Mount Sinai shares lessons from hospital-at-home program

Ania Wajnberg, associate professor in the department of medicine at the Icahn School of Medicine at Mount Sinai (Photo: Mount Sinai)

While some hospitals and health systems have begun offering acute care at home during the COVID-19 pandemic, Mount Sinai has been doing it a little longer.

Mount Sinai launched one of America’s first hospital-at-home programs in 2015.

Ania Wajnberg, associate professor in the department of medicine at the Icahn School of Medicine at Mount Sinai, told Chief Healthcare Executive® in a March interview that she’s heartened by its progress.

• Read more: Hospital at home: Special Report

Mount Sinai has seen a low readmission rate and shorter hospital stays, she said.

“We really believe in it as a model,” Wajnberg said.

“There are big advantages for health systems in throughput of patients, and improving the patient experience and saving the high acuity beds for patients that need it,” she explained.

As of late May, more than 280 hospitals across the nation are offering acute care programs at home, according to the Centers for Medicare & Medicaid Services.

Wajnberg offered some perspective on Mount Sinai’s experiences and some advice for health systems that are just beginning such programs or are considering it but not ready to make the leap.

• Read more: Hospital at home: Leaders describe encouraging outcomes

(Some healthcare leaders talk about their hospital-at-home programs in this video. The story continues below.)

Assessing patients and homes

With hospital-at-home programs, patients are required to be seen in person at least twice per day, under Medicare rules. Patients are also monitored at home and receive check-ins from hospital staff.

Since Mount Sinai has been doing acute care at home, Wajnberg says the system has learned some lessons along the way.

Initially, Mount Sinai only sent oxygen home with patients that needed it, she says. But eventually, some patients who didn’t immediately need oxygen would need it later. Often, the calls for oxygen would come late in the evening, even if patients were already seen by nurses or clinicians earlier.

“Now, everybody goes home with oxygen,” Wajnberg said..

Since patients need to be seen on a daily basis, hospitals have to consider contingencies for severe weather, especially in areas that get a lot of snow in winter. “We’re out there regardless of the weather,” Wajnberg said.

• Read more: Saint Luke’s Health System sees early success with hospital at home

At Mount Sinai, patients can get acute care at home but those who are deemed to need intensive care, or even a step below, are treated in the hospital, Wajnberg said.

“We are looking for patients with the lowest likelihood of clinical deterioration,” she said. “We hope their diagnosis is somewhat clear.”

Beyond the diagnosis of the patient, Wajnberg said it’s critical to ensure the safety of the patient’s home environment, which she said is “probably the trickiest part.”

Mount Sinai will offer acute care to patients at home who live alone if they can do so safely, but Wajnberg says it’s easier if someone is there to watch and help the patient.

Critically, hospitals need to have robust emergency plans if a patient’s condition deteriorates and needs to get to the hospital.

“You need a team that can do a rapid response, by video and in person, and you need a mechanism to escalate them quickly into the hospital if needed,” Wajnberg said.

• Read more: WellSpan Health sees high patient satisfaction in hospital-at-home program

‘Find the right people’

Beyond such practical considerations, health systems that are interested in offering acute care at home need to consider how it fits in with the hospital’s entire approach to care, Wajnberg says.

“Think hard about how to make this part of the flow in your health system, so it's not viewed as a separate project but can be integrated into the admission process for patients,” Wajnberg said.

In hospital-at-home programs, staff play an enormous role, and some may need additional training for delivering care outside the hospital. “Many physicians who do it don’t have home experience,” Wajnberg said. “We do some training and support.’

“This asks your clinicians to do something that’s pretty new, and something many maybe weren’t exposed to in their training,” she added. “You need to find the right people who are excited about the model.”

Mount Sinai has developed strong buy-in for the home hospital program, but Wajnberg said that it took some time.

And as she noted, “We’ve had more time than many.”

Generally, nurses who offer acute care at home enjoy the opportunity to have more one-on-one time with patients than they would have in the hospital, Wajnberg said.

Wajnberg is excited to see more hospitals develop acute care programs at home. Now, the key is to develop them to scale so they can serve more patients, she said.

The federal government eased restrictions on hospital-at-home programs - and telehealth more generally - due to the COVID-19 pandemic. Congress and lawmakers have approved the extension of waivers for home hospital programs through the end of 2024.

Some healthcare advocates are hoping to see permanent reforms. And some analysts have said some hospitals are waiting until they have more certainty on Medicare reimbursement before they begin trying to offer acute care at home. Wajnberg said it would be “tragic” if home hospital programs are shut down due to the lack of payment mechanisms.

Wajnberg said she’s excited about the potential of hospital-at-home programs, and offering treatment where patients are most comfortable.

“Even though it’s the future, it’s kind of like going back in time,” Wajnberg said. “This is how healthcare used to be.”