美国国家公共电台 NPR--Post-pandemic, even hospital care goes remote（在线收听）

Post-pandemic, even hospital care goes remote

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David and Marcia Elder packed their bags anticipating a month-long stay at the Mayo Clinic in Jacksonville, Fla., when David went in for a bone-marrow transplant in late February, as part of his treatment for multiple myeloma, a blood cancer.

A few hours after surgery, the couple were amazed when staff offered them the option of returning home that day. "They came to us and said, 'We have this hospital-at-home program' and I was like, 'What? I'd never even heard of it,'" Marcia Elder says.

By dinnertime that day, paramedics had set up a make-shift recovery room in their living space and they returned to convalesce at home.

Such a thing was unimaginable, just a few years ago. The Mayo Clinic was among the first hospitals in the country to experiment with sending acute patients home for remote care four years ago. Now, some 250 similar programs exist throughout the country.

That's largely because during the pandemic, the federal agency that runs Medicare and Medicaid relaxed normal rules requiring around-the-clock, on-site nurses for hospitals requesting the exception. This allowed at-home hospital care programs to rapidly expand. Those pandemic-era waivers will remain in place until at least the end of 2024, although some experts anticipate policy changes allowing such programs to remain in place permanently.

David Elder flashes his hospital bracelet from the comfort of an easy chair in his own home, which he was sent back to just a few hours after his bone marrow transplant surgery. He said it was a lot more restful to be home.

Marcia Elder

As a result, at-home hospital care is fast becoming an option for acute care for many conditions, even for treatment of cancer, or for patients like Elder, recovering from complex procedures. Such shifts could potentially reshape the future of hospital care, affecting many more patients.

The practice has been enabled by other recent trends as well – for instance the increase in traveling medical staff and the prevalence of portable Internet-enabled devices to connect with medical help remotely. The crisis of the pandemic also normalized remote care. And dealing with COVID surges made hospitals — as well as regulators and health insurers — more receptive to the notion that at-home care might be healthier, cheaper, and generally more pleasant than at a hospital.

"People do better; they're more mobile, they recover faster," says Michael Maniaci, an internist who directs virtual care for the Mayo Clinic. "They use physical therapy or skilled nursing care less. You ask: Why is that? Because there's something magical about being at home."

Of course, not every patient is stable enough to qualify for at-home care, and the program is purely voluntary, so about a quarter of patients opt not to. But of nearly 700 patients studied at Mayo, none died while receiving care at home. Fewer than 10% required hospital readmission in the first month.

Letting patients recuperate in the comfort of home

Nine days after surgery, when physician's assistant Jessica Denton came to visit David Elder in person, his living room was serene and sunny.

Denton rang the doorbell and walked into his home, as Elder, 60, greeted her from his favorite recliner, looking out onto a backyard patio. Behind him stood a pole to hang intravenous fluids. A card table set up next to him keeps pills, an oxygen monitor and a tablet for video calls within reach.

He said he finds comfort in all the familiar things a hospital can't provide — his own TV remote, his favorite food, his wife's helping hand.

"Honestly, there's a lot more restfulness, here at home," he said. Sitting next to him, his wife agreed: "We've been married 37 years, and I think he sleeps better when I'm next to him, too."

The comfort of the familiar home environment, Maniaci says, is better for patients regardless of whether they live in a home with others, or alone — and even if they're acutely ill.

He says hospitals are — ironically — terrible environments for healing, with their constant swirl of staff, noise, and risk of infection. "They're away from family, they're isolated, they're hungry, they're sleep deprived all night with all the vital sign checks, beeps and creeps," he says.

David and Marcia Elder at home with their grandchildren, before David got sick. During his recovery at home, he looked forward to visits from the grandkids.

Marcia Elder

Elder said there were many benefits to recovering within the community he's a big part of. Until last fall, when he got sick, Elder had been a pastor at his church in St. Augustine. It's something of a family business; his sons, also pastors, live nearby and could visit with the Elders' grandchildren.

Risks of care without in-person nursing

Most hospital-at home programs provide in-person medical visits twice or three times a day – nurses or paramedics take patients' vitals, replenish medications and supplies, and consult with a doctor via video conference, if necessary.

But some argue the hospital-at-home trend can put patients at risk, leaving them at home, and alone in some cases, when immediate care might be called for.

"This is crisis standard of care being normalized to the normal standard of care — it's substandard care by its definition," says Michelle Mahon, assistant director of nursing practice at National Nurses United. Mahon argues hospitals are trying to reap more profit by providing fewer skilled nurses and doctors, and relying on cheaper, less-trained staff to go into peoples' homes.

Mahon, who is a registered nurse, says she's had many experiences with seemingly stable patients who then had pulmonary embolisms or other sudden deteriorations in their condition that required immediate intervention. She argues it's a matter of time before things go very wrong for patients who do not have that kind of wrap-around care at home.

"We don't need the data to know what will happen in the home, because we know what's happening in the hospital," she says.

Mahon worries that the pursuit of savings will mean the American hospital industry generally will try to make at-home care standard for most patients.

"Hospital-at-home programs are billing in-patient care rates while shifting all of the care responsibilities to family members, the patients themselves, and the public 9-1-1 system," she says.

