In a recent note, I discussed the question of whether hospitals are becoming obsolete (see: Are Hospitals Becoming Obsolete; Consequences for Pathology and the Labs). I believe that the answer to this question is partly true with some supporting evidence provided by the emergence of "bedless hospitals." They are being built primarily to provide ambulatory care services, clinical labs, radiology, operating rooms, and telemedicine (see, for example: The Design of Bedless Hospitals Continue to Evolve Based on Cost and Technology; Some Additional Ideas About the Bedless Hospitals of the Future). These ideas were running through my mind when I read a recent article about establishing a Hosital-at-Home (HaH) program (see: Why I Believe in Hospital at Home). Below is an excerpt from it:
....Hospital at Home (HaH) [is] an [excellent] option for some patients with community-acquired pneumonia, exacerbations of heart failure or chronic obstructive pulmonary disease, cellulitis, and (recently) other conditions.....A candidate for HaH is usually identified in the emergency department, where an ED physician deems the patient sick enough to warrant inpatient admission....The patient must meet validated clinical-appropriateness criteria for HaH and have housing where care can be provided safely. Common reasons to deem a patient inappropriate for HaH are uncorrectable hypoxemia...and ischemic chest pain....However, having multiple chronic conditions and living alone are not obstacles to eligibility.....An HaH nurse meets the patient at home, provides initial care, and educates the patient and her daughter about the daily routines of HaH. The nurse stays for three to four hours to ensure that all needed services are in place, that the patient is clinically stable, and that she and her family are comfortable with the care. The nurse then communicates the patient’s status to the HaH physician, who acts as a home hospitalist, and a care plan is developed collaboratively. As the health system shifts to value-based care, HaH will challenge the traditional, facility-based model....And technological advances, such as biometrically enhanced telehealth modalities, will make HaH more viable....After treatment (which averages 3 days), the patient is “discharged” from HaH, with subsequent care-transition services as needed.....A 2012 meta-analysis of randomized controlled trials of HaH showed a 38% lower 6-month mortality rate for HaH patients than hospitalized patients....Along with other home-based care models, HaH can be a versatile platform for creating an alternative to skilled-nursing-facility care after hospital discharge, a complement to early-discharge programs, and an option for post-surgical care.
Most hospitals will have little or no financial incentive to place a patient seen in the ER into an HaH program as opposed to admittance as an inpatient. Such admissions are very common from the ER and thus an important source of hospital revenue (see: Most Unscheduled Hospital Admissions Now Come Through ER). However, consider for a moment the incentives in a bedless hospital which may have only a small number of beds but which would be reserved for trauma patients or those who are seriously ill. Such bedless hospitals would have a strong financial incentive to develop an HaH program which could be financially attractive. Bedless hospitals also offer ambulatory surgery and, as noted above, an HaH program is suitable for post-surgical care. Bedless hospitals also are designed to provide telemedicine services which can be perfectly integrated into HaH programs.
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