Amid surge in patients, hospitals treat more people at home
By Priyanka Dayal McCluskey Globe Staff,Updated December 16, 2021, 8:52 p.m.
Nurse Eric Thibodeau of UMass Memorial Health checked Leonice Quinlan's temperature at her home in Shrewsbury.Craig F. Walker/Globe Staff
When Eleni Nicolau became sick with COVID after Thanksgiving, a breakthrough infection that hit the 83-year-old hard, she found herself alone in a hospital room, separated from her family and struggling to breathe.
Then doctors gave her a new option: Did she want to finish her hospitalization at home?
An ambulance brought Nicolau to the triple-decker where she lives in Worcester, and where for the next five days, nurses gave her oxygen, steroids, and antiviral drugs. Doctors talked to her on daily video calls. A biosensor on her arm tracked her vital signs around the clock.
"Everything you would have in the hospital, my mom had here," said her daughter, Fran, who helped care for her.
Nicolau was part of a new program at UMass Memorial Health to treat patients who need hospital-level care inside their own homes, an initiative that Massachusetts hospitals are expanding to help manage unprecedented demand and a shortage of hospital beds and staff.
Hospitals are canceling nonurgent surgeries to concentrate on the sickest patients, many of whom delayed treatment earlier in the pandemic. At the same time, the number of people hospitalized for COVID in Massachusetts has more than doubled over the past month, to 1,473.
"Hospital capacity is stretched more than it has ever been," Steve Walsh, president of the Massachusetts Health & Hospital Association, told state lawmakers at a public hearing Thursday.
A few small home-hospital programs were in place before the pandemic. But with COVID cases rising again and the health care system stressed, hospitals are under greater pressure to find new ways to take care of patients.
"This is the quickest and least costly way to build a hospital unit," said Dr. Ryan Thompson, medical director of the home hospital service at Massachusetts General Hospital.
"If you pick the right patients, they tend to do better at home," he said. "They sleep better, they eat better."
MGH is treating about five or six patients a day at home and is working to double that. Brigham and Women's Hospital, which launched a hospital-at-home program in 2016, expanded during the pandemic to treat 15 patients per day — about the size of one unit in a brick-and-mortar hospital.
UMass Memorial started a home-hospital program in August with just two patients and is rapidly expanding: it's treating about eight patients at home every day and plans to continue increasing the number to as many as 50 patients per day over the next several months.
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"Our emergency department is too full right now. We have patients who are sick with COVID and other diseases who we need to meet where they are, in their home," said Dr. Constantinos "Taki" Michaelidis, medical director of UMass Memorial's Hospital at Home program.
"The home hospital is going to play a very important role in our meeting the surge demand from patients over the next couple months."
Although the programs are relatively small, doctors and hospital leaders say they help alleviate bottlenecks at a time when patients are waiting in crowded emergency departments — sometimes in hallways — for inpatient beds to open up.
Patients eligible for hospital services at home include those with congestive heart failure, chronic lung disease, pneumonia, skin infections, kidney infections, and urinary tract infections — similar to the patients in a traditional hospital setting. Some hospitals are treating COVID patients at home if they're sick enough to need oxygen and medications to heal, but not so sick that they need intensive care.
Related: Hospital group boss cites 'terrifying increase' in hospitalized COVID-19 patients in Mass.
Each patient receives a tablet to video-chat with doctors. They can call a nurse if they have questions or problems. They wear armbands that monitor their heart rate, temperature, and oxygen level 24 hours a day. Doctors track these vital signs remotely and receive alerts if the readings hit abnormal levels.
"I can see everybody's vital signs on my phone, on my computer, almost like it's a Twitter feed, and each patient is a tweet," said Dr. David Levine, who heads the Brigham's home-hospital program.
Nurses such as Eric Thibodeau visit patients at least twice a day. Craig F. Walker/Globe Staff
Nurses or paramedics visit patients at least twice a day, sometimes more. In rare cases, patients call 911 to be rushed to the hospital by ambulance.
Leonice Quinlan, 74, came to the emergency department at UMass Memorial Medical Center in early December when her chronic lung disease flared up. After waiting in the ER two days for a bed, and starting to feel desperate, she agreed to be hospitalized at home.
When her nurse, Eric Thibodeau, visited one recent morning, Quinlan was showered and dressed, her nails painted, a pendant around her neck. "You look good," Thibodeau said.
But she didn't feel good: her voice was hoarse and her breathing labored. In the cozy living room of Quinlan's Shrewsbury apartment, Thibodeau checked her oxygen level and blood pressure. He held the tablet while Quinlan video-chatted with her physician, Dr. Bhavin Patel. He drew some blood and gave her an IV steroid. He observed as she walked from the living room to the kitchen, and back again.
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Quinlan was grateful to be at home for the entire encounter, a petite Christmas tree in the window, and the TV playing softly in the background.
"My own environment, my own bed, my own bathroom," she said. "There's so much activity [at the hospital]. This is so much more relaxing."
A randomized study by Levine and his colleagues published last year found that the cost of providing hospital-level care to patients in their homes was 38 percent lower than in the traditional hospital setting, partly because home-hospital programs don't need to employ a full fleet of night nurses. At home, patients also used fewer lab orders and imaging tests, spent more time moving around, and were less likely to need to go back to the hospital.
A milestone for this model of health care came in November 2020 when federal officials agreed to cover the costs for patients with Medicare or Medicaid coverage. Until then, insurance programs did not regularly pay for home hospitalizations.
Over the past year, 188 hospitals across 34 states have implemented home-hospital programs, according to the Centers for Medicare & Medicaid Services.
The federal rule change was meant to help hospitals manage the COVID health emergency, but doctors are lobbying to make the change permanent.
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"I don't think this is a genie you put back in the bottle," said Dr. Pippa Shulman, chief medical officer of Boston-based Medically Home, which provides technology and training for hospitals treating people at home. "Too many people have seen the advantages of having care in the home."
Among Medically Home's clients, which include nationally known health systems such as the Mayo Clinic and Kaiser Permanente, up to 3 to 5 percent of hospitalizations are now happening at home. But Shulman said a far greater number — up to 20 percent of hospital admissions nationwide — safely could be done in patients' homes.
And while not all patients may want to be hospitalized at home, those who choose it tend to like it.
In Worcester, Fran Nicolau was relieved when her mother, Eleni, came home from the hospital under the close watch of nurses and doctors. Instead of being isolated from her mother, she cooked meals and translated medical advice into Greek, her mother's primary language. She helped her mother walk around the house.
"Within three or four days, my mom just felt better with her family instead of being isolated on the COVID floor," Nicolau said. "We were so happy she was home."
Priyanka Dayal McCluskey can be reached at priyanka.mccluskey@globe.com. Follow her on Twitter @priyanka_dayal.