Sunday, May 19, 2024
Virtual Heart Care
Telehealth 

Telehealth’s New Horizon: Providing Smart Hospital-Level Care in the Home

Editor


Introduction: Expanding Telehealth to Include the Hospital at Home Model

During the COVID-19 pandemic, medical providers have expanded telehealth into daily practice, providing many medical and behavioral health visits, even urgent visits, remotely over video or phone. Telehealth helps streamline hospital/clinic operations and ensures the safety of health care workers and patients. The telehealth market was already conducting home health care with increasing levels of sophistication before COVID-19.1 Among the emerging telehealth practices, telephysical therapy; teleneurology; telemental health; chronic care management of congestive heart failure (CHF), chronic obstructive pulmonary disease, and diabetes; home hospice; home mechanical ventilation; and home dialysis are some of the most prominent.

To optimize hospital operations, reduce overcapacity, and for many beneficial reasons to be described herein, we recommend expanding home telehealth to a comprehensive delivery of medical care across a distributed network of hospitals and homes, linking patients to health care workers through the Internet of Medical Things using in-home equipment and smart medical monitoring devices to create a “medical smart home.” We envision a future in which we transition the provision of medical care from hospital to home, just as, during the COVID-19 pandemic, students adapted to distance learning and adults transitioned to remote work from home.

Patients are comfortable and psychologically at ease in the familiar and supportive home environment; this may enhance healing and drive the market for home health services. Telehomecare has been shown to save money and improve patient outcomes.2–4 If we implement enhanced home telehealth now, then when any future emergency occurs (i.e., a pandemic or natural disaster), the hospitals would already have greater capacity without needing to reallocate resources. The hospital at home (HaH) is a dual-use health care system; it helps patients in everyday life and during disasters.5,6

Medical care models have come full circle. For hundreds of years through the mid-1900s, doctors and midwives visited patients at home. From the 18th century, through the industrial revolution, hospital care became standard. Our vision of expanded telehealth combines the best of both models, supporting comprehensive medical care that links patients and providers across a distributed network of hospitals and homes nationwide (Fig. 1).5,6

Fig. 1.

Fig. 1. Telehealth network: a simplified network approach (linking large academic hospitals, smaller regional or field hospitals, and patients with hospital rooms at home) will help to treat patients in isolation and balance the patient load in the national health care system. This map is illustrative for the COVID-19 pandemic, but is not based on actual data. Circles with larger gray areas indicate a higher percentage of COVID-19–positive patients in that area or hospital.

Current Models of Telehealth Care in the Home

Many existing programs demonstrate proof of the concept that home health care is a growing market, popular with providers and patients.

The Onsite Medical Clinic in a Congregate Living Site

A new trend in senior housing offers private homes centered on a community medical clinic, from which the doctor can treat patients. The homes have network connectivity and connections to provide oxygen (O2), and the clinic can deliver medical equipment if needed. During COVID-19, the elderly, as a high-risk population, can isolate and receive care in the comfort of their homes. Providers manage all patients from the onsite clinic, with access to a larger network of specialists through telehealth.

Telehospital Medicine, Telehomecare Services, and HaH Models

One aspect of the home telehealth market is called telehospital medicine—which provides remote physician support including daytime patient rounding, emergency department consults, 24 × 7 night and weekend call coverage, and admissions.7 Private companies now offer telehomecare services, many supplemented with visits from nurses and aides. Intermountain at Home provides home-based care through telehealth and remote monitoring for patients with CHF, renal and intestinal conditions, certain cancers, and palliative care, supplemented with at-home care visits.8,9 Northwell Health provided at-home care to COVID-19–positive patients that included sending a nurse in full personal protective equipment (PPE) to evaluate one patient, who was receiving intravenous (IV) fluids and medications and supplemental O2, and had her blood drawn and medicines prescribed, all at home.10

Medically Home partners with Mayo Clinic, Adventist Health, and Tufts Medical Center; their interdisciplinary team monitors patients through an electronic health system that gives the care team immediate access to all patient health information, including real-time vital signs.11 Their founder cites COVID-19 as a catalyst for the HaH model, “because of … hospitals needing more capacity and patients’ concerns surrounding hospitals.”2 Atrium Health HaH rapidly deployed a virtual hospital model for 1,477 COVID-19 patients in early 2020, providing home hospital-level care and monitoring through a virtual observation unit and virtual acute care unit in the home.12

