Why we should expand hospital-at-home during the COVID-19 pandemic

As the COVID-19 pandemic expands globally, we need to ease the burden on increasingly overwhelmed healthcare systems. In the US, the federal government has declared a state of emergency, opening up the opportunity for dramatic changes to care delivery. And world leaders are making unprecedented modifications to healthcare systems and social services.

As countries around the globe weigh new policies, they should consider the expansion of primary care to include hospital-at-home services. After all, a hospital admission prevented by strong outpatient primary care is an extra hospital bed for a patient who needs acute care due to COVID-19.

Primary care is uniquely positioned to manage acute care needs during the ongoing pandemic. Delivery of good primary care prevents emergency department visits, saves resources and prolongs life.

Primary care delivery systems should incorporate hospital-at-home programmes, which allow hospital-level assessment and management in the home. These programmes are feasible, save resources and prevent in-hospital transmission of COVID-19. In the longer term, these programmes will be key components of robust primary care systems, helping advance the goals of higher quality, cost-effective, more accessible care.

Primary care-driven hospital-at-home programmes have been developed in the US with promising outcomes. Medically Home, as one example, delivers hospital-level care in the home in the Boston, Massachusetts, area for patients with a variety of conditions, including heart failure, pneumonia and chronic obstructive pulmonary disease. After a patient is identified as qualifying for hospital care in the home, clinicians assess the patient in the home and can arrange for nursing, durable medical equipment, oxygen therapy and even home radiology, and use telemedicine technology to frequently reassess patients. The service has been found to be safe, cost-effective, better for patients’ ability to complete activities of daily living and appreciated by patients. Similar programmes are being tested at the Brigham and Women’s Hospital and Johns Hopkins, among others.

Internationally, hospital-at-home programmes have been piloted successfully in countries including Australia, Italy, New Zealand and the United Kingdom. In one meta-analysis, home-based hospital care in these countries was shown to be safe and reduce mortality in the six months after patients received hospital-level care, while also reducing costs.

There are many benefits of hospital-at-home during the COVID-19 pandemic.

First, the programme allows delivery of hospital-level medical and social services in the home both for patients with COVID-19 and for patients with other conditions. This frees up hospital beds and other resources for patients truly requiring aggressive inpatient therapy.

At the same time, it would keep vulnerable patients out of the hospital, protecting them from the risk of acquiring the coronavirus. As one group in Italy recently reported, hospitals have the potential to be epicentres in this pandemic. Moreover, this programme permits the delivery of care to patients who might otherwise not seek care at the hospital for fear of acquiring COVID-19.

Health systems must act quickly to see the benefits from these programmes. Payment models most conducive to the development of hospital-at-home involve some component of capitation for primary care, as these models allow the financial flexibility required to initially invest in the necessary infrastructure. In settings where healthcare is reimbursed on a fee-for-service basis, government funding should be earmarked to establish these programmes swiftly.

A robust infrastructure for telemedicine is also required, as telehealth technology allows clinicians to monitor patients in-home and make treatment recommendations. Although historically this infrastructure has been lacking, telehealth has seen a rapid boom in response to the current crisis.

A key component of hospital-at-home care is effective management of social and behavioural health needs. These determinants of health are often overlooked but become increasingly prevalent in times of crisis. The Organization for Economic Cooperation and Development (OECD) is predicting that the pandemic will dramatically impact global economic growth. More people will be at risk for unemployment, housing instability and food insecurity. Likewise, it’s probable that anxiety, loneliness and depression will skyrocket in the coming days. Post-traumatic stress disorder rates will also likely rise, too, as shown in studies of psychiatric illness after Hurricane Katrina.

With no other avenue for food, shelter and mental healthcare, patients may be forced to seek care at the hospital. Before the time of COVID-19, this would have been an ineffective and costly outcome. Today, it’s more dangerous than ever, as patients are at high risk of becoming infected at the hospital. To address these needs, funding should be made available to employ community health workers and expand mental healthcare availability in primary care practices.

Community health workers are experts in the resources associated with the local community. They work in concert with primary care providers and are able to help patients complete housing applications, find food pantries, connect with local shelters and navigate the healthcare system. Their work has been shown to reduce costs and preventable utilization of healthcare. Licensed clinical social workers and psychiatrists likewise would deliver invaluable psychotherapy to help patients in times of crisis. These providers can interface with patients through hospital-at-home programmes to ensure that all factors affecting patients’ health are being addressed, and to see that patients are not forced to seek care at the hospital.

Even after the COVID-19 pandemic resolves, governments should continue the expansion of primary care and hospital-at-home services. We anticipate that patients and primary care teams will find that these services improve the care experience and outcomes, both during and after the pandemic.