At-home care is not without its risks. Some days into his recuperation, Elder developed a fever and sores in his throat — common signs of infection — and he landed back in the hospital 30 miles away for enhanced monitoring. He returned home a day later, but paramedics remained on standby in case of emergency.

I asked Marcia Elder if she worried about not having the doctor down the hall. She says no, pointing to words emblazoned on her blue shirt: "Look back and thank God and look forward and trust God."

"We've had to do that," she said. She said believes the hospital wouldn't have sent him home, if they weren't certain he was safe. "We've had to trust God and the doctors."

Maniaci says there are safeguards in place to protect patients. Local paramedics and transportation are on call, in case a patient must be readmitted, for example. And at-home patients have 24-hour access to doctors on call with the touch of a button. In addition, a doctor calls in to check on Elder about twice a day.

When David Elder went in for a bone marrow transplant, he was expecting a multi-day stay in the hospital. Instead, staff at the Mayo Clinic offered him the option to recuperate at home. The model can cut health care costs.

Marcia Elder

On the day of Denton's visit, Dr. Patricia Chipi called in via video link on Elder's tablet and asked about his sores, and his appetite, then verified his vitals with Denton, the physician's assistant — all while getting input from Elder's wife.

Still, at-home care means those doctors, in turn, also often rely more on family members like Marcia Elder for the various tasks of caregiving, from keeping medication schedules to bringing the patient food and water. For patients who live alone, or for family members who cannot give care, the hospital can order a home health aide to help with these tasks.

For Marcia, at-home care is a more "intense" responsibility than watching others carry out those tasks at the hospital, but that's also a huge advantage to being at home. Hospital care involves lots of waiting — for the nurse, the medicine, the paperwork — but with this at-home setup, she can swiftly take care of business and still access a doctor online, at any hour.

"The minute I see him start to get nauseous, I can grab the pills, call and say I want to give him [anti-nausea medication] and he's got it in him probably within 60 seconds," she says.

Marcia Elder took care of her husband David during his at-home recuperation. "We've been married 37 years, and I think he sleeps better when I'm next to him, too," she says.

The Mayo Clinic runs its hospital-at-home program from its virtual command center, right across from the brick-and-mortar hospital. At any given time, 20 doctors and nurses stationed there can care virtually for up to 150 patients, including in Wisconsin and Arizona, near Mayo's other hospitals.

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By comparison, the gleaming white hospital across the street is 20 times bigger and operates with eight times the health care staff — but can treat only double the number of patients.

That kind of data sold Maniaci on the virtual hospital concept. At first, he was a vocal skeptic arguing, "there's no way I can take care of people in the home. I've got to see them every day!"

Maniaci changed his tune when he saw patient care improve, and costs reduce. Virtual care can save up to 15% over hospital care, according to Maniaci. The programs are still new, so it's not clear where cost savings will end up, or how those savings might be passed on to patients, but the American Hospital Association says early data show there are also potentially big cost savings from lower hospital readmission rates for patients receiving care at home.

Maniaci says seeing those savings made him more keenly aware of the waste in routine hospital care: "We over-monitor people; we do too many I.V. meds and not oral meds; we overuse medicine at the hospital because the resources are available."

One of the most complex aspects of providing at-home care is coordinating all the various supplies and services that would normally be found in the hospital. Mayo partners with Boston-based company Medically Home to handle the logistics — making sure medical supplies, transport, medical meals, and services are available at the patient's home.

The company was started in 2017 by a group of engineers, one of whom lost his father due to poor hospital care. That prompted them to try to engineer software and logistical systems that might enable more care to be delivered safely at home.

CEO and co-founder Rami Karjian says the pandemic transformed the concept of at-home from radical idea to mainstream in very short order. Hospitals became hazard zones, and the sudden search for alternatives made their at-home business boom. "That really encouraged so many more hospitals to come ... and start developing the capabilities to offer these types of programs," he says.

Currently, a hospital or health system that wants to roll out such a program must request a waiver from Centers for Medicare and Medicaid Services, the federal agency managing those programs. Some industry leaders hope Congress and CMS will act to extend the ability of at-home hospital programs to continue beyond the current end date of December 2024.

"Hospitals realized that you don't just have to use hospital-at-home to manage COVID patients," says Mark Howell, director of policy and patient safety for the American Hospital Association. "We're all better off if Congress decides to move forward and authorize a permanent program."

Maniaci agrees. He says, the time spent not running the hallways of a hospital gives him more time to spend at patient bedside — virtually, of course. Plus, remote care lets him peek into their lives, chat with family caregivers, or see telling details, like when a heart patient drinks too much grape Kool-Aid. Once, he warned a patient that pet birds chirping in the background might carry allergens.

"Even though I'm not physically with my patient, I'm giving better care than I did for the last 15 years in the hospital — it's kind of a strange thing to me," he says.

But then again, it isn't strange at all, he says, pointing to an old leather doctors' bag on display at the entrance of Mayo's offices. A century ago, doctors used them to carry medicines and exam tools to patients' homes, because all medical care was done by house call. "This is just the modern version of that," he says.