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The overall percentage of the elderly living in nursing homes is <5%.

Source: US Census Bureau


     

Source: °  
   ° 
  ^ational Center for Health Statistics, p66-67.
 

º Ñatients >65 years old comprised 27% of the hospitalized


population but 43% of all adverse events.
º 58% of patients age 65 or older hospitalized for >15 days
suffered at least one iatrogenic complication
 
    
º How do you think hospital-at-home care compares
in cost to traditional inpatient care?
Costs more
Costs the same
Costs less
   

Throughput x High-margin cases = Max $$$


Surgical vs. medical

Shorter More
lengths- cases
of-stay

Also desire an uncomplicated,


predictable clinical course
   

Throughput x High-margin cases = Max $$$


Surgical vs. medical
Long Fewer
lengths- cases
of-stay

The elderly have the longest and


most complicated clinical courses.
  !" 

º Medicare patients represent:


37% of hospital admissions and
50% percent of hospital bed-days
º Medicare also has lower reimbursement rates

*   
        


         
         
     
    
  
      
   !
 

Staff inputs
Consumables
Equipment (provided by the Red Cross on
contract to the community trust)
Overhead costs (local scheme management and
administration, car leasing and travel costs, the
management and finance functions of the
community trust)
Capital costs associated with the scheme's health
centre base

Siu et al. °   2009.


 
#
$ 
º Three main sources of increased cash flows:
1.) More open hospital beds, leading to a higher
case capacity (with some of those hopefully
higher-revenue surgical procedures)
2.) Direct revenue from charging for the outpatient
HaH program
3.) Reduction in loss from the common potential
complications that could arise from admitting the
chronically ill elderly

Siu et al. °   2009.


  %  
&    
  #
º Ñrospective non-randomized study at:
Univera Health and Independent Health, in Buffalo, ^
(Medicare managed care plans)
The Fallon Health Care System, in Worcester, MA
(Medicare managed care plan)
The Ñortland, OR Veterans Affairs Medical Center
º 2 consecutive 11-month phases:
Observation phase ± Ñatients eligible for HaH were
followed up through usual acute hospital care.
Intervention phase - all HaH±eligible patients were offered
at-home care
  #


ü 


ü 
  '    

º Ñhysician-associated costs
were also evaluated:
Emergency dept physician
costs were significantly
 in the interventional
group when combined across
sites
^on-emergency dept physician
costs were significantly
ü  when combined
across sites
 (& 
#
 (& 

º When physician-associated costs are added to the


hospital costs, once again only CHF and COÑD
show statistically significant cost reductions
Ñneumonia and cellulitis show a trend to reduction
º Ñossible explanation: ³Ñatients treated in the acute
hospital may receive unnecessary laboratory tests
and procedures because of their geographic
proximity to them.´
Ñneumonia requires limited tech to diagnose and treat
COÑD and CHF are associated with more technology
usage
   

º Hospital-at-home is noninferior both clinically


and economically to traditional inpatient care
for elderly patients presenting with acute
flare-ups of certain chronic conditions
By some measures (fewer complications such as
delirium, increased patient comfort), HaH care
could be considered superior to traditional care
HaH cost significantly less than traditional care in
the 3 participating hospitals (but this difference is
due to reimbursement schemes)
!   ) ( 

º Medicare¶s fee-for-service model does not currently


recognize HaH innovations and thus does not
specifically reimburse for this type of care
Fee-for-service hospitals will be unlikely to direct patients
away from reimbursable inpatient services
Johns Hopkins has submitted a proposal to Medicare to
develop payment models for HaH
º Hospitals that have integrated care delivery systems
(such as the VA or HMO-affiliated hospitals) with
capitation-style payments are best positioned to
realize savings from HaH
 

 *$ ) 
º Returning to the three main sources of
increased cash flows:
1.) More open hospital beds, leading to a higher
case capacity (with some of those hopefully
higher-revenue surgical procedures)
2.) Direct revenue from charging for the outpatient
HaH program
3.) Reduction in loss from the common potential
complications that could arise from admitting the
chronically ill elderly
Siu et al. °   2009.
'  *

º Hypothetical 300-bed hospital


85 percent average occupancy
Total discharges of 20,234
Length-of-stay (LOS) of 4.6 days
Medicare discharges of 7,486, Medicare LOS of
5.7 days; and average cost per Medicare case of
$10,495.

Siu et al. °   2009.


'  *

º In capitated systems, Hospital at Home savings result from substituting other services for inpatient
care. In fee-for-service, reimbursement may be less than program costs. The model assumes a
$579 per day cost above billable net revenue. All cases participating result in 100 percent
increase in hospital bed capacity due to diversion to home setting.

Siu et al. °   2009.


    

º Hospital-at-home may generate savings for


hospitals even if the Medicare fee-for-service
scheme is not altered to accommodate HaH
º Larger-scale trials in a wider variety of
hospitals are needed to better assess the
economic impact of this program