As the nascent model becomes more entrenched, physicians are playing key roles and appreciating the experience

By Bonnie Darves, a freelance health care writer

Physicians who are eager to expand their practice horizon and are interested in using innovative technologies to deliver comprehensive virtual care beyond the video sessions that proliferated during the pandemic may find a good fit in the emerging hospital-at-home programs that health systems are implementing. Physicians who have at least a few years of hospital-based practice experience are being tapped to serve as chief care facilitators or medical directors for hospital-at-home programs, and the demand for such expertise is predicted to grow in the coming years.

Hospital-at-home programs enable patients to receive high-acuity care in their homes, with the clinical oversight of physicians, typically hospitalists, and a combination of remote and onsite care providers. Most models operate from command centers and feature a robust equipment and technological backbone for vitals monitoring and patient communication. In an ideal scenario, hospital-at-home care is intended for patients who are sick enough to warrant hospitalization but stable enough to be safely cared for at home.

Primary candidates include patients with chronic-condition exacerbations or infections, those undergoing cancer treatment, and immune-compromised individuals at high risk for contracting infections. Some hospital systems are also exploring using the model for post-surgical patients. In many current models, patients who present to the emergency department or are already on medical-surgical units are evaluated by physicians for their potential to be safely treated at home instead of admitted to the hospital.

Hospital-at-home programs are not new. In Canada, England, Australia, and many European countries, such care models are well established, in part because they’re easier to implement with single-payer models. In the United States, hospital-at-home programs were relatively rare until the COVID-19 pandemic push came to shove — catalyzing virtual care implementation in 2020 and spurring hospitals to create new programs on the fly.

Johns Hopkins pioneered the hospital-at-home model in the mid-1990s, but a movement didn’t ensue. Most of the programs in place today are nascent. However, as the US Centers for Medicare & Medicaid Services continues to grant approval for hospital-at-home programs that meet its criteria — as of June 2024, 331 hospitals in 37 states had been authorized to provide such services, according to the American Hospital Association (AHA) — the model is expected to become more prevalent. AHA, which has 5,000 members, reports growing interest among members in establishing hospital-at-home programs.

The recently formed Hospital at Home Users Group has more than 100 active members, and an additional affiliate group includes hospitals and health systems that are considering establishing programs. These developments will increase demand for physicians, primarily hospitalists, who can help launch and direct hospital-at-home programs.

What hospital-at-home looks like on the ground

Not surprisingly, the hospital-at-home programs that are moving to full implementation are being led by large health systems and commandeered by hospital-based physicians. At Mayo Clinic in Florida, a program initially developed as a response to strained hospital capacity during the pandemic is now a full-scale Advanced Care at Home program. It is staffed by 12 physicians who practice within Mayo’s command center and direct care for patients admitted through multiple Mayo hospitals in Florida, Arizona, and Wisconsin.

“What we’ve created is essentially an ecosystem that enables us to deliver hospital-level care at home, providing most of the services that eligible patients would receive in the hospital,”

— Michael Maniaci, MD, Mayo Clinic

Dr. Maniaci notes that approximately 70 percent of patients who go to the hospital through the emergency department are treated and released; those who would benefit from continued clinical oversight are ideal candidates for hospital-at-home care. Other patients are admitted via hospitals’ medical-surgical units.

In the Mayo model, started in 2020 to address the capacity-shortage issues the pandemic created, physicians rotate through the command center on a periodic basis. They work in tandem with nurses and advanced practice providers (APPs) and orchestrate the provision of services ranging from lab tests, imaging, and IV therapies to physical therapy and wound care, among others. Patients are equipped with computers and monitoring devices and a phone line that connects them directly to clinicians at the command center. As in inpatient models, the care team conducts rounds and loops in specialists as warranted. APPs, nurses, and paramedics, Dr. Maniaci explained, are the “boots on the ground.”

Laila Hakam, MD, a hospitalist and senior associate consultant at Mayo who helped establish the program and now devotes approximately two-thirds of her practice to hospital-at-home care, quickly became enamored of the model. “It’s actually become another admitting arm for us, and we’re finding that it retains a superior standard of care,” Dr. Hakam said. “It’s proving a very collaborative approach, and we [physicians] find it’s helpful that our virtual nurses are literally just a tap away.” Dr. Hakam and her colleagues appreciate the fact that the model gives them a view into home and the supports a patient has — or lacks. “It’s contextual medicine practice, and I feel that I’m more available to my patients,” she said.

To date, more than 2,000 Mayo patients have been cared for in the hospital-at-home program, and volumes will increase as Mayo expands its program to incorporate a new STAT home-care program and other offerings.

Care models stress multidisciplinary, integrated approach

North Carolina-based Atrium Health, a large integrated system with 68 hospitals across four states, has been a forerunner in positioning physicians at the frontline of virtual, comprehensive home-based care. The program was established rapidly during the pandemic to accommodate urgent overcapacity issues and deliver care to COVID-19 patients. It has since evolved into a sophisticated permanent program that, to date, has treated more than 12,000 patients.

Today, a core group of eight full-time equivalent (FTE) hospitalists and the program’s medical director work in tandem with APPs to oversee care in Atrium’s Hospital at Home program. An additional 40 hospitalists have been trained and now rotate into the program as moonlighters on an as-needed or as-wanted basis.

Daniel Davis, MD, Atrium’s senior medical director of continuing health, expects that number to expand rapidly in the next few years as the health system expands its patient capacity. It permits them to combine “brick-and-mortar” practice with virtual care — and develop a new skill set in the process. “It’s been a great option for our physicians who have been working in the hospital for ten to 20 years.”

“This is definitely an emerging practice area for physicians, and we’re seeing a growing number of physicians who are interested in this hybrid practice model.”

