Posted On 28 Mar 2020
As rapidly filling hospitals scramble to make room for coronavirus patients, a growing number of providers are experimenting with a new approach to free up beds: sending patients to receive hospital-level monitoring and care in their own homes.
In Boston, Brigham and Women’s Hospital is launching a program next week to send some coronavirus patients home with devices that allow doctors to monitor their oxygen level and heart rate remotely — the kind of close observation that typically requires hospitalization, Dr. David Levine, a physician and a researcher at the hospital, said.
“It’s going to empty our really important beds and slow the drain on personal protective equipment,” he said.
A remote monitoring program is also underway in Washington state at Providence Regional Medical Center, which reported the first coronavirus case in the United States.
Under the programs, coronavirus patients with respiratory problems or who require intensive care will still be hospitalized. But data from China and Italy indicate that the vast majority of those hospitalized do not need intensive care, Levine said. Brigham and Women’s program will use an algorithm to help select patients, who will be able to report their condition and symptoms to providers multiple times a day, he added.
Brigham and Women’s and New York City’s Mount Sinai Health System are also expanding more intensive “hospital at home” programs, which set patients up in their residences with IV drips, oxygen tanks and sensors that send vital signs directly to clinicians, with in-person visits twice a day from nurses and daily check-ins with a doctor. All patients must live within a short distance from the hospital, in case they urgently need a visit from a nurse or a paramedic, or to be readmitted.
Unlike the remote monitoring programs, which can track hundreds of patients at a time, the more comprehensive “hospital at home” programs in Boston and New York are far smaller in scale and currently limited to non-coronavirus patients — often those with congestive heart failure, chronic obstructive pulmonary disease, bacterial infections or pneumonia. But home hospitalization still opens up critical beds for the influx of patients with the virus, said Dr. Linda DeCherrie, a professor at the Icahn School of Medicine at Mount Sinai.
“We’re trying to triple the number of beds in the New York area,” DeCherrie said. “Freeing up beds for other patients is really important.”
The shortage of beds across the U.S. has left hospitals, federal officials and local authorities scrambling to find makeshift solutions.
In New York City, the center of the crisis, all hospital beds are expected to be full by April 1, according to an internal briefing from the Federal Emergency Management Agency, obtained by NBC News. While a temporary hospital at a Manhattan convention center is expected to open by then, and a hospital ship sent by President Donald Trump is heading to the city this weekend, New York will still need far more beds, according to the latest estimate by Gov. Andrew Cuomo.
Home-based treatment and monitoring come with their own risks. Even with careful screening, coronavirus patients can have symptoms that worsen quickly, potentially requiring care that can only be found in a hospital. And any patient could have an accident at home requiring medical attention.
But the enormous pressure that the coronavirus is placing on hospitals and other medical facilities has led them to consider alternatives. Home hospitalization could be an option for convalescing patients who might otherwise be sent to a post-acute care center such as a skilled nursing home or an inpatient rehab facility. If patients are still infectious, they could potentially endanger other highly vulnerable patients at such facilities, prompting some leading experts to recommend home-based care when possible.
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In addition to freeing up beds, providing home-based care for patients who don’t have the coronavirus could also protect them from becoming infected while in the hospital — a longstanding problem with other infections, as well, DeCherrie said. “Lots of infections are around the hospital,” she said. “Patients are often safer at home.”
Hospitals are also debating whether they can provide home hospitalization including IV drips and oxygen therapy to coronavirus patients. But acute care at home would require specially trained staff and personal protective equipment at a time in which both are in short supply, DeCherrie and Levine said. Patients could also risk infecting family members if they return home while they are still ill.
Well before the current pandemic, the explosive growth in medical costs — as well as the health risks to patients in hospital settings — had spurred more institutions to consider home-based patient care. Studies have shown that home hospitalization can produce better health outcomes, fewer hospital readmissions and a lower mortality rate, as well as significant cost savings.
Despite those savings, one of the biggest barriers has been financial: The federal government does not pay for home hospitalization through Medicare, the country’s biggest health insurer, which limits the pool of eligible patients and makes hospitals more reluctant to participate, Levine said. A federal advisory committee recommended having Medicare cover home hospitalization in early 2018.
But Health and Human Services Secretary Alex Azar rejected multiple proposals to do so, citing concerns including patient safety and overutilization of the program.
Some medical providers are now pushing the federal government to reconsider in light of the coronavirus’ strain on medical facilities across the U.S., said DeCherrie, who has been in discussions with federal officials about the issue.
The Centers for Medicare and Medicaid Services declined to comment on its plans, but pointed to the agency’s recent decision to expand telehealth services under Medicare, allowing more patients to see doctors remotely.
Hospitals across the U.S. are already making plans to ration care if they run out of ventilators, bed space and other critically needed resources. In Italy, doctors have been forced to choose which coronavirus patients will receive lifesaving treatments.
A group of Italian doctors from Bergamo — the area where hospitals have been hardest hit — recently published a paper urging other countries to use home-based care to “release pressure from hospitals.” The doctors recommended the use of oxygen therapy and monitors in the homes of patients with more moderate symptoms or who are recovering from the virus.
Doing so would help protect patients and health care workers, as well as reduce contagion, the authors said, warning of the risks of failing to act quickly.
“The more medicalized and centralized the society, the more widespread the virus,” the doctors wrote. “This catastrophe unfolding in wealthy Lombardy could happen anywhere.”