Vivify Health, which provides remote patient care through a connected care platform, published a white paper, “Aging in Place with Remote Patient Care” that offers advice to help health care systems and clinicians adopt telehomecare.13

Since Johns Hopkins first piloted the hospital-at-home program 20 years ago, many hospital-based pilots for health care at home have been conducted, many ongoing. These include:

  • □ Penn Medicine SOAR Program, with a network of three hospitals and two regional medical centers has a “flipped discharge” program for older adults over 70, with care coordination for patients leaving the hospital, bus transport home with lunch for the patient and caregiver, and a nurse who visits to bring medications directly to the home and check medication use with the patient at home in a calmer environment. Twenty-seven percent of patients avoided skilled nursing facility placement and there was high patient satisfaction with this model.14

  • □ Markham Stouffville Hospital, Ontario, Canada’s program is designed to support patients with cardiac failure who have been discharged from the emergency department and are determined to be medically stable enough to be monitored virtually. When the patient has new symptoms, they call a nurse triage line, and paramedics consult with the patient virtually and work with clinicians to adjust medications to alleviate breathing problems. A nurse navigator coordinates all care including later follow-up care in radiology and the laboratory.14

  • □ Mount Sinai’s “Hospital at Home-Plus (HaH-Plus)”: This system’s pilot allowed 685 medically eligible adult patients to receive inpatient care and 30 days of rehabilitation at home instead of in the hospital. Mt. Sinai created several in-home hospital units, called “Palliative Care Unit at Home—PCUaH”; “Observation Unit at Home—OUaH”; “Post-Acute Rehabilitation at Home—RaH,” and a “Hospital Averse at Home” program.15 DeCherrie et al. note the value that Mt. Sinai has created through the range of at-home services they established capable of replacing traditional inpatient services. Also valuable is the 24-h health team, equipped to handle a diverse set of clinical needs across the health system, allowing for greater flexibility, efficiency, and patient-centered care.15 Mount Sinai has continued its home-based programs through contracts with multiple health plans.16

  • □ Many hospitals now offer HaH services, including Johns Hopkins in the US, UK, Canada, Australia, Israel, and others.3,16 A small pilot randomized control trial in 2017 determined that, “the use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity.”17

Veterans Affairs Programs

Veterans with CHF, chronic obstructive pulmonary disease (COPD), or other eligible conditions can use the Veterans Affairs Telehealth/Care Coordination program to monitor and track their progress. A registered nurse monitors vital signs, provides patient education, and coordinates any needed consults, specialist visits, and follow-up care.18

“ICU in a Vest” to Replace Lung and Kidney Function

Andriy Batchinski, MD, a trauma surgeon and researcher at the U.S. Army Institute of Surgical Research, has invented a device called the Combat Resuscitation Organ Support System (CROSS) or “ICU in a Vest.”19 This wearable vest delivers lifesaving care to the patient through a catheter in the jugular vein, replacing lung and kidney function and avoiding the need for intubation. Dr. Batchinski says, “COVID patients who end up in ICUs on ventilators had an 88% death rate in older, obese, hypertensive patients in New York. This current standard of care contradicts the natural breathing patterns of humans and should be replaced with direct oxygenation and CO2 removal, i.e., breathing carried out in the blood by extracorporeal life support (ECLS).”20

The vest provides patient care at home or at the point of injury, maintaining breathing, blood circulation, and kidney function, providing medication and fluids for up to three days. It reduces the need for ICU beds and allows patients to remain conscious and moving. This device will help injured soldiers awaiting evacuation and patients in the home hospital setting. The renal support system is FDA approved while the lung support device is pending FDA approval.

Benefits and Costs of the HaH Model

An evaluation of the HaH model concluded that management of patients with chronic and acute illnesses was feasible, safe, and efficacious. Costs of care were lowered through avoiding unnecessary hospitalizations and reducing readmissions.4 Medically at Home reports a reduction in both readmissions and the “…fixed costs of the hospital… which are being arbitraged out, because we are using the patient’s home as the site of care,” said founder Raphael Rakowski. “Those costs that are no longer in play can [serve] to provide more care over a longer period… which reliably creates higher patient satisfaction.”2 Home telehealth visits became reimbursable during the COVID-19 pandemic.21 Home nursing care visits are covered by Medicare22 and other insurances, though coverage differs based on patient age, medical conditions, and other factors.

