The hospital of the future will be your home

Not a single shovel has gone into the ground and yet, within the next few years, Mass General Brigham in Boston intends to open a new 220-bed hospital. How are they doing it? By keeping people at home.

The initiative – a coordinated effort to merge and expand the home-based care programs already in place at Massachusetts General Hospital and Brigham and Women’s Hospital, the two leading teaching institutions that make up the health network – is part of a broader shift to shape what the next phase of virtual care can and should look like, says Dr. Lee Schwamm, vice-president, Digital Patient Experience and Virtual Care at Mass General Brigham.

“We’re reframing a lot of this work through the lens of a digital patient experience and virtual care is one of those experiences,” said Dr. Schwamm. “Home hospital is a really nice example of hybrid care and I think that’s where we’re going to end up in this next phase.”

Hybrid care refers to a combination of remote and in-person care, he explained. A patient journey is divided into discrete elements, and each one “is accomplished in a way that is most cost effective and convenient, and meets the needs of the provider in terms of completeness.” A patient who is treated at home may return to hospital for testing, for example, while receiving home visits from mobile integrated health teams and video consults from a treating physician or hospitalist at the same time.

The drive to expand the home hospital model was prompted by the COVID pandemic as Mass General Brigham experienced a rapid acceleration of demand for remote care. Prior to 2020, the network was averaging 10,000 virtual visits a year. That number scaled to 1.7 million visits out of necessity, said Dr. Schwamm.

“The idea is: Can we actually safely shift low acuity care back into the home? And it’s a funny thing, because we’re kind of going backwards in time,” he said. “When my grandparents were growing up, that’s where you usually saw the doctor – at home.”

The home hospital strategy is intended to reduce spending, but it also affords valuable benefits to patients through an improved patient experience. According to Mass General Brigham, research shows that home-based care can provide more patient-centered and satisfying care, lower complication rates, reduce emergency room visits and lead to improved patient outcomes.

A recent global report from Signify Research has the remote patient monitoring market climbing to just under US$3 billion by 2026, driven by fiscal and political commitments from governments, implementation of reimbursement frameworks and larger structural shifts in healthcare delivery. Longer term, hospital at home initiatives are expected to be fuelled by the shift towards value-based care and population health models.

Massachusetts General Brigham has been shifting to a home hospital model for patients that can appropriately and safely be cared for at home since 2016. As they look to scale their program, they’ve named Heather O’Sullivan as inaugural president of Home-based Care, to lead a team of more than 1,000 employees skilled in nursing, physical therapy, occupational therapy, case management, social work, speech therapy and home health.

To be eligible to participate in home-based care, Mass General Brigham patients must meet a specific set of criteria. They are typically identified as candidates upon arrival at emergency or on their first or second day of hospital admission. The program covers a range of acute medical conditions and is staffed as a dedicated hospital rotation, providing patients with equipment and services at home as needed.

As it expands with the goal of offering more than 200 home hospital ‘beds’, Mass General Brigham is looking to automate the process of identifying good patient candidates, possibly through a system of ‘smart’ rules that would flag people as they are entered into the hospital’s electronic health record. The biggest challenge is how to manage logistics, in other words the flow of people and “stuff,” said Dr. Schwamm.

“To achieve that scale, we really need to solve those logistics problems,” he said. “If you have to touch base at the hospital every time you need to dispatch material, that’s going to be an inefficient process.”

One proposal is to operate home hospital similar to a ride share service, where an app would optimize the routes for nurses or paramedics visiting patients at home. Dr. Schwamm also envisions a network of supply depots strategically located throughout the community so that medical devices and equipment could be more efficiently dispatched.

“As we cohort patients of lower acuity into these home environments, they will need a lower cost structure to manage them,” he explained. “If we can keep the supply chain and logistics costs low, not only do you save money on direct care delivery, but you also open up a new bed for a more acute patient whose care is going to be safer and cheaper than if they spend the first three days of their hospital visit in an ER.”

An urgent need to increase bed capacity prompted Jewish General Hospital (JGH) in Montreal to launch their hospital at home program at the start of 2022 – the first in Quebec and one of only a few so far in Canada. Amid a burgeoning fifth wave of the pandemic, the program was initially implemented to care for COVID patients only.

Based on its success, it has since expanded to include patients with heart failure, lung conditions like pneumonia or COPD, urinary tract infections and cellulitis, as well as patients recovering from certain types of surgery. Pathways are also evolving for mental health patients, and the hospital is in the process of creating a facilitated discharge pathway so qualified patients can spend their last few days of a hospital stay at home.

