Home, Sweet Hospital
Decades in the making, Bruce Leff’s bold vision — to bring acute-level care to patients in the comfort of their own homes — is poised to take off, to the benefit of patients in Baltimore, across the country and around the world.
Every morning, even before the gray pre-dawn has crept into the Baltimore sky, Johns Hopkins geriatrician Bruce Leff wakes up to go for a run. He also wakes up in the hospital of the future: his home in Baltimore County. “One day, hospitals will just be ERs, intensive care units and operating rooms. Everyone else will be treated at home,” he predicts.
It’s a bold vision decades in the making, which came to Leff because of a patient named Walter, who was one of Leff’s patients when he was a medicine resident at Johns Hopkins Bayview Medical Center in the late 1980s. The Dundalk resident was regularly in and out of the hospital with complications from congestive heart failure and COPD, a result of his decades working at the Sparrows Point Bethlehem Steel plant. When Leff told Walter he needed yet another hospital admission (the ninth that year), he refused. Walter had an aging cat at home to care for, and he was not eager to revisit the other assorted indignities and inconveniences of a hospital stay.
“You run a great hospital, Doc, but it’s a lousy hotel,” Walter told Leff.
So Leff, guided by his Johns Hopkins mentors John Burton and William “Buck” Greenough III, assembled everything Walter would need to get the hospital care he needed from the comfort of his Dundalk home. And in the many years since then, Leff has begun every talk he gives on his concept of “hospital at home” with a photo of Walter, sitting at home with his cat contentedly snoozing on his lap.
The experience showed Leff, Greenough, Burton and Burton’s wife Lynda (then a health services researcher at the Bloomberg School of Public Health) that they could bring acute, hospital-level care to patients in the comfort of their own homes.
Over several decades, Leff has persisted in his vision to build a decentralized system where all but the sickest patients could be cared for at home. He has gotten buy-in from some of medicine’s other heavy hitters, with the Mayo Clinic, Cleveland Clinic, Mount Sinai in New York, Geisinger and private health care firms like Medically Home all starting their own hospital at home programs inspired by his pioneering work. Researchers studying these initiatives have found they lead to shorter stays, fewer medical errors, falls and other complications, and a virtual elimination of delirium — all tied to cost savings.
“Patients do not live in hospitals, patients live in the community,” says Raphael Rakowski, CEO of Medically Home. “To really deliver care around the patient we need to go to where they are, just the way Amazon comes to [consumers].”
But convincing hospital systems, long driven by financial incentives that centered around filling beds, has not been an easy task. Until very recently, the Centers for Medicare and Medicaid Services (CMS) has been reluctant to pay for such services. In its hospital at home program, Mt. Sinai Hospital had to form a joint venture to negotiate with private insurers. Without a pathway for reimbursement, many hospitals that had interest in developing their own full-fledged programs — including Johns Hopkins — have faced challenges in guaranteeing the needed income to cover their upfront investments.
“It’s expensive to stand up these programs,” says Mark Howell, senior associate director for standards and drug policy at the American Hospital Association. “Hospitals need to think whether or not the investment upfront is worth it, and whether they can provide enough services under a hospital at home program to make it worthwhile for everyone involved.”
The landscape changed dramatically with the onset of the COVID-19 pandemic, however, with CMS announcing its willingness to reimburse hospital at home care at the same rate as standard inpatient stays. Since November 2020, more than 140 health systems around the United States have received the CMS waiver. Closer to home, a Johns Hopkins team comprised of home-based experts, acute care providers, administrators and IT specialists have quickened plans to launch their own wraparound home care program in 2023 — a year earlier than planned.
“This is the kind of network that needs to happen in forward-thinking hospitals. It’s better care. It’s cost effective. And patients are more satisfied,” Burton says. “Bruce has led a national movement in home-care medicine.”
‘We Need to Think About the Future’
Under Burton’s supervision, Leff began making house calls to many of his homebound patients as a young medicine resident at Bayview, and he impressed his mentors with his passion for patient care.
Burton says that Leff had a knack for noticing seemingly minor factors that were interfering with a patient’s health, such as difficulty reading prescription bottles, while also considering the big picture of how the health care system could work more effectively to better manage patients’ chronic conditions and help them achieve a better quality of life.
After residency and a geriatrics fellowship, Leff completed a brief stint in Korea as a medical officer with the U.S. Army before Burton lured him back to Bayview.
Not long after Leff returned from overseas in 1994, with support from The John A. Hartford Foundation, he began to work on developing a hospital at home program to care for patients like Walter. The challenges were daunting. Few people at that point had cellphones. Broadband internet had yet to catch on, and a dial-up modem required a phone line and made ear-splitting squawking sounds when it connected. But Leff, Greenough and the Burtons had confidence that hospital at home could work.
The next hurdle: convincing the top hospital brass to let them give it a try.
It was a big ask because hospitals depended heavily on patients filling beds to make ends meet. Leff and team were essentially asking Johns Hopkins to give up vital income, and to provide funding to support their work, since the care would not be reimbursed by payors like CMS.
In the early 1990s, the group made their case to Ronald R. Peterson, then president of Bayview Medical Center (now the president emeritus of the Johns Hopkins Health System). Leff and the team had decided upon four conditions for which elderly adults were commonly hospitalized: pneumonia, congestive heart failure, exacerbation of chronic airway disease, and cellulitis. These hospitalizations were also fairly routine. This meant physicians knew exactly what to do and there was less of a chance a patient would too rapidly deteriorate for a mobile team to respond. Because these conditions were so common among older adults, the researchers would readily be able to compare costs and outcomes.
