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When Doctors Make House Calls—For Real

August 18, 2012
by Mark Hagland
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Presbyterian Health Services’ Melanie Van Amsterdam, M.D., talks about the groundbreaking Hospital at Home program she’s helping to lead in Albuquerque

At Presbyterian Health Services, an integrated delivery system in Albuquerque, New Mexico, clinician and operational leaders have created a groundbreaking program called “Hospital at Home,” which sends out teams of doctors and nurses to care for patients in their homes rather than admitting them as inpatients. Those patients are very carefully screened, using rigorous criteria, and fall into certain well-defined care categories.

The concept, which the Presbyterian folks adapted after studying a white paper by Bruce Leff, M.D., a professor of Medicine at the Johns Hopkins University School of Medicine, who conceived of the idea and coined the phrase, is aimed at improving outcomes for certain frail elderly patients, while at the same time reducing care costs and optimizing care management practices. Using this model, the Presbyterian organization has been able to reduce costs per episode by about 20 percent on average, while improving outcomes and dramatically improving patient satisfaction. The Presbyterian program is the first Hospital at Home program to be established outside several that have been launched within the Veterans Administration health system.

Under the Presbyterian program, a patient is “admitted” to Hospital at Home if s/he meets the rigorous criteria for program admission, and then a physician is sent out once a day for a diagnostic and treatment visit, followed up at least once, sometimes twice, a day, by nurses and nurse specialists. The patient’s vital signs and other key clinical status indicators are carefully monitored, and a great deal of phone communication between the patient’s home and the Hospital at Home team is involved as well. The program is designed specifically for patients with one of several chronic illnesses, including congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and renal failure, and for patients who it is determined will benefit from care in the home rather than from inpatient admission, for specific situations.

Presbyterian  Health Services’ innovative program has received coverage in the mainstream press recently, including from Kaiser Health News/USA Today.

Dr. Leff and the leaders of the Hospital at Home program at Presbyterian, including Lesley Cryer, Scott B. Shannon, and Dr. Van Amsterdam, have also recently published an article on its results in a recent issue of Health Affairs.

 The September Healthcare Informatics cover story presents the Presbyterian Health Services case study in the context of the broader push taking place towards care management and population health management health system-wide. In preparation for the publication of the September cover story, HCI Editor-in-Chief interviewed Melanie Van Amsterdam, M.D., an internal medicine specialist and Hospital at Home’s lead physician, regarding her perspectives on what the program has been achieving, and her involvement in it. Below are excerpts from that interview.

Why are you glad you’re involved in this program?

Number one, I get to spend time with my patients; that’s lost in medicine these days. It’s also probably numbers two and three.

What were the biggest challenges in setting up this program? And what have the biggest learnings been so far?

The biggest challenges are really educating people about what we are and how to use us, and kind of getting through other providers’ heads that there is another option besides the ER and the inpatient hospital. And of course, reimbursement.

This program seems obviously replicable to me.

Yes, obviously, this is extremely replicable, especially for integrated systems. If you have a large enough population and an integrated system, yes, it is.

Could this be done in conjunction with health plans that aren’t provider-owned?

I think so, absolutely. And we have a replicable payment methodology.

Karen Thompson, the program’s director, has said that the physicians, including yourself, who are participating in the program, were interviewed very carefully for mutual fit.

Yes. We looked at hospitalists, and they were definitely not comfortable working in the home. They basically wanted the structure [that they have in the inpatient hospital], and working without that support network wasn’t something they wanted to do. We also interviewed primary care providers, some of whom were not so comfortable with the acuity of the patients. So we’ve been very fortunate; we have Dr. Elizabeth Ward, who trained with Dr. Bruce Leff, and she’s worked with rural patients, etc. You’ve met Dr. Ward, and Linda Martinez, an advanced clinical nurse specialist with prescriptive authority; she and Dr. Ward and I are the key providers.

I’ve heard that you make sandwiches and do laundry, too??

Yes! Recently, Darren [Darren Maestas, R.N., the program’s patient care manager] and I had this 94-year-old woman who was debilitated, baseline, but also got sick, and her son was scheduled to go on vacation, and so she depended on us for three meals a day, for a few days in a row. So the home health aide came in and put the laundry in, and I took it out. And that patient also wanted a grilled cheese sandwich with onion and tomato, which I prepared for her.

With regard to information technology, what kinds of tools would you like that you don’t have right now?

So many things! I would love to have a custom-built system—we’ll be on Epic soon, but—I don’t type, I dictate. And I would love to have the history and physical created in a system in which the diagnoses are generated, the orders are generated, and they would automatically populate the system, and one in which DME [durable medical equipment] orders, oxygen as well,  are automatically generated. Because this is labor-intensive. It often takes me an extra hour to fax everything, and you have to give copies to the patient.

What would your advice be for CIOs, CMIOs, and other healthcare IT leaders, in this area?

Well, they have to be able to deliver integrated services—the whole delivery side should be on one information system, and  a program like this ultimately needs to encompass some form of telemedicine, which we don’t have yet. There are technology companies looking at facilitating telemedicine visits. What would be a big breakthrough would be to have a nurse practitioner visit in which the physician is connected telemedically. We have telehealth capability now, but it hasn’t been incorporated into Hospital at Home nurse visits. All that having been said, I have very mixed feelings about that element, because there’s nothing like a physician sitting down with a patient, because you can use all your senses, and there’s a lot you can discover in person that simply isn’t possible via telehealth. For example, are the patient’s lips psyanotic—blue? And you can smell strep from a mile away. But you could use telehealth very effectively for follow-up visits.

Is there anything else you’d like to add, with regard to the Hospital at Home concept?

I would encourage people to try it. It’s a cost-effective way of producing good patient care, with improved outcomes.


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