— Daniel Davis, MD, Atrium Health

In Atrium’s model, physicians and nurses work from home rather than from a site-based hub, and clinicians engage in formal multidisciplinary teams. The team includes a “quarterback” physician who assesses referrals and oversees clinical operations. On a given day, a patient might receive imaging, infusion, and therapy services, and Atrium also provides meals when needed. Physicians “see” their patients at least once daily. Those video visits frequently incorporate virtual nurses, onsite paramedics, and family members in the same visit.

Dr. Davis acknowledges that, for physicians, there is a definite learning curve in adapting to the virtual care model and its team structure. “Taking a patient history via video can be challenging at first because it’s a different skill set. Physicians also must be very intentional about building relationships with other team members — and trusting them,” Dr. Davis said.

Cleveland Clinic, a recent entrant, launched its Hospital Care at Home program in April 2023. Like Mayo, it utilizes a command-center hub, called the Clinically Integrated Virtual Care (CIViC) Center, as its base of operations. Two hospitalists conduct patient rounds and intakes, and five nurse managers provide active oversight and ensure that all services are delivered according to protocol. That physician team is likely to grow soon as Cleveland Clinic expands the model to encompass additional hospitals.

“We’re seeing a lot of interest among physicians and nurses who want to join the program,” said Richard Rothman, MD, chief of medical operations for Cleveland Clinic in Florida. “In hospital medicine in general, there is a general perspective among physicians that the way we deliver care today isn’t the way we’ll deliver it tomorrow. We’re learning as we go.”

What’s in it for physicians?

Even though it’s early days, Mayo, Atrium Health, and Cleveland Clinic are receiving positive reviews from physicians practicing in their hospital-at-home care models. “Our hospitalists are seeing the value of the program for both patients and physicians,” Dr. Rothman said. “The hospitalists find that they’re having more direct interaction with their patients than they might in the inpatient setting, and that it’s easier to incorporate families in discussions about care using the video model.”

“In hospital medicine in general, there’s a general perspective among physicians that the way we deliver care today isn’t the way we’ll deliver it tomorrow. We’re learning as we go.”

— Richard Rothman, MD, Cleveland Clinic

Although there is no formal supporting data to date, Dr. Rothman is optimistic and hopeful that providing hospitalists with care-setting alternatives via the hybrid care model may help reduce the burnout with which many physicians struggle today.

From a career-option standpoint, hospital-at-home practice is best suited to physicians who have at least three to five years of hospital-based practice experience. That is important, all sources concurred, because physicians must first be deeply familiar with hospital care systems before they attempt to safely replicate comprehensive care in the home setting. “Physicians probably need three to five years of experience in brick-and-mortar work before they transition to a virtual model,” said Dr. Davis. “They have to learn what a sick patient looks like,” he said, to determine appropriate care plans and decide when interventions are needed.

Irene Rahman-Garcia, MD, an early-career hospitalist who is helping Cleveland Clinic expand its hospital-at-home program, cites a practice benefit some hospitalists are reporting: improved patient compliance with prescribed treatment and services. “We’re seeing that patients seem to be more comfortable and peaceful receiving their care at home, where they can be with their family or caregivers and their pets,” she said. “Hospitalists get to witness that transition and see the benefits — that the home environment is better for some patients.”

Dr. Maniaci hears a similar story from his hospital-at-home physicians. They report that communicating with patients in their home environment helps physicians get to know their patients better. Physicians also appreciate the technological infrastructure and ability to get orders managed expediently. “Our younger, tech-savvy physicians jumped right in when we started the program,” he said, and are excited about the sophistication of the care model.

At Atrium Health, hospitalists have been impressed with the efficiency of hospital-at-home care. Initial skeptics have become converts over time, according to Kara Gallagher, MD, a family physician who has practiced full-time in the program for two years and now trains and mentors newcomers. She noted that many physicians are surprised by the level of care provided in a home setting and how comprehensive it truly is.

“Our hospitalists are impressed with the magnitude and scope of what we can offer patients at home. It’s not like babysitting a patient at home — it’s comprehensive care, and that surprises the physicians initially.”

— Kara Gallagher, MD, Atrium Health

Boston Medical Center, which introduced its hospitalist-staffed hospital-at-home program in April 2024, is already witnessing benefits for its physicians and patients, according to Fitzerald Shepherd, MD, the program’s medical director. “What we’re hearing from physicians is that seeing patients in their home setting gives them a new dimension into patient care — seeing what happens when a patient goes home from the hospital and the social issues that may impact care,” he said, has proved instructive for our hospitalists,” Dr. Shepherd said. “Some of our physicians think that [the care model] will help reduce burnout among doctors and nurses.” In addition, because the hospital-at-home physicians are physically co-located with nurses, relationships between the two groups, anecdotally, appear to be strengthening, Dr. Shepherd said.

All the programs featured in this article are seeing good results on the all-important measures of patient safety and how patients fare from an outcomes standpoint. Although data are still being gathered, early experience suggests that emergency department visits and hospital readmissions are down and that relatively stable patients appreciate the option of getting their care at home. Colleen Hole, BSN, MHA, who helped Atrium found its hospital-at-home program, said that the ability to provide patients with a “soft landing” at home has lowered ED visits and readmissions, as well as referrals to skilled nursing facilities. “This model has mitigated a lot of the risk,” she said, for suboptimal outcomes, which in turn is a relief to physicians. “The hospital-at-home is now truly part of the care continuum.”

One observation made by all the sources interviewed for this article is that patients perceive the hospital-at-home services as more attentive and coordinated care rather than “remote” care. “Patients often say that they feel they spent more time with clinical staff at home than when they were in the hospital,” said Dr. Davis, “and our physicians appreciate how holistic the care model is.”