A Different Kind of Perioperative Surgical Home

A PROMISING INNOVATION WITH IMPLICATIONS FOR SURGICAL CARE Postoperative surgical care in the United States continues to be shaped by strong financial incentives in the healthcare system designed to control cost and enhance value.1,2 There has been substantial investment to control drivers of surgical cost, such as length of stay (LOS) and readmission. None have examined whether postoperative hospital-based care can be substituted for hospital-level care at home—an emerging model now backed by evidence that it is a safe and less expensive alternative. Hospital at Home (HaH) is a healthcare delivery model in which a patient receives services in their home similar to inpatient hospital care. Patients are enrolled through the Emergency Department (ED) as an alternative to inpatient admission or during inpatient hospitalization as an early transition to home. HaH mirrors an inpatient stay: (1) an admission intake performed by a provider team, typically a physician or nurse practitioner (NP); (2) scheduled visits daily by the physician or NP and multiple times per day by a nurse; (3) laboratory tests obtained from home phlebotomy; (4) imaging including x-ray and ultrasound using portable machinery; and (5) administration of intravenous medications and fluids. Patients are cared for until they are appropriate for discharge. HaH has been studied in patients with acute medical problems, such as chronic obstructive pulmonary disease exacerbations, heart failure, and cellulitis. The earliest programs in the United States were initiated at Johns Hopkins in 1997.3 Studies emerged in the 2000s from experiences with patients in Medicare Advantage Plans and since then data have continued to accumlate.4–8 Two metanalyses of randomized controlled trials found that HaH programs have the same or lower mortality compared with standard inpatient admission.9,10 Adverse events such as transfer to ICU, intubation, myocardial infarction, delirium, urinary tract infection, and fall were either the same or lower in HaH cohorts.6,9,10 No difference was found in process of care metrics, such as the timeliness of antibiotics for infection.6 Patient satisfaction with their care was consistently higher.10 Furthermore, HaH demonstrated a 19% to 30% reduction in cost compared with traditional inpatient care. Savings accrued from a reduction in LOS compared with equivalent inpatient admission, fewer laboratory and imaging tests, and elimination of room and board fees. Metanalyses have confirmed these findings.9,10 In the United Kingdom, Canada, and Australia, HaH has become part of routine care. In Australia, 6% of bed-days are provided by HaH.11 One challenge in the United States has been a lack of HaH-specific payments in Medicare. In 2017, however, CMS funded a pilot program in which HaH was bundled with a 30-day postacute care episode payment. Federman et al demonstrated that such a payment model could be implemented successfully, paving the way for new CMS billing codes.12 In the meantime, several commercial insurers have taken the lead by including HaH among their reimbursable services.13 AN OPPORTUNITY IN SURGERY The care of postsurgical patients presents an unexplored opportunity to study HaH programs. With appropriately trained staff, HaH is well suited for patients with select postoperative complications traditionally requiring readmission, or for patients typically admitted after surgery whose postoperative care could be transitioned entirely to the home. The potential value of HaH in surgery has 3 components. First, HaH could lower costs by replacing postoperative inpatient readmissions and reducing inpatient LOS for index surgical hospitalization through early discharge. Cost containment in these areas is critical as expanding bundled payment programs in CMS do not pay for readmissions after surgery and payment for inpatient stays are already bundled into a single capped amount. Second, HaH could reduce inpatient congestion so that surgical patient throughput could increase. This may enable hospitals to schedule elective surgeries in a timely manner and large medical centers to more readily transfer in patients from outside hospitals who need tertiary surgical attention. Third, surgical patients may benefit from the same reductions in nosocomial complications and increases in patient satisfaction demonstrated in medicine patients compared with traditional inpatient care. Although there is little evidence of common surgical complications being cared for at home instead of in the hospital, much of the care rendered by HaH programs for medical patients—including intravenous fluids, medications, and wound care—aligns well with common postoperative diagnoses. For example, surgical site infection, a leading cause of readmission, could be managed with intravenous antibiotics and wound care at home while tracking white blood cell counts and monitoring for signs of systemic infection.14 High-volume output after ileostomy creation could be treated by HaH with aggressive fluid administration, electrolyte repletion, and stool monitoring. Vomiting and dehydration after bariatric surgery could be managed with intravenous