Levine et al. conducted a randomized controlled trial in adults over 18 to compare outcomes of home hospital versus usual hospital care. They reported a 38% reduction in adjusted mean costs for home patients, who had had fewer laboratory orders, imaging and consultations, and lower readmissions.17 Casteli et al.’s comprehensive review to determine outcomes of successful HBH models identified 26 nursing care measures, six additional indicators, and two factors to help health systems assess and calculate direct and indirect costs.23

Implementation of the Home Health Care Model

To implement a home telehealth model, national capacity at different levels must be in place. The necessary baseline requirements are summarized hereunder.

Home Health Infrastructure and Technology

Home health care delivery through telehealth requires robust bandwidth, a stable broadband internet connection, and electrical backup through generators, batteries, or solar panels.24 The technology needed is a computer and wearable devices to monitor vital signs including blood pressure, O2 saturation, heart rate, respiratory rate, temperature, eyes, nose, food intake, nutrition, urine output, and others. Many such devices exist, including one by Philips© that provides early detection of deterioration in COVID-19 patients.25–28 Devices that administer IV fluids and medications and provide O2 are also needed. Autoregulating mechanical ventilators are being developed and could be used at home. Several companies offer home lighting systems with chips that can sense individuals in a space, track their health conditions, and convey the data to remote monitoring software.29

With the Internet of Medical Things, medical companies are rapidly designing multitiered systems that connect patients to providers through wearables and remote patient monitoring systems,30–32 which will support the expanding home telehealth market.

Nursing/Operations Support

Assistant health care providers, whether family members or professionals coordinated by the Visiting Nurses Association (VNA), home care agency, or care manager, will still be required for basic medical care and activities of daily living for many patients; whereas the smart medical technology, guided by critical care or hospital medicine providers, will deliver and monitor the medical care. The vast network of VNA services can facilitate assessment, setup, and management of telehealth equipment in the home. Increasingly, emergency medical technicians and paramedics are helping with chronic care conditions, medication adjustment, etc., to avoid crises. Especially in rural areas, they become familiar with their patients due to repeat visits.33

Organizational leaders need to develop safety practices and policies to mitigate potential safety risks and exposures that medical providers might experience when providing care in a patient’s home.34 The long list of required components needed for HaH model success also requires that system leaders ensure a sufficient workforce of highly skilled in-home clinicians, especially nurses and health aides.35

Design, Storage, and Fabrication

As home telehealth expands to monitor chronic conditions such as CHF and COPD,4,18 the need exists to maintain a nationally scalable stockpile of high-tech equipment for hospital suites at home. Since some suites may be only employed in a crisis, having ready-to-assemble kits kept in bulk storage with little-to-no maintenance that can be constructed at the time of deployment will minimize costs and streamline processes. A simple-design home care kit could contain monitoring and IV capabilities that can be easily assembled. The mechanical/structural elements can be 3D printed as needed. Kits can leverage existing electronics and offload computing to the cloud to save money. Secure HIPAA-compliant software exists for transferring patient data to appropriate servers.

System Implementation

Effective initiation of the more robust HaH model and/or kit will require a team that is able to rapidly address operational, technical, medical, and care-coordination aspects of the initial implementation, ongoing support, and troubleshooting. Initiating the HaH system for a new patient will require onsite technical support staff who can set up the system, inform patients about how to check and report worsening medical signs and symptoms, and help them coordinate with medical and care management providers.

