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Kaiser program brings hospital care to the patient's home

Frequent medical visits had become a way of life earlier this year for John and Audrey Stanton of Hemet in Riverside County.  

John, 86, suffered from serious eye problems; a painful skin infection called cellulitis,and more recently, repeated shortness of breath — all of which kept landing him in the hospital.

"It was one thing after another. Like the doctor said, 'Somebody is after you!'" Stanton laughs. 

And for his 81-year-old wife Audrey, the nearly two-hour drive to-and-from Kaiser in Riverside was a tough haul.

"I’m not a long distance driver so I had to be real careful," she says. "It was stressful." 

But that stress dissipated last summer when John was admitted to the hospital — at home.  

"I thought, 'Wow! This is amazing. I love this!'" he says. "This is what people need!"

Pneumonia, cellulitis or congestive heart failure

Stanton is one of about 125 patients who’ve been enrolled in an experimental hospital at home program run out of Kaiser’s Permanente’s Riverside Medical Center.

Launched two years ago, the program is designed for people who need treatment - typically only given in the hospital — for one of three conditions: pneumonia, cellulitis or congestive heart failure.

"Our goals are to have patients be safe at home and to have them recover at home and to have a high-quality experience," says Dr. Earl Quijada, one of three Kaiser doctors assigned to the program.

Not every patient with one of the three conditions qualifies for the program. It's restricted to those who are not at risk for complications that could require more intensive care, says Dr. Nirav Shah, senior vice president and chief operating officer for clinical operations at Kaiser Permanente Southern California. 

"We ask if that patient wants to be admitted [to the hospital] or admitted at home," Shah says. "If they choose to be admitted at home, we'll send a truck home with them with all the equipment they need."

For John Stanton, the program saved two to three days in the hospital as well as a number of return trips for follow-up visits, Quijada says.   

"Things are just so much more relaxed"

Stanton’s at-home care for a pneumonia diagnosis involved an intravenous antibiotic; a phlebotomist to check his blood and house calls from a nurse and Quijada. Hospital rounds — usually done by the patient's health care team in the hallway outside the patient's room — took place instead on the phone. 

Caption: John and Audrey Stanton of Hemet say they're both fans of Kaiser Permanente's hospital at home program, which helped John this year. Photo: Stephanie O'Neill/ KPCC

"We talk about the case just like we would in the hospital," Quijada says. "We also have access to infectious disease specialists and cardiologists over the phone."

But the best part, he says, is the quality of interactions he has with patients in their homes. 

"That’s the beautiful thing," he says. "When you sit down at the kitchen table, things are just so much more relaxed you just get way more information."

Home visits, he says, also allow him to assess other issues that may affect patients' well-being and safety.

"When I come into the home, I'm used to looking at the interface between the floor and the carpet," he says. "I look for cords, where animals are. I look to see if things are clean and where the medicines are stored."

Treating a patient at home also eliminates hospital-acquired infections and common hip fractures caused by falls from unfamiliar beds, although some doctors worry about the safety of patients who aren’t under constant supervision. 

Lower costs

Studies have found providing treatment at home rather than the hospital reduces the cost of care – sometimes significantly. Johns Hopkins University's hospital at home program, which started in 1994, found at-home care to cost 32 percent less than similar inpatient care during the program's first decade of operation.  Likewise, Kaiser officials say data from the pilot indicate that it, too, is saving money.

"When you shift the care to the house, believe it or not, it’s actually cheaper," says Dr. Kavita Patel, a senior fellow at the Brookings Institution who specializes in health care policy.  "Because all the facility costs,  infrastructure, none of that exists ... in your home."

Patel says the "hospital at home" approach can also meet the three goals of the Affordable Care Act: better care, greater patient satisfaction and lower costs.

"How much more patient-centered can you be than being in your home?" she asks.

Programs treating people at home instead of in the hospital have caught on in a number of countries with single payer health care systems, such as Britain, Canada and Israel. Patel says there are barriers to widespread adoption of this approach in the United States — the biggest being health care economics.

"Hospital at home" can make good financial sense for managed care systems, such as Kaiser, which receive a fixed annual fee for each patient no matter how much care they use. But, Patel says,  it’s somewhat problematic for those using the more-common fee-for-service model.  That system rewards volume by reimbursing providers for each test and treatment. And, Patel says, fee-for-service typically only reimburses for care provided in a doctor’s office or hospital.

"It’s not often that you can — even within the Medicare program or Medicaid program or in commercial health insurance — send a bill from the house," she says. 

But that’s starting to change.

Medicare is slowly shifting away from its fee-for-service model. At the same time, the Affordable Care Act is promoting more experimentation with at-home programs.

And still another important factor could be demand from patients, like John Stanton, who’s now a fan of getting treated at home instead of the hospital.