fluids, electrolyte repletion, and antiemetics. HaH may also successfully reduce inpatient LOS for patients in whom the key milestones of postoperative recovery consist of monitoring symptoms and laboratory tests. For example, patients with prolonged ileus after abdominal surgery could be managed at home with nasogastric tube decompression, fluid and electrolyte repletion, and monitoring for return of bowel function. A case series of 50 patients in a HaH program in Spain demonstrated that patients could be safely discharged after laparoscopic colectomy earlier with 10-fold lower cost of care.15 CHALLENGES FOR A HaH PROGRAM IN SURGERY Patient and surgeon trust. For some patients, HaH may not be a welcome alternative. Our institution has found that medical patients already in the ED and expecting inpatient admission may reject an unfamiliar alternative care pathway. Patients should be educated during the preoperative office visit or at the beginning of their postoperative recovery to build trust. As important is the surgeon's willingness. In our institution, we seek to ensure that surgeons find it as easy to send a patient to HaH as to the ED. A practitioner in a “Navigator” role receives all HaH requests, performs intake evaluations, and coordinates services. Standardized Care Pathways and Quality Assurance Defined diagnoses with established management algorithms make standardized HaH care pathways in surgery possible. Figure 1 provides an example of such a pathway for colectomy patients developed at our institution in whom ileostomy dysfunction with dehydration is a leading cause of readmission. Key aspects of the history, physical examination, and diagnostic testing should be prospectively defined. Dose, frequency, and escalation criteria for treatments help support bedside nursing care.FIGURE 1: Hospital at Home pathway for patients with ileostomy dysfunction with dehydration. F, Fahrenheit; IV, intravenous; PO, per os.Inclusion and exclusion criteria are explicit to ensure enrollment is a safe option for the patient. Hemodynamic stability, clear mental status, ability to toilet independently, and a stable home environment are criteria used in our institution. Physical examination and imaging data needed to clarify the patient's status should be obtained before enrollment. Stratifying the patient's risk for decompensation should be linked to adjustments in their HaH care, such as the frequency of visitation from staff. Rapid response protocols should be established such that if a patient experiences acute decompensation they are readily escalated to an inpatient setting without delay. Quality metrics for HaH must be standardized and tracked. Given that HaH seeks to replace inpatient admission, quality metrics tracked in the past have mirrored those for inpatient admission, such as nosocomial complications, ICU transfer, and mortality. Measures unique to HaH that must be tracked in surgery include time-to-provider response and transfer to an inpatient facility. One important consideration is how outcomes should be attributed in HaH. For example, for patients transitioned to home early after their index surgery, should the LOS of the HaH stay be attributed to the index hospitalization? These determinations will have implications for surgical quality reporting and registry data. Personnel and Communication Training HaH staff so that they are effective and comfortable with providing care in the home setting is essential. This includes wound care, drain management, pain control, and ostomy upkeep. Expectations regarding the content, frequency, and mode of bidirectional communication between HaH staff and surgeon should be established. Surgeons or representatives from their teams must be available to consult when urgent needs arise. Technologies that offer secure HIPAA-compliant provider-to-provider photo sharing and video conferencing can enable surgeons to engage with the team and the patient in the home. Care Resources Safe care in the home demands timely availability of the tools and supplies that clinicians require. Our institution developed a partnership with an independent home infusion organization that delivers compounded medications and fluids to the patient's home. They also obtain intravenous access, including peripheral intravenous central catheters. An additional consideration is the logistical challenge of ensuring that staff see enough patients to make their time cost-effective. Geographic dispersion of patient homes and traffic patterns must be accounted for. To avoid inefficiencies, our program has a defined catchment area of 8 to 10 miles. HaH can be a safe, less costly alternative to inpatient hospitalization for surgical patients. It is time for HaH programs in the United States to be rigorously studied in surgery. Pathways must be developed in conjunction with surgeons to maintain excellent patient care and ensure appropriate usage. Responsible reporting will help build a reliable evidence base so that CMS and other insurers appropriately reimburse for HaH, which would enable effective scaling of these programs. In doing so, surgeons can pioneer new approaches that could transform postsurgical care in the United States.