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Hospital at Home: Amid hospital capacity crisis, OHSU offers an alternative

Program provides virtual alternative to in-hospital care; after launching during the COVID-19 pandemic, clinical leaders see opportunity for growth
Lesley Malinoski, Hospital at Home patient, stands by her apartment door, smiling.
Lesley Malinoski, 83, began Hospital at Home on Aug. 12, 2022, when laboratory results during a routine clinical checkup revealed evidence of toxicity in her blood, associated with her ongoing treatment for lung cancer. (OHSU/Christine Torres Hicks)

With brick-and-mortar hospitals at or near capacity, Oregon Health & Science University is ramping up a new service to provide patients with hospital-level care within the comfort of their own home.

Hospital at Home currently has about eight patients admitted at any one time. Even though that’s a small fraction of OHSU’s overall capacity of 576 licensed hospital beds, the program has an important impact on OHSU’s ability to care for all patients — inside the hospital and out.

Matthias Merkel, M.D., Ph.D., near trees.
Matthias Merkel, M.D., Ph.D. (OHSU)

“Every patient we have in Hospital at Home is one who is not waiting in the emergency room or a hallway for a bed to become available in the hospital,” said Matthias Merkel, M.D., Ph.D., OHSU senior associate chief medical officer for capacity management and patient flow.

At the same time, clinical leaders describe the response from patients as overwhelmingly positive.

Darren Malinoski, M.D., next to a gray background.
Darren Malinoski, M.D. (OHSU)

“It’s a better experience for patients, plus it increases our system’s capacity to provide care for all the people who need it,” said Darren Malinoski, M.D., an OHSU trauma surgeon who also serves as chief clinical transformation officer for OHSU Health. “It allows us to make good on our promise to take care of the state as best we can.”

Over the long term, Malinoski sees the program’s ability to expand as “potentially infinite.” The service started at OHSU in November and is just getting off the ground, but studies elsewhere in the country have shown the concept to be cost-effective, with shorter lengths of stays and better health outcomes for patients.

In fact, Malinoski is so convinced that of the program’s value that his own mother is one of the first OHSU patients to be admitted into Hospital at Home from a clinic visit.

‘It was unbelievable’

Lesley Malinoski, 83, was admitted to Hospital at Home on Aug. 12, when laboratory results during a routine clinical checkup revealed evidence of toxicity in her blood, associated with her ongoing treatment for lung cancer. Normally, she would have been admitted directly to the hospital so clinicians could adjust her medication under continual monitoring.

Instead, she was admitted to her apartment in the Raleigh Hills area west of Portland.

“It was unbelievable,” she said. “I had the feeling of being well taken care of. I was in my own home. I could cook, I could rest — anything I wanted and still have all this care.”

Malinoski is among 100 OHSU patients to receive hospital-level care at home since the program began late last year. Hospital at Home uses technology to virtually connect patients 24/7 with physicians and nurses; the virtual care is supplemented by real-time monitoring and daily in-person visits from nurses and paramedics contracted by OHSU.

Patients are monitored for vital signs such as blood pressure and heart rate, and they’re able to connect with physicians and nurses around the clock by way of a smart tablet. Lab work and routine imaging studies can be done in the patient’s home. When necessary, paramedic service provider Metro West will transport patients to OHSU for more sophisticated imaging or other procedures that aren’t possible in the home.

They also get at least two daily visits for necessary hands-on care from nurses and paramedics.

In Malinoski’s case, she’s convinced she received more sustained and focused attention than she would have in the hospital, amid trilling alarms and clinicians attending to other patients.

“They didn’t just come in and run out,” she said. “I felt like a celebrity.”

Cultural transformation

Currently, the vast majority of OHSU patients who have been admitted to Hospital at Home have transitioned out of the hospital’s medical and surgical units, as opposed to directly from the emergency department or a clinic, as in the case of Lesley Malinoski.

Her son, Dr. Malinoski, said he expects interest in the program will grow as clinicians become more accustomed to delivering hospital-level care virtually — similar to the sudden and widespread adoption of telemedicine for clinic visits with the onset of the COVID-19 pandemic. Still, it will require a cultural transformation, he said.

Ayako Mayo, M.D. (OHSU) next to a gray background.
Ayako Mayo, M.D. (OHSU)

Ayako Mayo, M.D., an OHSU hospitalist who serves as the program’s medical director, agrees.

“As a physician, you really have to get comfortable with not being able to lay your hands on a patient,” she said. “That’s a hard transition to make for some clinicians. As medical students, we’re taught how important the physical exam is.”

Nonetheless, Mayo said physicians and nurses quickly adjust to rounding with patients through a smart tablet, mainly because they see the benefits of a patient remaining in the comfort of their own home.

In addition, clinicians can get a much better sense of the patient’s overall health by glimpsing their home life directly. They can learn about their typical diet, sleep patterns, exercise and social connections — all foundational aspects of a healthy lifestyle — by seeing the patients in their daily life at home rather than in the hospital.

“It’s almost like you’re pulling back a curtain on an aspect of the patient’s life that you would have never seen in the hospital,” Mayo said.

Prompted by pandemic

Jeremy Carr, OHSU’s assistant director for inpatient digital health, joined OHSU in August, moving over from the hospital at home program that had been established at Adventist Health Portland in the early days of the COVID-19 pandemic. The concept had been tried at a handful of hospital systems around the country beginning in the 1990s, but interest surged with the pandemic.

“It really took off during the pandemic,” Carr said.

Anticipating a crush of patients sickened by COVID-19, federal authorities created a waiver program in 2020 that eased the ability of hospitals to offer acute care for patients at home.

Like others around the country, OHSU’s Hospital at Home program is made possible through a federal waiver granted by the Centers for Medicare & Medicaid Services, as part of the federal public health emergency related to the COVID-19 pandemic. To continue after the official emergency expires, the program would require Congress to enact legislation making the waiver permanent.

Although COVID-19 is one of the primary diagnoses for patients admitted to Hospital at Home, the program is well-suited to handling other cases.

“Are we going to send an ICU patient home to get care? No,” Carr said. “But for the right type of patients, this is absolutely the right setting for them.”

Carr anticipates the program becoming well-established to the point that both clinicians and incoming patients consider it first, before admitting a patient to an acute care bed within the brick and mortar hospital. In addition, patients admitted for surgeries may be suitable candidates to transition to Hospital at Home following an initial stay in the hospital.

“Maybe we can’t take a complex patient on day 1 or day 2, but we can maybe take them at day 4 or day 7,” said Christian O’Keeffe, the program’s nurse manager.

Lesley Malinoski, who was discharged successfully after a week of care at home, said she wouldn’t hesitate to check into Hospital at Home if she ever needs it again.

“It was a pleasure to have them in my home,” she said.

Eligibility Criteria:

OHSU is admitting patients to the Hospital at Home program with diagnoses that can be managed remotely, such as COVID-19, pneumonia, cellulitis, congestive heart failure, and pyelonephritis or urinary tract infections.

Current eligibility criteria include:

  • Inpatient hospitalization required.
  • The patient is older than 18.
  • The patient’s primary residence is within a 25-mile radius of OHSU Hospital.

 

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