The traditional brick-and-mortar hospital system is broken, often leaving patients in a condition that’s worse than when they first arrived.
That’s according to a May report from the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). The findings throw further support for facility-based care alternatives, including the types of hospital-at-home models that lean heavily on home health and home care agencies.
“Given the scale and persistence of patient harm in hospitals in the decade since our last report, HHS leadership and agencies must work with urgency to reduce patient harm in hospitals,” stated the report.
As part of their work, OIG investigators examined medical records for a random sample of 770 Medicare patients discharged from acute care hospitals during October 2018 – a period of relative normalcy long before the COVID-19 crisis. The examination included a preliminary review where nurses screened records for possible patient harm, as well as a physician-led review to further assess the severity of adverse health events.
Among their findings, investigators determined that one in four hospitalized Medicare patients experienced harm during their stay.
For nearly 25% of those individuals, the “harm events” resulted in additional costs to Medicare. Additionally, physician-reviewers determined that 43% of the harm events could have been prevented if patients had been provided better care.
A similar OIG effort in 2010 found that 27% of hospitalized Medicare patients experienced harm during stays in October 2008, with nearly half of those events preventable. While the earlier investigation has led to an increase in federal oversight and internal efforts from hospitals to strengthen clinical practices, there are clearly still problems.
“Addressing patient harm and promoting patient safety takes on added urgency in light of the ongoing pandemic and its effects on hospital operations,” the report continued. “Despite substantial action by HHS agencies and success in reducing certain types of events, patient harm remains pervasive, is often preventable, and continues to cost the Medicare program and patients.”
The most common type of harm event was related to medication, such as patients experiencing delirium or other changes in mental status. Other common events included hospital-acquired infections, pressure injuries and problems that arose during procedures.
In October 2018 alone, OIG estimated that medicare spent $520 million on costs associated with patient harm events. Two-thirds of patients received care that was paid under the Medicare Inpatient Prospective Payment System (IPPS).
“We found that 20% of patients covered by IPPS who experienced harm events incurred additional costs to the Medicare program and potentially to the patients themselves as a result,” the report noted.
To combat systemic problems, OIG broadly recommended more checks and balances, with further federal oversight. Yet long-term investment in hospital-at-home models that shift higher-acuity care into the home – or prevent hospitalization in the first place – could also make a major difference.
A 2012 analysis, for example, found that hospital-at-home patients had a 19% lower six-month mortality rate compared to hospitalized patients. A more recent study found that hospital-at-home patients also had a lower risk of long-term care admission, with lower rates of depression and anxiety.
Other studies have suggested hospital-at-home patients recover quicker and have a lower risk of outside infection due to a more controlled environment.
New York-based Mount Sinai Health System launched its own hospital-at-home program in 2014 as part of a three-year grant from the Center for Medicare & Medicaid Innovation (CMMI). Since then, the Mount Sinai team has repeatedly observed outcomes that surpass traditional hospital care.
“Outcomes were better and we were able to reduce complications,” Dr. Al Siu, director of Mount Sinai at Home, previously told Home Health Care News. “We were able to show we could do this safely, and that there was another option for patients and their families.”
The hospital-at-home concept isn’t new, but programs have dramatically increased since the start of the pandemic, partly thanks to the temporary Centers for Medicare & Medicaid Services (CMS) “Acute Hospital Care at Home” waiver. As of May 17, 97 systems and 225 hospitals in 35 states had been approved for the waiver, which will end when the public health emergency expires.
The OIG report suggests that policymakers consider a more permanent replacement, ensuring that hospital-at-home programs can continue thriving moving forward. That’s something hospital-at-home stakeholders are certainly pushing for, specifically in the form of the Hospital Inpatient Services Modernization Act.
“There’s a lot of interest and support for the waiver,” Jeremiah McCoy, director of policy and government relations at Moving Health Home, previously told HHCN. “We just need to continue to build on that and make sure that the Hill is hearing what everyone’s saying, not only for what the opportunity has been during the pandemic, but what this means for a future iteration of the acute care home model in Medicare.”
In addition to hospital-at-home models, the OIG report also suggests that policymakers consider further investments in home health and home care.
Home health and home care agencies often enable hospital-at-home programs by being the “eyes and ears” in the home. But home-based care agencies themselves have repeatedly been found to prevent hospitalizations.