At-Home Hospital Care

Today, June 27, 2023, in Optum Washington we launched our #hospitalathome program!

My memories surrounding my grandmother’s death are fuzzy.?As a little girl in the Philippines, I recall being told my 96-year-old grandma, while gardening, collapsed.?What followed were days of seeing her mostly up in her rocker.?She was my first encounter with what I will later learn in medical school as “pitting edema,” where her congestive heart failure and anasarca manifested with indentation in her skin and legs wherever and whenever I pressed my fingers into them.?From her rocker to her bed, days passed and she died at home.?Without hospice support, I know she must have suffered from the shortness of breath until she was no longer aware and passed away.?But, still, she was at home, surrounded by people, her cat, and things and smells that she loved, were familiar and gave her comfort.?

Contrast that with my father’s experience in the U.S..?He had Alzheimer’s dementia and, before enrollment into hospice, he was hospitalized once for possible stroke.?My sister shared that, while in the hospital, she found him so agitated one day, naked, roaming the halls, and ultimately required sedation for his safety.?Having been a hospitalist, trained, and practiced medicine primarily in the hospital for almost 20 years, I’ve taken care of people like my dad, my grandmother, and younger, though very ill, people in hospitals.?We’ll always need hospitals for certain levels of care.?And, as a care delivery program, we (and, as physicians, must) continually innovate, re-imagine and re-engineer care, inspired and propelled by our expertise, lived professional and personal experiences, loved ones, families and patients.

Any given day in Washington state, we have over 100 people waiting to be discharged from hospitals, lacking adequate number of skilled nursing facilities and other options for their safe discharge before they can be cared for at home or at a new home.?And so many more are waiting to get INTO the hospital for emergent care needs, including those who have deferred or had their complex surgeries delayed.?According to Washington State Hospital Association , last year alone, many were 120 to130% full, leading to hours-long (for some a few days-wait) in the emergency departments to be admitted into a staffed hospital bed.?And I do mean “staffed” bed, for while there may be empty beds, staffing gaps and shortages also often mean hospitals are unable to take more patients. From a population and physical capacity perspective, in March 2022 Becker's Healthcare highlighted our limited hospital bed capacity in the Pacific Northwest. According to the American Hospital Association 2015-2020 data (accounting for 85% of all hospitals in the U.S.), among the 50 states, Oregon and Washington ranked among the bottom states in capacity at #44 and #45, respectively, with 1.64 and 1.58 hospital beds per 1000 people (South Dakota was #1 with 4.82 beds per 1,000 residents). But/and we don't necessarily need to build many more brick-and-more hospitals, especially in these times with capital constraints, total cost of care and resource stewardship considerations.

Hospital-at-home has been around since the1990s in the U.S. when the earliest pilot launched.?This type of program exists and has existed in England, Canada, Israel, Australia, and many others, and continues to grow across the globe. In the U.S., without a durable payment model to support it for health systems, without support from more physicians, payers, health system executive (physician) leader sponsorship-- and regulations to allow it to scale-- it has crawled to adoption.?With remote patient monitoring and logistics improvements, accelerated adoption and necessity wrought by the global pandemic-- enabled by public health emergency waivers-- many more states and health systems now run these hospital care at-home programs.?I’ll always be grateful to Governor Kate Brown and Oregon hospital regulators for their engagement, openness and curiosity to be able to launch the first program in Oregon early in the pandemic.?Partnership with Medically Home , Mayo and Tufts Medical Center in advocacy of a PHE hospital-at-home waiver with the White House, CMS/CMMI, Department of Health and Human Services et al will always be a highlight of my career, especially when the waiver came through.

Studies have shown at-home hospital programs can reduce readmissions, increase patient and family satisfaction, reduce and eliminate hospital-acquired infections and complications like delirium, and cut costs. This is not home health on steroids. This is truly hospital-level care in the home. Well-monitored 24/7 care, with redundancies in the systems, physicians and nurses from virtual command center are connected with the patient and family via telehealth. Together, they and in-home care provided by other clinicians, nurses, respiratory techs -- with x-ray, ultrasound, blood/lab draws and more done at home-- make up the team.

Once you've set up the highest level of care at home (i.e. hospital level care), an entire population of our most vulnerable and highest risk can have their daily, maintenance chronic care, all the way through their acute care needs, provided at home. The center of gravity of care, then, is truly AT HOME. Or wherever the person and their family says is home.

And so, today, June 27, 2023, we open our Optum WA #AcuteCareAtHome hospital-at-home program.?There are many to name and thank to get us to this launch.?There’ll be many more to whom we are grateful as we keep it going.?As we all acknowledged this morning, this #passionproject is not just for our patients, communities and families—it’s also for us, our #reinvigoration in the mission and calling.?#Re -imagine.?#Re -engineer.?#Re -invigorate.?3Rs of innovation, transformation.

It’s been the privilege of my life to always find and land in a place working, learning and growing with committed, devoted, and compassionate people.?And so I find myself in such a team for my 3rd hospital opening— my 1st was a brick-and-mortar hospital that broke ground in 2009 (the first in 40 years in Portland area) and opened in 2013; 2nd, a hospital-at-home program at the beginning of the global pandemic in May 2020 in Oregon; now, the 3rd, a hospital-at-home program Optum Washington! To our partner Medically Home and our teams and teammates in The Everett Clinic, The Polyclinic, and Optum WA Network practice partners, we truly are #bettertogether #strongertogether and #OptumWAproud !

??Never doubt that a small group of thoughtful committed individuals can change the world.?In fact, it’s the only thing that ever has. Margaret Mead

#virtualcare #careathome #healthequity