with the home hospital team. Given the relative novelty of the home hospital service, no standard- Although home hospital programs are mostly in the early phases of development, it is important to focus on solutions that will allow equi- This may include providing portable air conditioning or heat and may eventually include more permanent solutions for problems at home. The COVID-19 pandemic has highlighted the limits of hospital capacity across the country. Home hospital programs have demonstrated the capacity to expand hospital capacity in a safe, efficient, and patient-centered manner while reducing the cost of care. 35 Future areas of research remain despite the robust current evidence base. Delirium is a life-threatening condition, characterized by an acute change in mental status and inattention, disorganized thinking, and/or altered level of arousal. 36 Although 8% to 17% of community-dwelling older adults in the ED have delirium, delirium occurs in 18% to 35% of hospitalized older adults. 14, 37, 38 Up to 50% of delirium in hospitalized older adults can be prevented through multicomponent prevention programs. 39 19, 20 it stands to reason that this aspect of delirium prevention would also be enhanced by a home hospital program. As a physical change in environment, such as hospitalization, can be a trigger for delirium in at-risk individuals, 14 avoiding hospitalization entirely may be even more successful in preventing delirium than nonpharmacologic delirium prevention strategies in the hospital. The evidence is mixed to date regarding the efficacy of home hospital programs to prevent delirium. 3, 20 However, one study of an in-home rehabilitation program demonstrated reduced delirium compared to inpatient rehabilitation program. 10 Furthermore, home hospital care for patients with delirium may be associated with reduced length of stay compared with usual inpatient care, with no impact on mortality. 41 It is critical that future studies of home hospital programs use validated tools to assess for delirium to better understand the impact of the programs on this important geriatric syndrome. Opportunity 2: Avoid hospital-associated, increased fall risk and novel home falls evaluation Low mobilization is common during hospitalization, leading to functional decline 43, 44 (eg, hospitalized patient's quote, "I couldn't get to the toilet when I wanted. You just have to rely on the nurses, there's nothing else you can do. I once had to call three times, and by the third time, I had wet my bed."). 45 In a non-randomized study, patients in home hospital were associated with improvements in instrumental activity of daily living compared with acute hospitalization. 46 Less ambient noise at home (eg, machine beeping) may also decrease sleep deprivation and delirium, leading to accidental falls. 47 Opportunity 3: Expand clinical indications for home hospital Access to home hospitalization remains limited to certain disease pathways. This limits the scope of practice and excludes many patients who may otherwise benefit from home hospital. We need to invest in research to better understand other conditions that may benefit from home hospital. For example, a recent trial found decreased cost and healthcare use among patients with cancer hospitalized at home. 54, 55 Studies published 2 decades ago demonstrated that patients with neutropenic fever may be treated at home with antibiotics and close monitoring and thus may be great candidates for home hospitalization. 56 Furthermore, other illnesses may be amenable to home hospital care by further exploring the literature and innovating care protocols. For example, home hospital is currently available for selected postoperative surgical patients, and this could be further expanded to include surgical re-admissions for ileus, small bowel obstruction, or other patients F I G U R E 2 Current and future of home hospital admission workflows. ED, emergency department; HH, home hospital; MD, physician; RN, registered nurse admitted by a surgical service from the ED who do not require immediate surgical intervention. 57 Opportunity 4: Automation of patient selection for home hospital Currently, the identification of patients for home hospital is time intensive to ensure the best possible match. The home hospital team must first review individual patient charts for numerous clinical and environmental factors to help determine which patient may be an ideal candidate. Using artificial intelligence, predictive models can be developed to help identify potentially suitable admissions. Given that machine-learning models have been shown to predict mortality in the ED, similar models could be developed to automatically risk-stratify patients and quickly identify the best candidates for home hospital. This model could also incorporate predictors of patient refusal for home hospital admission. 58 An automated process would help optimize the clinical and administrative process for patient selection. A relatively simple research design would be to first retrospectively and then prospectively compare the results of the current manual selection of patients for home hospital with an automated machinelearning model to select patients. Predefining specific patient-centered and caregiver-centered outcomes (eg, caregiver burden) becomes essential to rigorously study the effect of such an automated algorithm. Opportunity 5: Protocols to bypass ED evaluations before hospitalization As telehealth technology, wearable medical devices, and point-of-care testing become more widespread, the remote evaluation of patients with acute illness is becoming more sophisticated (Figure 2 ). In the near future and depending on the condition, physicians may be able to determine if a patient requires hospitalization through a remote or paramedic-facilitated visit with point-of-care testing only. 59 This could change the admission process, which currently requires an in-person evaluation. If such a bypass of ED evaluation is possible, this may reduce caregiver burden further during an acute illness, which is also an important outcome to consider throughout the evaluation of home hospital service. More research is needed to demonstrate the safety and efficacy of such an ED bypass protocol. The future "upstream" possibility exists that a patient may be evaluated by a physician, admitted, and discharged without ever leaving his or her home. With the right protocols in place, such a model may help bring home hospital to rural areas, where nearly 1 in 5 Americans lives. 33, 34 2.5.6 Opportunity 6: Technology for remote patient monitoring Home hospital is reliant on accurate, reliable remote patient monitoring to provide a safe, effective, and scalable home-based hospitalization environment. This need has spawned significant interest in health technology companies and venture capital to rapidly produce new devices, including wearable biosensors and peripheral monitoring devices. The current technologies provide the clinical team with near real-time monitoring of patients' vital signs and physical activity level, allowing the care team to intervene early if a problem should arise. A primary opportunity for research and care improvement is predictive algorithms based on vital sign data and activity level to predict clinical decline. This would provide clinicians the opportunity to make medication adjustments, perform further diagnostic testing, or perform therapeutic interventions earlier in the clinical course. Ample opportunities exist to enhance the current remote monitoring so that clinicians can monitor the well-being (eg, physical, psychological stress, hydration status) of their patients beyond basic vital signs and physical activities. 60 Home hospital is a safe, effective, and cost-efficient acute care service, which could be especially beneficial for older adults presenting to the ED. Home hospital will rapidly disseminate to become the standard of care in the United States but requires the buy-in and expertise of emergency physicians to facilitate this paradigm change. Opportunities exist to further improve this line of clinical service in the near future. Dr. Ouchi is supported by National Institute on Aging (K76AG064434) and the Cambia Health Foundation. Dr. Levine reports grant funding and codevelopment with Biofourmis and grant funding from IBM that is separate from the present work. 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