Phyllis Petruzzelli spent the week before Christmas struggling to breathe. When she went to the emergency department on Dec. 26, the doctor at Brigham and Women’s Faulkner Hospital near her home in Boston’s Jamaica Plain neighborhood said she had pneumonia and needed hospitalization. Then the doctor proposed something that made Petruzzelli nervous. Instead of being admitted to the hospital, she could go back home and let the hospital come to her.
As a “hospital-at-home” patient, Petruzzelli, 71, learned doctors and nurses would come to her home twice a day and perform any needed tests or bloodwork.
A wireless patch a little bigger than her index finger would be affixed to her skin to track her vital signs and send a steady stream of data to the hospital. If she had any questions, she could talk face-to-face via video chat anytime with a nurse or doctor at the hospital.
Hospitals are germy and noisy places, putting acutely ill, frail patients at risk for infection, sleeplessness and delirium, among other problems. “Your resistance is low,” the doctor told her. “If you come to the hospital, you don’t know what might happen. You’re a perfect candidate for this.”
So Petruzzelli agreed. That afternoon, she arrived home in a hospital vehicle. A doctor and nurse were waiting at the front door. She settled on the couch in the living room, with her husband, Augie, and dog, Max, nearby. The doctor and nurse checked her IV, attached the monitoring patch to her chest and left.
When Dr. David Levine arrived the next morning, he asked why she’d been walking around during the night. Far from feeling uncomfortable that her nocturnal trips to the bathroom were being monitored, “I felt very safe and secure,” Petruzzelli said. “What if I fell while my husband was out getting me food? They’d know.”
After three uneventful days, she was “discharged” from her home hospital stay, and the equipment removed from her home. “I’d do it again in a heartbeat,” Petruzzelli said.
Brigham Health in Boston is one of a slowly growing number of health systems that encourage selected acutely ill emergency department patients who are stable and don’t need intensive, round-the-clock care to opt for hospital-level care at home.
In the couple of years since Brigham and Women’s Hospital started testing this type of care, hospital staff who were initially skeptical have generally embraced it, said Levine.
“They very quickly realize that this is really what patients want, and it’s really good care,” he said.
This approach is quite common in Australia, England and Canada but it’s faced an uphill battle in the United States.
A key obstacle, clinicians and policy analysts agree, is getting health insurers, whose systems aren’t generally set up to cover hospital care provided in the home, to pay for it.
At Brigham Health, the hospital can charge an insurer for a physician house call, but the remainder of the hospital-at-home services are covered by grants and funding from Partners HealthCare’s Center for Population Health, which is affiliated with Brigham Health, said Levine.
Health insurers don’t have a position on hospital-at-home programs, said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry trade group.
“Overall, health insurance providers are committed to ensuring patients have access to care they need, and there are Medicare Advantage plans that do cover this type of at-home care,” Donaldson said in a statement.
Levine, a clinician-investigator at Brigham and Women’s Hospital and an instructor at Harvard Medical School, was the lead author of a study published last month that reported the results of a small, randomized, controlled trial comparing the health care use, experience and costs of Brigham patients who either received hospital-level care at home or in the hospital in 2016.
The 20 patients analyzed in the trial had one of several conditions, including infection, heart failure, chronic obstructive pulmonary disease or asthma. The trial found that while there were no adverse events in the home-care patients, their treatment costs were significantly lower, about half that of patients treated in the hospital.
Why? For starters, labor costs for at-home patients are lower than for patients in a hospital, where staff must be on hand 24/7. Home-care patients also had fewer lab tests and visits from specialists.
The study found that both groups of patients were about equally satisfied with their care, but the home-care group was more physically active.
Brigham Health is conducting further randomized controlled trials to test the at-home model for a broader range of diagnoses.
Dr. Bruce Leff began exploring the hospital-at-home concept more than 20 years ago, conducting early studies at Veterans Affairs medical centers and Medicare Advantage plans that found fewer patient complications, better outcomes and lower costs in home-care patients.
Caregivers reported less stress, Leff’s research found. For caregivers, traveling to an unfamiliar hospital, finding and paying for parking and trying to time bedside meetings with clinical staff, all the while worried about a loved one’s health, is wearing, experts note.
Hospitals, accustomed to the traditional “heads-and-beds” model that emphasizes filling hospital beds in a brick-and-mortar facility have been slow to embrace change, however.
There are practical hurdles, too.
“It’s still easier to get Chinese food delivered in New York City than to get oxygen delivered at home,” said Leff, a professor of medicine and director of Johns Hopkins Medical School’s Center for Transformative Geriatric Research.