Home-hospital care

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Tune into this episode of PwC's Next in Health to hear PwC Health Research Institute's Trine Tsouderos, and Strategy& Principal, Igor Belokrinitsky, in discussion with PwC Director, Kristin Craig, on the evolution of delivering acute care at home, including:

  • Defining the home-hospital care model
  • The current home-hospital care landscape and the economic, operational, and clinical implications for health systems
  • Potential tailwinds and headwinds of home-hospital care
  • The future of home-hospital care

Topics: home-hospital care, healthcare, health, providers, payers, hospital

Episode transcript

Find episode transcript below.

Trine Tsouderos (00:04):
Welcome to HRI's Next in Health podcast. I'm Trine Tsouderos and I lead PwC's Health Research Institute. I'm also a management consultant at PwC working with pharmaceutical companies on vaccines, mRNA, MADS and other drug products,

Igor Belokrinitsky (00:19):
And I'm, Igor Belokrinitsky and I'm a Principal with Strategy& the strategy arm of PwC. And I help leading health organizations develop winning strategies and operating models. And today Trine and I are joined by our friend Kristin Craig is a director in our provider practice. Now with Kristin today we're going to discuss an very interesting topic that combines and touches on a lot of the themes that we have covered in the past few months. Everything from how consumer behavior has changed during COVID to the role of virtual care, to the looming shortages of providers. And it all kind of comes home today, as we will talk about the growing role of delivering care in particular acute care at home. Welcome Kristin.

Kristin Craig (01:07):
Thank you. I'm so glad to be on the program today.

Trine Tsouderos (01:10):
So Igor and Kristin, when I think about hospital at home, I think a little bit about how it reminds me of the way that care was delivered for hundreds of years in Europe and in the United States, where care that we think of as hospital care was delivered in the home. And you can see this, if you look at any engravings or paintings of care of people who are very ill, it's often a home scene surgeries were done in the home, for example, without anesthesia for a long time, which you can imagine what that must have been like. And so then we had the development of hospitals and hospitals were generally with exceptions, meant to care for people who were too poor to have care at home. And then we moved to hospital care in the hospital, the modern version of delivering this kind of care to people.

Trine Tsouderos (01:58):
And now here we are, and we're talking about hospital at home again. And so I think it's always fascinating to see things come full circle. Of course, what we're talking about is a far cry from the care you might've gotten 200 years ago, but nevertheless, it's kind of an interesting echo of the model from before. So Kristin, really excited to talk to you about that.

Kristin Craig (02:18):
That's right. And my grandfather was actually a small town, rural doctor in Wisconsin. And so that was even 50, 70 years ago. They were still delivering a lot of their care in homes. So certainly is full circle. Indeed.

Igor Belokrinitsky (02:31):
Excellent. Well, Trine and I inevitably drift back into the past and started discussing the history of healthcare. The very first hospital. It was the traditional departments and faculties isn't like least, and then eventually drifted over to Europe like Kristin let's come back to the 21st century. Let's talk about the state of the industry today. When you think about delivering acute care in the home, what is the current definition? What is covered what's included when you think about delivering acute care in the home?

Kristin Craig (03:02):
Care at home is huge. As we all know, there's lots of services that you can have from a virtual urgent care appointment that you take from your computer on zoom, to remote monitoring of chronic conditions with the device, or even texting with your doctor. And hospital acute care at home is the ability to move patients from an inpatient bed and then provide that same level of care at home. So it's not a discharge, it's literally the same inpatient care that you would receive in the hospital. So for example, a COPD patient might have a flare up that would typically require them to be admitted and get continuous oxygen, CPAP, regular medication doses, and under defined eligibility criteria. You know, they're not too likely to deteriorate, you know, they have XYZ other conditions that the clinical team was aware of. They would be identified and able to move home and they could have their oxygen and medications, et cetera, delivered to the home new software and equipment to have a medical team monitor them and potentially a combination of virtual visits and an in-person visit to continue while during their stay while they're a patient in this program.

Trine Tsouderos (04:10):
So Kristin, can you kind of paint a picture of the landscape of hospital at home who's involved with this is this all large hospital systems, are there a large array of organizations that are involved? What does it look like right now? And I guess also if you could talk a little bit about how maybe it's changed recently, that would be great too.

Kristin Craig (04:29):
It's really interesting. This is such an interesting time for hospital care at home. Before COVID you could count on almost one hand, the number of hospitals and health systems that had a program to do true acute care at home. And since then, it's north of 150 and in glass count was 165. So really has exploded in just the last couple of years as health systems dealt with both capacity constraints in their hospitals and beds that were fill up with COVID patients and others and trying to triage, and also patients that were will reluctant to come to the home. This kind of coinciding with a lot of the technology innovations and patient willingness provider, willingness to change has led to just a real explosion in the industry. We've heard so much about the virtual health explosion. I think it's growing something like ADX since COVID, but hospital home was almost a nascent industry. Just run by a couple of small players who were really pioneering the field and has exploded just in the last couple of years.