Robotics that Facilitate Patient Care

Robots are increasingly used in hospitals for surgery, patient care, medication deliveries, and cleaning. Robots extend the availability of staff to provide quality care and help isolate staff and patients from illness. Robots can autonomously navigate around IV lines and obstacles, connect with diagnostic devices, and access patient data from the electronic medical record.36 Stanford Hospital uses 23 mobile robots to deliver supplies to wards by automatically operating elevators and avoiding obstacles; three robots track medication inventory and count pills for administration.37 A robot in the Neuro Intensive Care Unit at Cedars-Sinai makes remote rounds.38

In the future, we envision robots also used in the home hospital suite, but at present, there are challenges. A ventilator can be operated remotely by human control using teleoperation and ventilator settings adjusted, but remote troubleshooting of ventilator issues cannot be done. Robots can do remote monitoring but cannot change a medication in an infusion pump yet. Cannulating peripheral blood vessels for blood sampling and IV administration of fluids are now possible using near-infrared and ultrasound imaging to scan for blood vessels and a robot to insert a needle using imaging and force guidance.39 The regular and integral use of robotics within this telehealth home health infrastructure will likely be incorporated into a future phase of design rather than the initial models.

Home Health Care: How It Helps Balance and Triage the Patient Load Between Hospitals and Home

We may consider health care as operating on three tiers, from most to least intensive: hospital ICU care, hospital inpatient care, and home care.

During a pandemic or other crisis (emergency event with many casualties, etc.), the ICU space must be fully available and perhaps increased. With telehealth, we could maximize ICU space by moving patients down the tiers:

  • □ ICU patients who are less critically ill move to hospital inpatient care.

  • □ Less ill non-ICU inpatients move to HaH. This expands the concept of surging capability by simply reallocating space within the hospital.40

During a pandemic like COVID-19 we would triage patients at each tier of medical care, starting with home care, as follows:

  • □ If all household members test negative for SARS-CoV-2 or have no symptoms of COVID-19, all should practice physical distancing, using masks in public places, including schools, workplaces, and stores.

  • □ If a household member tests positive for SARS-CoV-2, but is not in need of hospital care, the person can be isolated in one bedroom (the hospital suite) and use a bathroom that is not shared. The remaining household members should quarantine. The patient could receive some aspects of home monitoring such as pulse oximetry, supplemental O2, and nursing care through telehealth. Many COVID-19 patients have been able to stay at home with O2 support and a pulse oximeter. At one hospital, 30 of 110 (27%) of COVID-19 patients were treated at home with O2 and pulse oximeters, collectively saving 1,200 nights of hospital stays.41

  • □ If the telehealth providers decide that the COVID-19 patient is too ill to stay in the home hospital room, transfer the patient to a hospital’s COVID-19 ward.

  • □ If the COVID-19 patient does not need ICU care, provide care and O2 in the hospital with the option of in-hospital telehealth to limit staff exposure and preserve PPE.

  • □ If the COVID-19 patient needs ICU care, provide care in the ICU and consider the role of Tele-ICU.

When parts of the country experience viral surges or other medical issues, telehealth can help balance the patient load. Rather than moving patients between hospitals, we might perform remote monitoring, rapid scaling, and movement of resources virtually.

Modifying Hospitals to Support Health Care at Home

Alternative Hospitals and Hospital Spaces

COVID-19 treatment in the United States required more ICU beds and ventilators than were available in some hotspots.42–44 To prepare for future emergencies that overwhelm ICUs, each hospital should be designed to quickly convert regular hospital beds to ICU level and to treat/move less ill patients to non-ICU areas or to the home. If local or regional ICU capacity is exceeded, clinicians can conduct tablet or cart-based consultation from non-ICU hospital rooms to distant intensivists. Repurposing of in-hospital space such as endoscopy suites and postanesthesia care units, as separate COVID-19 units, is very beneficial for pandemics, especially if the hospital can isolate such areas by changing the heating, ventilation, and air conditioning system to negative pressure. Most recommend using this surge process for critically ill patients rather than building field hospitals.40,45,46

Oxygen

O2 is needed for ventilators and for high-flow use in the home and hospital to avoid the need for mechanical ventilation. Currently, no technology exists to generate O2 in the volumes and flows to easily make it available for high-flow consumption, whether through heated high-flow nasal cannulas or through ventilators for home use. As a result, home care becomes limited, and field/nonfixed facilities rely on liquid or shipped-in O2 supplies with inherent storage, power, and transportation-related logistic constraints. This is a technical challenge we must overcome to make the home hospital work. Home O2 concentrators provide low-flow O2 but cannot support high-flow nasal cannula (HFNC) or ventilators.47

Noninvasive Ventilation

We should examine the best way to oxygenate and ventilate (remove CO2 from) patients, including high-flow O2 administration through the nose and continuous positive airway pressure/bilevel positive airway pressure through nasal or facemask. For example, many COVID-19 patients presented with profound relatively asymptomatic hypoxemia but not ventilation defect. If promptly identified, providers can treat these patients with O2 through noninvasive HFNC.

