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Hospital at Home: A New Frontier for Community Paramedics
For community paramedics (CPs), who have found ways to contribute to their community’s health in multiple settings and circumstances beyond picking up patients and delivering them to the emergency room, hospital at home represents a new frontier.
The concept, introduced in this country at Johns Hopkins University in the 1990s,1 got a boost during the pandemic from the federal government’s March 2020 National Public Health Emergency Declaration and November 2020 waiver program, which allowed qualified providers to bill Medicare for “Acute Hospital Care at Home” at rates equivalent to hospital DRGs.2 The waiver provisions were extended for two more years by Congress at the end of 2022.3
Advocates claim that hospital at home delivers an equivalent level of staffing, interventions and acute hospital medicine for patients with conditions such as congestive heart failure, chronic obstructive pulmonary disease, deep vein thrombosis, cellulitis or urinary tract infections that would normally qualify them for a hospital admission but instead can be safely managed in their own homes. This acute level of support allows them to receive acute-level care in a familiar and comfortable environment while avoiding exposure to hospital-acquired infections, reducing readmissions and ER crowding, and freeing up hospital beds.
Hospital at home typically involves in-person visits from the clinical team at least twice per day, with virtual online access to doctors and nurses plus high-tech equipment such as ultrasound, X-rays, EKGs, oxygen, intravenous pumps, blood draws and point-of-care lab testing—driven to the patient’s home.
Although there is considerable variation in how health care organizations assemble these pieces for their hospital at home programs, some established programs have opted to use community paramedics (CPs) to perform many of the required, twice-daily, in-person visits. For example, Erik Koper, a CP in Boston, performs home hospital visits for both Brigham and Women’s Hospital and Massachusetts General Hospital, both part of the Mass General Brigham system.
Meeting Patients Where They Are
“Unlike treating patients in a controlled environment like a hospital, where you know where all your patients are at all times, we don’t have that luxury,” Koper explains. “We have to meet the patients where they are. We understand the practical implications of seriously ill patients being in their own homes.”
Koper is part of a pool of hospital at home CPs who work for Mass General Brigham Ambulance Services, which serves the system’s health care at home programs and provides other mobile integrated emergency services. The CPs work staggered 12-hour shifts from 7 a.m. to 10 p.m., typically making six home visits per shift. Many of the visits are scheduled in advance, but the program also allows a buffer for crisis or surge needs. “I do admissions of patients coming home from the hospital and visit patients who need infusions or after-hours medications,” Koper says.
“You don’t know what you’ll see when you enter somebody’s home,” Koper continues. Emotions can run high. Most of the patients are chronically ill with underlying complications and have had multiple hospitalizations. “They know how sick they are,” Koper says. His role may also include advising whether the home setting appears unsafe or if the patient has taken a turn for the worse and needs to be readmitted to a bricks-and-mortar hospital building.
Koper estimates he spends up to half of a typical shift behind the wheel of a dedicated Ford Explorer or Chevy Tahoe stocked with a mini-pharmacy and a variety of medical equipment. He does this on metro Boston’s notoriously difficult roadways, and the parking is no picnic either. Another big difference from traditional paramedics: Koper visits solo, though he is in frequent virtual contact with the team by text or via Microsoft Teams with an onboard screen like those that Uber drivers use in the truck and a laptop in the patient’s home.
Favorable Outcomes
Numerous studies have documented reduced lengths of stay, lower rates of complications, higher patient satisfaction and cost savings for patients receiving hospital at home vs. comparable patients receiving their care in actual hospitals.4,5 But growth has been slow for this innovative model, with lack of standardization and variation in the regulatory environment from state to state. There is still some reluctance among potential stakeholders, including patients, referring physicians and payers other than Medicare. A lot of hospitals have applied for the waiver, but most programs are still quite small.
But this field is evolving quickly, stresses David Levine, MD, MPH, MA, attending physician and clinical director of research and development for Mass General Brigham Healthcare at Home. Now is a time for experimentation and program building, with the emergence of national companies to supplement and enhance the local hospital-based home programs, he says.
“We were among the first to use CPs in hospital at home,” Levine says. Home hospital CPs are seasoned, qualified, certified, advanced paramedics who have received additional training for this role. “Our community paramedics are used to doing acute care, but they learn the more advanced skills such as intravenous antibiotics and urinary catheters, along with softer skills like end-of-life conversations and care coordination,” he said. “I think CPs are a great fit for home hospital. They are trained and comfortable working in patients’ homes and communities. They love working closely with our physicians and nurses.”
Tia Radant, MS, NRP, a paramedic by training, directs the community paramedicine and hospital at home programs for the HealthPartners health system based in the Twin Cities of Minnesota. “Our eight CPs are fully integrated into our program,” Radant says. “They chart into the hospital’s EPIC electronic medical record.”