Igor Belokrinitsky (05:33):
Kristin as you've described this say I'm a hospital administrator, and I have to think through the logistics of taking my services and instead of doing them in the familiar four walls of my facility, all of a sudden I have to do them in the patient's home. I have to think clinically potentially doing some things differently, definitely operationally. This is quite different from my day to day. And even on the financial and reimbursement front, it might be very different than what I'm doing today. So how are hospitals and other health systems thinking through these clinical operational financial implications, taking acute care and moving it to the home?

Kristin Craig (06:11):
They're doing a lot of different ways. You can stand up a hospital care at home program pretty quickly. And we saw this actually in COVID. Some systems were able to stand up a hospital, a care brand new program within just a couple of weeks during the public health emergency to send some of their inpatients to the home setting. But a lot of the true integration involves a lot of longer term considerations. As you were starting to lay out everything from how we deliver care, the care model evolution, to how we train our staff, clinicians who are going to be caring for the patient clinicians who are going to be discharging the patient, bringing them back on maintaining that continuity of care, connecting them to the various specialists, you know, for post-stay follow-up all the way down to much longer term considerations like reallocation of capital footprint with hospital care at home.

Kristin Craig (07:02):
We estimate that at maturity, which obviously it's not at yet, we could move 25% of services into the home setting. Hospital care right now is a trillion dollar market. That's a huge set of care that could be moving to the home in the future. And the kinds of changes if you need a 25% fewer hospital beds, imagine the impact that that's going to have on health systems. On the flip side, there's still a lot of uncertainty. So how will the payment side look once the COVID emergency measures have expired? CMS has included hospital care at home as part of its temporary waivers during COVID, which essentially has allowed them to relax regulations and guarantee reimbursement to providers who are providing everything from telehealth to hospital care at home to their patients in order to kind of accelerate this. And it's really led as we discussed earlier to the explosion of a lot of these areas, but what's going to happen once we're on the other side of COVID, will these CMS policies become permanent?

Kristin Craig (08:04):
Will the reimbursement be at parody? Will it be less, how will private payers respond? Are they gonna follow CMS is lead our hospital systems gonna have to negotiate with each payer separately to contract this particular instance and how willing will providers be to offer it and to discharge patients out of the care within the comfort of the hospital walls, once this crisis and capacity pinches over. And then additionally, operational challenges, staffing is a huge one. As many health systems are facing a shortage of post-acute nursing, as it is. I think it's daunting for a lot of health systems to think about launching entirely new home care programs when they're really struggling to get enough nurses to staff, the facilities that they already have. So there's a lot of operational problems that we haven't even probably listed them all patient experience, continuity of care, insourcing versus outsourcing is certainly a lot of challenges.

Kristin Craig (08:57):
But also as we were talking earlier, a lot of opportunity and a lot of excitement around this field that is growing and that has a lot of momentum behind it.

Trine Tsouderos (09:05):
So Kristin I think one of the things that we're hearing from you that we've been hearing podcast after podcast is the impact of the pandemic on the healthcare system. I think hospital at home falls into that camp. One of the things that we've been seeing is even the way that regulation has changed in the face of the pandemic and CMS swept aside regulation to allow this hospital at home to flourish. And so I'm wondering if you can talk a little bit about the tailwinds, so the sort of regulatory changes and things like that. And also the headwinds that hospital at home is facing, what are you seeing?

Kristin Craig (09:41):
That's right. The CMS and reimbursement policies are definitely a big tailwind. When that initiative was launched in November of 2020. I think there were a lot of health systems who had really kicked the can on a fossil in an acute care setting, into the far distant future, move it very much so into their present. Once this reimbursement question was at least temporarily addressed. I think also the capacity peaks that hospital systems have been feeling during COVID has been a real push to come up with solutions beyond just wanting to be at the innovative cutting edge of being a pioneer at home health. You know, a lot of these hospital operators are really blocking and tackling and trying to make it through the day and serve the patients in their community. And if their beds are filling up, they come up with a field hospital. There was a recent study that a field hospital bed is something like $75,000 per patient to take care of them and alternate settings, temporary settings.