Extending COVID-19 Hospital Models to Home

Application of some telehealth approaches that served smaller rural hospitals during the COVID-19 pandemic could be extended to the home. These include remote monitoring and on-demand live interactive audiovisual support by intensive care doctors and nurses (and/or hospitalists and specialists). As an example, Dartmouth-Hitchcock Medical Center Connected Care created a “just-in-time” network of support from its tertiary medical center’s Tele-ICU Hub to rural critical access hospitals for COVID-19 consultation using telemedicine carts and telehealth videoconferencing software.48 They also utilized their tele-emergency providers to perform tablet-based evaluations of COVID-19 patients under investigation in the emergency department (ED) while limiting exposure and preserving PPE.

Discussion and Conclusion

Partly in response to the COVID-19 pandemic, telehealth is advancing along the path of home health care, with increasing levels of sophistication (e.g., home hospice, home mechanical ventilation, and home dialysis). Currently, however, such services exist in a piecemeal manner; they are not well integrated as we propose here and depend mostly on a patient’s resources.

Can the HaH Service all Patient Populations?

Initially, the HaH was piloted using elderly patients with more frequent care needs. Over time, as expenses come down and barriers such as training expand, then we see a democratized application of the home care model to all populations, including at-risk populations. One review cited a key implementation barrier to HaH being patient eligibility, often due to the structure of the HaH model and local and national legislation.23 We propose to employ HaH based on medical need, across all populations. Older adults have more comorbidities, so home telehealth/hospitalization is relevant for them. However, COVID-19 has highlighted the already-known dangers of hospitals—delirium, nosocomial infections, falls, isolation, etc.

Telehealth can now keep patients at home who otherwise might have spent 1 or 2 days in the hospital; examples include infections requiring IV antibiotics, postorthopedic procedures, pain management, and obstetrical prenatal/postnatal care. These patients avoid exposure to the risks of hospitalization. Telehealth frees up acute-care capacity in hospitals,14 which equally impacts all populations.

Telehealth can help patients who do not wish to visit the hospital or have economic barriers. In a study of attitudes toward home-based Primary Care (HBPC) among homebound adults over 50 with multiple health issues (44% Caucasian, 6% Asian, 50% African-American, and mostly rural),49 patients reported challenges with transportation to the hospital and other barriers. The authors recommend educating patients about home-based care and developing “comprehensive, patient-centered HBPC to meet the needs of home-bound individuals.” We envision HaH as part of a spectrum that includes hospital ICU and inpatient care, ambulatory care, and home care. We believe that over time, hospitals will recognize and promote HaH as a way to load balance their operations while maintaining or even increasing hospital revenue.

What Barriers Impact the Success of HaH Programs in At-Risk Populations?

The literature on at-risk populations cites serious barriers to telehealth implementation for at-risk populations with moderate to severe social determinants of health. Such populations may include but not be limited to economically disadvantaged inner-city, suburban, or rural patients of all ages and ethnicities; minor children; elders; tribal communities; incarcerated persons; and racial minorities. Healthy People 2020 organizes the social determinants of health into five key domains: (1) economic stability, (2) education, (3) social and community context, (4) health and health care, and (5) neighborhood and built environment.50

The most often cited barriers to the use of telemedicine/telehealth for economically disadvantaged people include:

  • □ Overall disparities in care for minorities with low socioeconomic status: Three barriers that overlap and prevent telehealth access are known as “the Digital Divide”: “absence of technology, digital literacy, and reliable internet coverage”.51 A report examining the digital divide by race/ethnicity and socioeconomic status (SES) in older adults found that disproportionately, “minority status combined with the lowest levels of SES substantially reduced the odds of using Internet for health information.”52

