FEATURE
Features
Resurrecting the House Call
New at-home strategies for hematologic conditions offer improved
outcomes and patient satisfaction
P
hysician home visits have become a thing of the past:
Nearly a century ago, house calls made up 40 percent
of U.S. doctors’ visits, but in 2015, they represented
just 1 percent of all consultations. 1
That trend could be reversing, as medical advances –
and a growing body of evidence favoring treating certain
conditions at patients’ homes – have helped drive a new
“at-home” treatment movement.
The availability of oral chemotherapy agents, for
example, has made it possible for patients with malig-
nant hematologic conditions to receive treatment in the
comfort of their own homes, significantly improving
quality-of-life measures compared with treatment deliv-
ered in the hospital. Management of deep vein thrombo-
sis (DVT) also has transitioned away from the inpatient
setting, with most patients now being treated at home
with direct oral anticoagulants (DOACs) after an initial
clinic visit. Researchers are even evaluating home-based
hematopoietic cell transplantation (HCT) and blood
transfusions for hematology patients.
“Over time, I think we are going to see hospitals
evolving into basically large buildings that have emer-
gency rooms, operating rooms, and intensive care
units,” Bruce Leff, MD, director of the Center for
Transformative Geriatric Research at Johns Hopkins
ASHClinicalNews.org
Medicine in Baltimore, told ASH Clinical News. “We are
going to see many fewer people in what we tend to think
of as the traditional hospital setting.”
The list of treatments being considered for the
home is expanding. Still, not all patients will qualify for
at-home treatment, depending on the intensity of the
intervention, required follow-up, and evidence support-
ing its use. ASH Clinical News spoke with Dr. Leff and
other clinicians and researchers about the possibilities
for “hospital-at-home” programs and the obstacles to
moving services into the home – including patient and
provider reluctance.
Bringing the Hospital to the Patients
During the 1990s, Dr. Leff and other clinicians at Johns
Hopkins developed a Hospital at Home program after
witnessing the deleterious effects that hospital stays can
have on older patients, including functional and cognitive
declines and a higher risk for adverse drug reactions. 2
Johns Hopkins’ Hospital at Home clinical model
launched in 1995. Through the program, older adults
who meet certain eligibility criteria can receive acute
hospital-level care in the home setting, rather than being
admitted to the hospital. 3
In a pilot study of the home-based treatment concept,
researchers demonstrated that completely substituting
acute inpatient care with at-home care reduced costs by
approximately 30 percent. Compared with traditional
inpatient care, at-home care also led to fewer clinical
services required and higher patient satisfaction.
“We found that patients wanted this care,” Dr. Leff
said. “[At-home treatment] helped patients avoid signifi-
cant complications, improved mortality, produced better
functional outcomes, lowered costs, and led to a better
patient-caregiver experience.”
Since its establishment, the Hospital at Home model
has been implemented in the Medicare managed care
setting with similar outcomes. The program now provides
tools to support the adoption and implementation of
the home-based model, including guides for recruiting
patients and assessing their eligibility, checking home
environments, and managing follow-up with at-home or
virtual visits.
Several other organizations also have developed
models of at-home care. In 2016, Atrius Health, a large
physician organization based in Massachusetts, founded
the Medically Home program. 4 Under this model, the
company contracts with nurses who visit patients at
home and coordinate care, medical supplies, and physi-
cian oversight through a central “command center.”
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