Participation in the program is voluntary. Patients are screened for admissibility to hospital at home by a hospital physician, based on their acuity and medical condition, and the exclusion criteria outlined by each practice area. They are then forwarded to a virtual ward transfer nurse who evaluates additional social perspectives, such as caregiver and family support. The COVID at home program, for example, was eligible to people younger than 70, who had a support person who could check in on them, who were able to communicate with a smartphone or tablet, and who could perform activities of daily living.

Patients accepted into JGH”s hospital at home program are provided with either an iPhone or iPad with LTE connectivity so that they can be continually in touch with their virtual care team. The program operates under the direction of the hospital’s command centre, which serves as a central hub to focus on patient quality and patient flow throughout the organization.

“All administrative systems are integrated and the patients appear as if they’re hospitalized; it’s the same as if the patient were in the physical hospital itself,” said Dr. Lawrence Rudski, JGH chief of cardiology.

Digital devices are also deployed as required. Some patients may be issued an automated blood pressure cuff, Masimo SafetyNet finger probe for oxygen monitoring, digital thermometer or weight scale. Others may require a BioBeat chest patch for continuous monitoring of vital signs, and the hospital also provides equipment to deliver IV therapies at home.

Patients are closely monitored and if a change in condition is noted, a nurse will call to check in. Dr. Rudski recalls a time when a patient’s heart rate was up and it turned out that he had actually gone for a ride on his bicycle. Another hospital at home patient decided to remove her oxygen mask while in the bathroom and a nurse was able to intervene, explaining the need to wear it at all times.

In a recent case, a 90-year-old patient stayed with her daughter in order to benefit from the program, and all three of her children were able to participate in daily multi-disciplinary meetings with her care team over video.

“We know that patients who are elderly tend to decondition and deteriorate rapidly in hospital,” said Erin Cook, associate director of Quality, Transformation, Evaluation, Performance and Ethics for the Integrated Health and Social Services University Network for West-Central Montreal (CIUSSS), which includes JGH.

“When we get them back into their home environment more quickly, we help them retain their autonomy better,” she added.

As of August, the JGH hospital at home program – which is currently staffed to accommodate 10 patients at any one time but is prepared to scale – had served 73 patients, saving 427 bed days. So far, every patient who has taken part in the program has rated their experience 10 out of 10.

“We’re trying to build a value-based care framework around this to look at not only the quality of care, but the overall cost of the service and the patient experience,” said Cook. “We know we have to start thinking differently about how we’re giving care because the current model is going to be really taxed over the next few years. We have an opportunity to leverage innovation and technology to think differently about how we’re delivering and transforming the future of healthcare and that’s certainly what we’re trying to do.”

St. Joseph’s Hospital in Hamilton, Ontario, is another organization leveraging remote patient monitoring to decrease capacity pressure and deliver excellent care for patients. Rather than a virtual ward approach, the hospital is zeroing in on a patient’s digital experience, partnering with different hospital programs to build remote monitoring pathways that engage patients as active participants in their healthcare.

“What we’ve learned along our journey is that there isn’t a ‘one size fits all’ in terms of technologies, so we really need to understand and partner with our patients in a design thinking way about what matters to them,” said St. Joseph’s director, Digital Solutions, Andriana Lukich.

“We’re thinking about this with an equity lens, making sure that patients have equal opportunities to be discharged and be successful at home, and making sure that what matters most to them is considered as part of their care recovery journey,” she said.

Each pathway outlines its unique requirements for remote care. Paramedic services are leveraged to help get patients set up at home and a dedicated team of nurses and coordinators provide remote support, escalating to a physician or surgeon as necessary.

A surgical transition pathway, for example, uses an app called Seamless MD to both prepare patients for surgery and help them recover safely at home afterwards. Patients use online daily surveys to report symptoms and the remote team is automatically alerted whenever a response is outside of normal range.

From June through August, roughly 200 patients used Seamless MD to recover at home following surgery. Patient reported outcomes show a reduction in length of hospital stay, as well as lower pain scores, less anxiety and a general feeling that they are more supported. The online checklists included in Seamless MD also motivated patients to reach their walking goals post-surgery.

Project manager Maria Campbell said there’s been a reduction in the number of calls and visits to hospital post-surgery because patients feel more comfortable and supported. “Overall we’ve seen really great feedback,” said Campbell. “Patients are feeling really confident, less worried … and one patient commented that they felt if they needed somebody, they knew somebody was there.”

Other remote patient monitoring pathways in place at St. Joseph’s are using technology from Aetonix and Cloud DX to maintain continuity of care as patients transition from hospital to home. The goal is to equip them with the digital toolbox that makes the most sense, ranging from simple patient portals to take-home tablets to devices like blood pressure monitors.

“We may get to a point one day where we look at having virtual wards, but right now we have centred a lot of our work on supporting and improving the patient experience, said Lukich. “The hospital of the future is your home,” said Lukich.