Kristin Craig (10:35):
And so if you could even ingest the case of dealing with excess capacity, propose this kind of a program as a solution, which on the flip side of not being so much more expensive is actually 30% to 40% less costly than a traditional inpatient bed. I think you're both addressing top line strategic considerations and also meeting really critical operational concerns for the people on the ground, which helps with a lot of the change management that happens with implementation of any change to the way that care delivery is performed. Technology innovation has also, I think been a huge tailwind much the same as the professional, you know, environments have exploded in terms of their ability to do remote work. And it's helped by all of the platforms that facilitate everything from the devices to the remote monitoring, to the patient and the provider critical access to high speed internet.

Kristin Craig (11:28):
There's increasing capabilities on both ends, both the provider side and the patient and readiness for these kinds of programs to be successful. And so I think that's another huge tailwind. From a headwind perspective, we talked about a couple earlier in any sort of new care model intervention. You're going to deal with needing to change the traditional way that providers, clinicians care teams have been delivering care. And so everything from changing protocol, different opportunities, different options for where a patient could go, what might be appropriate education about eligibility criteria, the benefits, and also assuring to the extent you can providing some context for how these providers will just lose the patient. I think that's always been a concern when you refer patients out of your care, are you going to lose them? Are you going to be able to track them and make sure that they're getting appropriate care down the line? Another potential headwind is while the CMS relaxation of the regulations certainly spurred initial growth. I think there is still some hesitation around reimbursement, particularly for health systems that are not as far along in value-based care where they're not well positioned yet to capture any value that they're creating through delivery of lower cost care that are they sacrificing some of their traditional inpatient volume to services that have uncertain revenues in the future that might be cannibalizing some of their historical revenue streams.

Igor Belokrinitsky (12:58):
Kristin you've really shown us a lot of the nuance in how to think about this opportunity, but overall, if I'm a health executive, a hospital executive, and I have a long list of potential growth opportunities ahead of be both organic and inorganic, why should I move this particular opportunity to the top? Why should I prioritize this acute care at home as something that is high potential for me?

Kristin Craig (13:23):
I think similar to what we were saying earlier to me, this home health expansion, including hospital care at home feels like such a no-brainer that marries both the strategist and the operational concern. So on the one hand, you're really setting yourself up for the future of healthcare. By getting in while this sector is growing, being part of learning, how it works before you fall behind and your competitors have already transitioned 25% of their care to this setting, they're able to out-compete you also, patients are really demanding it. The patient satisfaction is high, frankly. They've been ready for transitioning inpatient care to the home setting. Since the nineties, there's historically been concern that folks wouldn't want to send grandma home. They'd much rather have her in the hospital. And frankly, the data shows otherwise in terms of the patient satisfaction. Similarly, on a quality scores, you see readmission scores go down, complication scores, go down, length of stay, go down.

Kristin Craig (14:21):
And so from a value-based care perspective, not only is it a lower cost setting, it's a reduced time that you're spending in the healthcare venue and likely lower costs down the line as well. So for the system and for health systems that are becoming increasingly involved in value-based care and risk-based payment models, there's a lot there as well to include this as part of that portfolio. I think too, as hospital systems think about care more broadly, think about patients more broadly, than just, you know, once they walk into their hospital doors, this is a real opportunity to have a much broader, more continuous form of care and touch point and really help them across their care continuum and their needs. There's a broad set of care at home that hospital systems can be helping to support. And this is certainly one where they have incoming expertise and can be a differentiator and also be kind of a way to lever a much broader care at home program as well.

Trine Tsouderos (15:22):
So Kristin, one of the things that this conversation has made me think about is there are some changes that the pandemic has brought about that will disappear as the crisis ebbs, and there are others that will remain sticky and that will stay with us going forward. As we all forget about the pandemic someday and put away our masks and go on with our lives. And one of the difficult things being in this moment is to be able to tease out what will remain and what will snap back to pre COVID days. And so I think hospital at home feels like one of those sticky kinds of changes. And so thank you so much for walking through all of this with us. It was really fascinating.

Kristin Craig (16:05):
Thank you for having me.

Igor Belokrinitsky (16:06):
We always learn something new when we talk to Kristin. For more on these topics and other health industry insights driven by policy, innovation and care delivery changes. Please visit our website @ pwc.com/HRI. Until next time, this has been Next in Health.

Announcer (16:29):
This podcast is brought to you by PwC. All rights reserved. PwC refers to the U.S. member firm or one of its subsidiaries or affiliates, and may sometimes refer to the PwC network. Each member firm is a separate legal entity. Please see www.pwc.com/structure for further details. This podcast is for general information purposes only and should not be used as a substitute for consultation with professional advisors.

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Jennifer Colapietro

Jennifer Colapietro

Cloud & Digital Leader, PwC US

Igor Belokrinitsky

Igor Belokrinitsky

Principal, PwC US

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