The care each patient would receive in their homes would be identical to what they would receive at Bayview. From blood draws to X-rays, the only difference in care would be that they would stay home (see “All Set Up,” above). Nurses, home health aides, even paramedics could provide hands-on care when needed and, together with physicians, monitor patients’ vital signs from a hospital-based hub. If someone needed a CT scan, MRI or other care that was only available in-hospital, a transport team would drive them to the hospital for the test and then take them home afterward. Leff tried to think of everything, including laundry services and food delivery for patients who didn’t have anyone to cook for them.
After they explained the hospital at home idea, the clinicians waited for Peterson’s reply.
Within a few minutes (“though it seemed like an hour,” Burton recalls), the hospital president signed on, offering the team a $100,000 grant to treat up to 20 patients in hospital at home and obtain basic metrics such as length of stay, rates of subsequent hospitalizations and, importantly, rates of serious complications.
Peterson said simply, “We need to think about the future. We simply cannot continue to build hospital beds.”
The hospital’s financial team regularly checked in for an accounting of how the grant was being spent. After a few months, the quartet reported back that they had completed the pilot study early and under budget. Not only did patients find it acceptable, so did caregivers.
The 17 adults who were part of the pilot study had an average age of 74, and stayed in their hospital at home for 2.9 days, compared to 3.4 days for controls. Their stays were cheaper, too, costing an average of $1,966 versus $3,253 for Bayview patients. Importantly, none of the patients had critical complications that couldn’t be handled at home. The 1999 paper summarizing these results, which appeared in the Journal of the American Geriatrics Society, received widespread praise and attention. Leff now had the data that he needed to apply for more funding for a larger, nationwide study.
This study followed 455 older adults who used two Medicare Advantage plans in Buffalo, New York, and Worcester, Massachusetts, as well as the Veterans Affairs hospital in Portland, Oregon. The researchers’ findings, published in 2005 in Annals of Internal Medicine, found that those who opted for hospital at home had a shorter length of stay compared to controls (3.2 vs. 4.9 days), as well as lower costs ($5,081 vs. $7,480). The team also found evidence that the hospital at home patients suffered fewer important complications. Patients had fewer falls and their rates of delirium, which can trigger a precipitous mental decline, dropped to near zero, thanks to being cared for in familiar surroundings. Their lengths of stay were several days shorter, and they had fewer complications. Their daily functioning was also more likely to improve.
“It became quite clear that if you had people that could get to the house with the necessary technology, you wouldn’t need to bring patients to the hospital,” Greenough recalls.
Leff’s vision proved powerful, and a handful of health systems asked him for help in setting up their own models. Some of these hospitals were small, forward-thinking systems, such as Presbyterian Health System in Albuquerque, which launched hospital at home in early 2008. As word spread, other larger systems began asking about setting up something similar.
“Bruce was a critical factor. He had the ability to bring what started as a [single] initial patient and turn it into a national program,” Greenough says.
Evaluations of the hospital at home program at Presbyterian in Albuquerque showed excellent patient acceptance of hospital at home care (opt-in rates of about 95 percent). What’s more, in an era of seemingly endless increases in health care costs, the Albuquerque hospital at home program was, on average, 19 percent less expensive than treating similar patients in Presbyterian’s brick-and-mortar hospital.
By the early 2010s, the early rollout at some hospitals had been so effective that doctors expanded the list of conditions that could be treated at home, adding dehydration, complicated urinary tract infections, and deep vein thrombosis.
Despite such positive findings, and advances in technology that increasingly made video visits possible in almost any home, the hospital at home concept fell short of becoming widely accepted.
Then COVID-19 struck, and resistance melted away seemingly overnight.
‘My Phone Didn’t Stop Ringing’
Although the pandemic didn’t change Leff’s vision for the hospital of the future, it did alter his morning routine. Beginning in March 2020, instead of greeting the morning with an early run, he started the day with phone calls and Zoom meetings. Seeing the coming tidal wave of COVID-19 cases, hospitals were emptying their wards to prepare for the surge of critically ill coronavirus patients. Suddenly, hospital administrators and physicians from across the country and around the world were calling Leff to ask for guidance in getting their programs up and running.
“My phone didn’t stop ringing for weeks,” he says. He saw it as his duty to answer every call, juggling his usual clinical schedule with endless video chats.
Some of those calls have been with fellow Johns Hopkins colleagues, including Mary Myers, president and CEO of Johns Hopkins Home Care Group. Myers also oversees Johns Hopkins Health System’s Home and Community-Based Services, a thriving home health sector that can provide everything from IV therapies to supplemental oxygen to patients, without requiring them to leave home. Over the years, the division has also begun caring for more complex patients, such as those needing ventilators, infusions, wound care and palliative care. But some patients needed hospitalization despite the best care possible, and for that, they would have to leave home.
Myers believes that Leff’s hospital at home program will enable more patients to remain at home. So, Johns Hopkins is investigating the feasibility of investing to develop a hospital at home program. Myers says leaders are still working out details on a phased approach for clinical protocols, service area and disease states.
If the program is approved, the plan would be to launch in early 2023. It will most likely focus on adults; however, pediatric specialists have challenged Myers and her team to consider expansion to children, as they see this as a very valuable intervention, she says. “When you have more than one child, caring for them in the hospital can be a huge burden. Home would be much easier.”
No one could be happier to see the widespread surge in interest and implementation of hospital at home than Bruce Leff. He sees it as a welcome culmination of his life’s work.
COVID-19, he observes, provided a preview for the hospital of the future, by forcing so many hospitals to be transformed into emergency departments and ICUs.
“Everything else,” he says, “can be moved out and into the home. It is now completely within our reach to create a full, home-based care continuum.”