The Hospital at Home: A Bright Prospect for Oncology Care?

by Heather Hylton, MS, PA-C

For many oncology patients, the home setting is typically a place for recovery following treatment for cancer or complications of cancer.  At times, this recovery is supported with formal home care services such as nurse and physical therapy visits, home health aide assistance, infusion services, and so forth.  These home care services may or may not be paid for by public and private payers.

“Hospital-at-home” programs enable patients to receive acute care in the home setting.  The general model for these programs consists of a multidisciplinary or interdisciplinary team who follows the patient closely and provides the needed medical services, including patient visits, in the patient’s home.  These programs have been implemented internationally and have demonstrated success in reducing complications and the cost of care while maintaining safe and effective care delivery and enhancing patient and caregiver satisfaction.

Implementation of the hospital-at-home model in the United States has been more limited although Johns Hopkins established this model over two decades ago, and their outcomes mirror the successes of international implementations.

Could the hospital-at-home model be feasible for oncology care such as administering chemotherapy here in the United States?  It seems there is real opportunity for such a program at the crossroads of patient and caregiver experience, optimization of physical facility capacity and utilization, and cost containment.

To bring this paradigm to oncology would require a number of points to be addressed:

  1. Payer policy. In general, payers have had limited agility to adapt to/address payment for innovative care-delivery models such as the hospital at home.  With ongoing efforts in payment reform and a heightened focus on value-based care over fee-for-service, there is opportunity to elevate the importance of this kind of model and determine fair payment practices.

  2. Adoption and referral. The success of any kind of program such as the hospital at home requires broad acceptance of the model and the timely and appropriate referral of patients to the program.  Clarity on how to refer and simplicity in the referral process itself are requisite.  Clear information on how safety and quality of care will be maintained and what metrics will be followed will be key to illustrating the value proposition of this care-delivery model.  In addition, establishing rigorous screening and selection criteria to determine appropriate cohorts of patients to participate in the program will be paramount.  Understanding, acknowledging, and addressing stakeholder concerns is essential to implementation and scaling of the program.   

  3. Close coordination and availability of services.  With the hospital-at-home model being a surrogate for hospital/outpatient facility delivery of medical services, the supplies and services needed to provide this care at home must be readily available and able to be rapidly deployed.  Implementation of the hospital-at-home paradigm may be more challenging in resource-limited settings where vendors or general availability of services may be sparse and geography over which those services are provided are more expansive.

  4. Patient and caregiver buy-in.  The hospital-at-home construct has repeatedly shown patient and caregiver satisfaction with the model.  From a practical standpoint, providing care in the home may serve to empower patients and the familiarity of the environment of care may be a source of comfort.  While studies have shown decreased complications such as delirium and falls in this model, proper and pertinent patient and caregiver education and ongoing engagement is key. 

  5. Optimizing technology. Leveraging technology, such as telemedicine, to enhance monitoring of patients in hospital-at-home programs is key.  This may also be a keen opportunity to incorporate patient-reported data and other innovations.  

  6. Appropriate pilot studies.  While extension of hospital-at-home services to oncology seem apparent, data on safety, feasibility, and cost in this patient population are limited.  CMS and private payers should be encouraged to support studies of this model in the oncology setting.

The hospital-at-home model for oncology patients offers high potential for patient convenience and satisfaction and lower cost compared with traditional inpatient care.  To scale such a model for oncology patients may bring yet another opportunity for unconventional partnerships thinking outside of the box and leading innovation in the health care space.