  • □ Lack of reliable access to high-speed internet, e-mail, smart phones, or computers, especially in rural areas53–56: A Harvard School of Public Health Report in 201954 found that 21% of rural Americans report access to high-speed internet as a problem for them or their family. The Rural Health Information Hub55 cites an FCC Report,56 which found that 30.7% of rural areas and 35.4% of tribal areas lacked access to high-speed broadband Internet. The Rural Health Information Hub concluded, “the availability of broadband affects the ability of patients to participate in video consultations, transmit health information, and monitor their health at home.”55,56 In addition to challenges related to inadequate broadband, “many rural households lack access to computers and digital technology.”57

  • □ Problems with sustaining telehealth services, including retaining clinicians, maintaining, and paying for telehealth equipment.55

  • □ Lack of, and urgent need for, customized telehealth services/training to serve distinct needs of specific groups, including minor children, older adults, veterans, tribes, and incarcerated people.58

  • □ Provider reticence: Not all rural clinicians are quick to accept telehealth, possibly due to their attitudes about telehealth or limited medical and telehealth resources.59

Some possible solutions that will facilitate the access of at-risk populations to telehealth include:55,58

  • □ Expanding broadband internet, including into rural and disadvantaged areas. This will increase availability and decrease cost, allowing ease of use and sustainability of services.60

  • □ Affordable technology: Telehealth is more accessible to a broader audience given the advancement in readily available low-cost wearables (such as smart shirts or bracelets) with sensors that monitor geographic, biologic, ecologic, atmospheric, and vital signs, combined with video software that runs on a cell phone. This information negates the need for expensive complex equipment and provides telehealth providers with important patient data. The low cost and accessibility extends telehealth to a broader population in a low-income or rural area, and the barriers are not technological.

  • □ Training and recruitment of telehealth providers61 with cultural sensitivity for groups including children, elders, veterans, minority groups, and incarcerated people:

  • ○ For minor children, sensitivity to privacy needs of children.58,62

  • ○ For the elderly, training on telemedicine for seniors and caregivers, and integration with skilled nursing facility programs.58

  • ○ For Native populations, keys to successful implementation include recruitment of health care workers sensitive to the culture, overcoming resistance to technology, and enlisting family and tribal support.55,58,63,64

  • ○ For incarcerated persons: Telepsychiatry, with integration between the treatment team and facility, meets prisoners’ needs by providing services remotely, and works well for providers who seek to avoid working in a jail/prison for health or safety reasons.65,66 Reduction in barriers to telemental health has been a priority for many years.67

Kruse et al. wrote a comment about rural native populations that applies equally to all at-risk populations. “Telemedicine offers rural Native American communities a means of accessing healthcare without incurring high costs. With attention to reimbursement policies, educational services, technological infrastructure, and culturally competent care, telemedicine has the potential to decrease costs, increase quality, and increase access to healthcare for rural Native American patients.”63 Burke et al., speaking about rural and inner-city children, concluded, “Telemedicine’s greatest strength lies in its ability to overcome the barriers of distance and time to reach medically underserved populations.”62

We must overcome technical as well as financial barriers to make home telehealth work seamlessly for all populations,68 and its success may require some truly novel concepts, as outlined hereunder.

  • □ Legislation must occur to streamline telehealth reimbursement processes, medical licensure, and credentials.

  • □ We must ensure and demonstrate that home telehealth reduces costs and generates income for the hospital, and possibly saves money for the patient, for it to be viable and not a threat to hospital finances.

  • □ Hospitals/systems need to collaborate on this initiative, ideally with state oversight.

  • □ The need for nurses, aides, and caregivers is crucial and challenging. Without nursing care, most forms of hospital care cannot exist outside of the hospital. Emergency medical services (EMS) systems may need to adapt their mission to support these endeavors.14 Johns Hopkins has a training program designed to build a pipeline of home health nurses, including an internship.61

  • □ This system could potentially offer great epidemiological information, for example, collecting data of all patients at home with COVID-19.

In summary, technical IT experts can make this system work. We need to get the acceptance by bill payers, home health care agencies, and even EMS, the professionals who would likely respond to emergent issues in the home. We need agreement from Medicare and the U.S. government, hospital systems, providers, and patients.

The telehealth “HaH” model of medical care provided across a distributed network presented herein will streamline cost-effective, efficient, safe, and quality care, during everyday operations, and during the inevitable crises.

Acknowledgments

The authors thank J. Suzanne Mosher, MD, for clinical expertise, research, and review, and Albert Raine, MBA, for medical device information and review.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References





Source link