House Calls Go High Tech

The wooden, glass-topped desk is covered with tidy stacks of printouts. The sheer amount of paperwork, and the orderliness imposed upon it, suggests that the man behind the desk is perpetually busy but always in control.

Without a doubt, George B. Hernández Jr. is indefatigably productive, but there’s only so much control he can exert as a health system CEO, due to constant regulatory changes and financial pressures in the health-care sector.

“The one thing I always say about health care is you have to be able to tolerate ambiguity because there are a lot of unknowns, and we sometimes make decisions without having all the facts,” he says.

Right now, he’s talking about one decision in particular—a big-budget initiative he’s already carried out. It’s an innovation that might well be considered a risky business, although that’s not how Hernández sees it. He sees it as good for patients. He sees it as good for margins. He sees it as the future of health care.

Hernández scoots aside one of his stacks of paper, revealing a bumper sticker tucked beneath the protective glass on his desk. He’s had this keepsake for nearly 19 years, ever since he became president and CEO of University Health System, which operates University Hospital in San Antonio as well as 35 outpatient and specialty clinics in the surrounding area. A gift from a colleague, the bumper sticker has become his guiding principle: “The best way to predict the future is to help create it.”

That’s what Hernández set out to do when University Hospital became one of the first inpatient facilities in Texas to establish a full-fledged hospital-at-home program, modeled after the federal government’s Acute Hospital Care at Home program that allows hospitals to provide inpatient-level care in patients’ homes. Intended as a temporary fix for hospital overcrowding during the worst of the COVID-19 pandemic, the program waives certain hospital safety standards, such as round-the-clock nursing. Thanks to lobbying efforts led by the American Hospital Association, the program has been extended beyond the public health emergency—but only until the end of 2024. What happens then is one of health care’s unknowns.

The Uncertain Future

“We’re hoping the program becomes permanent, but it’s hard to read the tea leaves,” says Cameron Duncan, vice president of advocacy and public policy for the Texas Hospital Association. “However, if you read the research, it spells out a pretty convincing business case for continuing the program.”

Nearly 300 sanctioned hospital-at-home programs operate in 37 states; Texas is closing in on 40. Among participating hospitals, studies have shown that total cost of care per patient is 25 percent lower in the home environment compared to the hospital setting; patient satisfaction rates are higher; length of stays are about 35 percent shorter; and readmission rates are three times lower, Duncan says.

Hospital at home is not the same as home health care provided by aides to ill or injured people who don’t require hospitalization. Eligible hospital-at-home patients receive the same level of acute care provided to inpatients, including diagnostic studies, treatments, and therapies. The program “is for people who are sick enough to be in the hospital but stable enough to be at home,” says Jackleen Samuel, cofounder and CEO of Plano-based Resilient Healthcare, which works with hospitals to recreate the acute-care setting at home.

The first point of contact is always at the hospital. For example, Jane Doe arrives at the emergency room acutely ill, but not critically so. She needs to be closely monitored. She may need IV infusions. She may need scans. But she doesn’t necessarily need to take an elevator ride upstairs, don an immodest gown and nonskid socks, and settle in for a hospital stay. As an option, she can voluntarily return home to receive acute-level care, minus the beeping noises, restricted visitation, and general commotion typical of a hospital unit.

“In this scenario, she’s admitted as an inpatient—that’s her official status in her health records—but, physically, she’s at home, where she occupies a licensed hospital bed and might have a quicker recovery,” says Jim Kendrick, president and CEO of Plano-based Community

Hospital Corporation (CHC), which is rolling out a hospital-at-home program at North Texas Medical Center in Gainesville, Texas, one of its hospital affiliates.

At-home patients must live within a certain distance of the hospital in case their condition takes a turn for the worse. The patient wears monitoring and emergency-alert devices, which send data in real-time to their electronic health record and attending physician. A registered nurse visits twice a day or more often, and the patient virtually consults with a doctor or nurse practitioner at least daily through a secure telemedicine portal.

Currently, a health-care provider that plans to start a hospital-at-home program must attain a waiver from the Centers for Medicare and Medicaid Services (CMS), the federal agency that ensures the applicant has the infrastructure and personnel in place to properly provide acute care offsite.

Transitioning acute-level care beyond hospital walls requires a substantial upfront investment, although it’s a cheaper way to provide care in the long run because it cuts down on overhead costs. In addition, by reducing readmission rates, hospitals avoid paying penalties.

Those aren’t the only ways the CMS waiver program benefits hospitals financially. As of now, reimbursement rates through Medicare are the same as those provided for inpatient care, including the facilities fee intended to cover hospital maintenance costs. As things stand, however, Medicare beneficiaries are the only patients who are guaranteed coverage for hospital-at-home services. Private insurers are not required to cover these programs and have resisted pressure to do so in the past.

