Behind the Scenes at the Nation’s Largest Hospital-at-Home Program
At the NAACOS fall conference, Lindsay Jubelt, M.D., chief population health officer at Mass General Brigham in Boston, gave a look behind the scenes of the largest hospital-at-home program in the country, which has more than 90 dedicated employees. “We have doubled our census over the past year and are rapidly growing,” she said.
A combination of increasing financial pressure and capacity constraints, changing regulations due to the pandemic, and advancements in digital health technologies caused Mass General Brigham to take the home health business opportunity more seriously.
“We've had a hospital-at-home program as well as other home assets,” Jubelt said. “We have a home health agency. We have palliative care in the home. But we really haven't said this is a business offering and a care model that we really want to take seriously and start to scale to solve some of our challenges and some of our patients’ challenges. We now are taking this quite seriously. This is one of the top five initiatives that we've taken on within our system over the past three years of strategic planning.”
Their average daily census in June was 23. It's already up to 25 and growing. “Our goals are within the next five years to get it to 183, so that it will be the same size as one of our community hospitals,” Jubert said. “This provides us a way to grow our hospital capacity without having to invest the capital, and in a way that matches where consumer demands are going.”
The program has had over 1,800 admissions since January 2022. “We really saw that balloon during the pandemic,” Jubelt said, “and we've saved an incredible number of acute-bed days that could then be preserved for people who really need that type of inpatient care.”
Mass General Brigham is focused on having its hospital-at-home model meet its equity mission as well. They are actively tracking both the proportion of white patients and non-white patients they serve. “We have an older age in our hospital-at-home than in our inpatient facilities. We are serving more non-white patients in our hospital-at-home than our inpatient facilities,” Jubelt said. “And we're also seeing more non-English-speaking patients than in our inpatient facilities. We're proud of this, but it also means we've got to continue to push our care delivery model to be able to meet the needs of a diverse number of consumers with staff that can speak different languages, technology that speaks different languages and meets different needs.”
The program is also helping Mass General Brigham address workforce challenges, she said. “What is exciting about this model is that it presents a much different experience of working than what an inpatient care experience is,” Jubelt added. “We have a much higher employee net promoter scores for our staff working in the home and greater retention of our staff working in the home. We all have seen so much burnout amongst our nurses and our physician communities, as well as many of our allied health and so many other workers in healthcare. Offering this opportunity to either work in your community or work in a different sort of setting has really been a breath of fresh air for so many of the providers that are working in this space. They report back the joy of practice that is returning to them, having more flexibility over their schedules, and really feeling like they're making a difference getting to know patients at a different level.”
They have developed hubs in communities so that they can distribute supplies, but workers also have a place to come back to that is based in their communities, and not based in big hospital settings.
Jubelt stressed that it is important to make a strong case for these programs to hospital leadership at a time when most are financially constrained. “The first thing is to stress that we have a direct revenue source. Once you get your license, CMS is paying for hospital at home,” she said. “In order to qualify, you have to get admitted into the emergency room first and then enrolled into hospital at home, so you can't pick patients up upstream before they go to the ER. But it still can offload our ER. We get direct payment that is right now one-for-one from inpatient. That is probably going to go down over time, but right now we're getting direct reimbursement under our 1115 waiver and it is offering reimbursement parity.”
Mass General Brigham also has been working with its other payers to include hospital at home in contracts. “Right now, they are paying about 75 to 85 percent of payment parity and we think this is very fair and appropriate,” she said.
Some of the work needs to be in person, but a lot of it can be moved to virtual, she added. “We're able to continue to find cost-per-day reductions that are greater than what you can find in facility-based care,” Jubelt said. “We are excited to push on more of that as we continue to expand and have economies of scale. Perhaps the biggest argument for us has been regenerating hospital capacity. In our hospital at home, we are able to cover our costs and make some money, but we're also opening up beds for the hospital to be able to serve more patients, and what we're taking out of the hospital are a lot of the cases for which the reimbursement doesn't necessarily cover the cost of an expensive inpatient admission.”
“We have incredible net promoter scores from our consumers and employee net promoter scores from our staff, so that's just sort of icing on the cake,” Jubelt said. “We've got the CEO, the board, and the system behind us in this as we think about moving this from just sort of a research project and a care model that we're piloting to a full-scale offering that we're looking to scale to be the size of a community hospital. This requires a lot of coordination with internal stakeholders, as well as extensive external partnerships. “We have done a lot of thinking about what we need to own and should own versus where we think it makes most sense to partner on things that are not our core capabilities,” she said.