In 2018 HealthPartners decided to conduct a hospital at home pilot for patients with CHF. The pilot was a successful proof of concept but elements of the initial model were too expensive, Radant reports. “We paused before retooling a new model with CPs doing all the home visits, and when COVID hit, our system realized we needed to provide this care on a broader scale.” Hospitalists on the hospital floor now conduct virtual joint visits when the CPs are in the home.
“I think the EMS world needs to consider expanded roles for EMS clinicians beyond 9-1-1,” Radant says. “The most unique part of this program is the direct partnership with our hospitalists. Our physicians need to rely on the CP’s intuition as to the patient’s safety in the home. It’s a fun job that allows CPs to grow their clinical skills in partnership with the hospitalists.”
Managing Chaos
Sean Kukauskas, MBA, NRP, is executive director of Mass General Brigham Ambulance Services, director of the home hospital CPs, and a paramedic with 30 years of experience. “My role now is largely administrative, but I spent a lot of time in the field as a CP when we were first building the program,” he says. “I’ve probably functioned in every job across my department and a lot of my team also has cross-training across the various roles.”
Another key is the communication specialist-dispatchers based at the home hospital program’s centralized command center, who field requests for service and dispatch providers as needed. “They are on the front lines of this work, just like the paramedics,” explains Kukauskas. “Many have some medical background. They play a central role in making our providers the most efficient they can be, operating deliberately and strategically, seeing two to three moves ahead, sending the right truck to the right patient at the right time.”
Considering how acutely ill the enrolled patients are, he says, “We manage chaos—finding ways to make it work. In the field, there are elements we can control and elements we can’t control. We can understand where the traffic is better or worse and when, and use that knowledge in planning our days. The program we’re building has to manage all of the logistical pieces, including the supply chain.”
One Spoke in the Wheel
There are a lot of flavors of paramedics and a lot of ways to deliver care in the community. “Home hospital is a care delivery model less constrained by traditional boundaries,” states Kukauskas. “We’re mobile, we carry our medical tools right to the patient’s bedside. We contribute flexibility. Home hospital is an exciting opportunity for CPs to be involved in delivering care the way it should be delivered.”
Typical EMS personnel see patients in distress, but their ability to provide care in the most appropriate setting for the patient is limited by their mandated protocols, Kukauskas concludes. “In home hospital, we’re practicing proactive care, managing patients so they don’t have to be in the hospital,” he says. “We are one spoke in the wheel, but we help to complete the circle of health care delivery through a program that is transforming how to deliver health care.”
References
- Leff B. A Vision for ‘Hospital at Home’ Programs. Harvard Business Review, 2015 Dec. 21.
- CMS.Gov: Acute Hospital Care at Home. https://qualitynet.cms.gov/acute-hospital-care-at-home.
- Wicklund E. Omnibus bill would extend telehealth waivers, hospital at home program. HealthLeaders Media. December 22, 2022. https://caresimple.com
- Leff B, Burton L, Mader SL, et al., Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients. Ann Intern Med. 2005 Dec; 143(11):798–808.
- Levine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21; 172(2):77-85.
Larry Beresford, a freelance health care writer based in Oakland, CA, writes about palliative care and hospital medicine for Medscape and the Quarterly Newsletter of the American Academy of Hospice and Palliative Medicine.
Comments
Why this will work:
Patient satisfaction: Providing healthcare services in the comfort of a patient's home can lead to increased satisfaction and a more personalized, patient-centered experience. This may help improve patient outcomes and adherence to treatment plans.
Reduced hospital readmissions: By offering hospital-level care at home, community paramedics can potentially identify and address medical issues earlier, reducing the need for emergency room visits and hospital readmissions.
Lower costs: The "Hospital at Home" model may help to lower healthcare costs by reducing the need for expensive hospital stays, while also optimizing resource allocation by freeing up hospital beds for more critically ill patients.
Integration of technology: The use of telemedicine and remote monitoring technologies can enable healthcare professionals to offer real-time support and expert advice to community paramedics, ensuring patients receive high-quality care.
Why this might not work:
Limited scope: The range of medical conditions that can be safely managed at home may be limited, and not all patients will be eligible for "Hospital at Home" services. Certain complex or critical cases may still require traditional inpatient care.
Workforce challenges: Implementing the "Hospital at Home" model may require specialized training for community paramedics, potentially adding strain to an already overstretched workforce. There may also be difficulties in recruiting and retaining qualified professionals to participate in this model.
Inadequate reimbursement: Current reimbursement structures may not fully support the "Hospital at Home" model, potentially making it financially unsustainable for healthcare organizations in the long term.
Unequal access: There is a risk that the "Hospital at Home" program may not be accessible to patients in rural or underserved areas, further exacerbating healthcare disparities.
In conclusion, the "Hospital at Home" model for community paramedics has the potential to revolutionize the way healthcare is delivered. However, it is crucial to address the challenges related to workforce, funding, and access to ensure its long-term success and equitable implementation.
—Raman Palabindala