But private payers are gradually “getting on board,” Kendrick says, because they tend to “fall in line” with what Medicare covers. “Besides,” he adds, “from a payer’s perspective, their number one driver is quality of care, and their second biggest driver is cost. And hospital-at-home delivers on both fronts, cutting costs without compromising care.”

Something to keep in mind, though, is that reimbursement rates will probably go down at private payers’ insistence.

The Right Fit

Just as home-based care isn’t appropriate for every patient, “hospital-at-home doesn’t make sense for every hospital,” Kendrick says.

One of the barriers to entry is the complexity and cost of coordinating all the necessary supplies, services, and workflows. University Hospital deployed its program with no outside assistance, but hospitals with fewer resources typically partner with third parties to provide goods and services including staffing, mobile medical equipment, pharmaceuticals, medical meal delivery, internet or cellular connectivity, smart monitoring devices, and HIPAA-compliant data transmission.

“There’s this whole new layer of technology that’s needed to orchestrate this, and interoperability—the ability to connect all these data sources to the hospital’s existing IT infrastructure—is where we come in,” says Lisa Esch, senior vice president of health care strategy at NTT DATA Services, an IT consulting firm in Plano that entered the hospital-at-home space last year with software that acts as a communications and logistics “command center.”

In addition to connecting patients with their clinicians and monitoring remote devices, the command center streamlines care coordination by taking stock of all the “care activities” a patient needs and “rolling them up” into a single visit.

Resilient Healthcare also provides a hospital-at-home IT platform, which manages staffing and scheduling, third-party contractual agreements, and other arrangements. “We’re your partner who handles all the other partners,”
Samuel says.

Samuel and Esch both cite investment and startup activity as evidence that the hospital-at-home care delivery model has staying power, despite the looming expiration date and the opposition of National Nurses United, the country’s largest union of registered nurses, which objects to the model on safety grounds.

“A lot of companies have popped up in the market in the last couple of years to tackle different parts that are required to deliver hospital-at-home care. As a health system, you would look at your own capabilities and think, ‘Okay, I’m going to do this piece, this piece, and this piece, and then I need to partner for this piece, this piece, and this piece,” Esch says. “There’s a lot of innovation being driven around this space right now. Organizations are teaming up as joint ventures to try to sell, like, an out-of-the-box solution to implement a hospital-at-home program.”

Case in point: Resilient Healthcare announced in August a joint venture with CHC to offer comprehensive hospital-at-home services to the latter’s 40-state hospital network.

Nationwide, venture capitalists and private equity firms are “pouring money” into hospital-at-home programs “to secure first-mover advantage in a hot market,” according to a January 2023 report from the Center for Economic and Policy Research report, a Washington, DC, think tank that comes across as wary of the emerging care model.

Still, Samuel has hedged her bets, devoting a substantial part of her business to traditional home health care so her overall success isn’t contingent on the CMS waiver program. And NTT DATA Services, as part of a well-established multinational corporation, has other service lines to fall back on.

Making It Happen

Although “providers other than hospitals” might like “a piece of the action,” as the report states, hospital executive Brad Comstock is looking for peace of mind. “The Dallas-Fort Worth area, which we serve, is one of the fastest-growing markets in the United States,” says Comstock, COO of virtual care delivery for Texas Health Resources, a North Texas-based health system with 20 acute hospitals and a hospital-at-home program available so far to patients living within 25 miles of either of its Fort Worth facilities. “When you add demand from aging baby boomers to our population explosion, we can’t build hospitals fast enough, and we don’t have the billions of dollars of capital even if we could. So, we’re fans of the model and have our fingers crossed that it will continue.”

In San Antonio, Hernández might not have his fingers crossed, but he has his finger on the pulse of his community. Consumer demand, he believes, will eventually ensure the program’s longevity—that, and the fact that the hospital-at-home model mitigates several persistent problems in health care. In populous regions, the program frees up hospital beds for higher-acuity patients. In rural and lower-income areas, the program broadens access to health care. In addition, hospital-at-home initiatives could help alleviate the nursing shortage because the model allows for flexible hours and is less stressful than working on an understaffed hospital unit.

Asked to gauge his level of confidence, Hernández gestures to his bumper sticker. “I think most CEOs try to create the future, to make it happen,” he says. “So, if they’re working on setting up hospital-at-home because it’s good for their community, my guess is that they are also working very hard convincing their congressmen that the program should be made permanent.”

CHC’s Kendrick will be among those lobbying, although the program’s results, he believes, should speak for themselves: “If you have a model that is giving good outcomes, if you have a model that patients are happy with, and if you have a model that is cutting costs, there’s no logical reason, moving forward, to say, ‘We’re just going to stop this.’ ”