Dr. Mark Prather
Chief Executive Officer and Co-founder - DispatchHealth
Foreword
As a country, we recognize the need to innovate in business and understand the importance of adapting to meet the needs of a changing world. Healthcare is no different, yet it has been more than fifty years since the industry has completely embraced a material change in how we deliver care in the United States, and the consequences of stagnation are catching up.
Americans spend an unsustainable $4 trillion on our healthcare system today—it is my belief one of the fastest ways to fix our underperforming healthcare system is to move as much care as possible to the home. By consolidating our hospital assets and developing centers of excellence that are maximally efficient and utilized for the sickest of our patients, a reduction in per-unit cost of care is realized. To achieve this consolidation, we need to develop the infrastructure to support care in lower-cost settings like the home, and in 2013, we did just that with the formation of DispatchHealth.
I liken the current hospital-at-home movement to the adoption of free-standing surgery centers in the 1970s—the idea of performing surgeries outside of a hospital raised brows, yet based on the drive of two physicians who wanted more timely, convenient, and comfortable surgical services for their patients, today there are more than 5,300 surgery centers in the United States, performing more than 20 million procedures annually and producing $38 billion annually in savings across the industry.
We founded DispatchHealth on a similar premise of “more timely, convenient and comfortable” care for our patients and, in 2013, began offering urgent medical care at home as an option for patients to receive same-day treatment for serious health concerns. Then, in 2019, we followed with a unique home-based alternative to hospitalization, Advanced Care.
Over the last decade, our expert medical teams have treated more than one million people in their homes across more than 30 states in the country—resulting in 58% emergency room avoidance, nearly half the average 30-day hospital readmissions, unprecedented 98% patient satisfaction, and almost $1.5 billion in medical cost savings. Along the way, we’ve learned that not only is hospitalization at home financially sound, but because of the intimacy and trust built by treating patients at home, our clinical teams can apply social and economic context that results in more personalized care plans that produce improved clinical outcomes.
Dr. Eric Topol, a renowned cardiologist and one of the top 10 most cited medical researchers, has boldly stated that hospitals, apart from intensive care units and operating rooms, are unnecessary and that the patient’s bedroom is ideal for everything else. Treating patients at home is a safe, comfortable, and economical site of care. We are on the cusp of realizing that statement, and DispatchHealth is proud of our contribution to the future of patient–centered healthcare. And we are just getting started.
Dr. Mark Prather
Advanced Care: Transformative hospital-level care at home
DispatchHealth’s alternative to hospitalization, Advanced Care, is a rare success story in the quest for the now quintuple aim of better clinical outcomes at a lower cost, with higher patient and provider satisfaction and an emphasis on health equity.
While the COVID-19 public health emergency brought a new spotlight to advanced levels of care at home, with the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home waiver creating much of the momentum, it is essential to understand the multifaceted value behind all the delivery models. DispatchHealth has built a unique alternative with a flexible platform to identify eligible patients through various avenues—including the CMS waiver program.
To underscore the model’s validity, I am proud to share what we believe to be the most extensive study of its kind. This white paper evaluates the experience of more than 1,000 Advanced Care patients treated over 18 months between January 2021 and July 2023. As shown in the included analysis, the model has proven capable of addressing the most relevant cases, including 50% of the top 10 and 35% of the top 201 most common conditions treated in U.S. hospitals and several of the most expensive.2 The numbers confirm our alternative to hospitalization is producing quality outcomes, with an unprecedented patient and provider experience at a lower cost and 30-day readmission rates nearly 50% below the national average.
30-day readmission rates nearly 50% below the national average.
1Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals, 2018 (ahrq.gov)
2National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2017 #261 (ahrq.gov)
The mechanics
Advanced Care is an ideal solution for patients with underlying complex medical conditions and an acute illness that would otherwise result in hospital admission. The model is unique in the level of complexity clinicians are empowered to address, having the tools, technology, and expertise necessary to treat patients across 60-plus diagnostic-related groups (DRGs) and a patient population rated in the top fifth percentile of complexity and risk with multiple comorbidities (5.5+ Charlson Comorbidity Index). On average, patients enter the program with eight comorbidities and a resulting case mix index where more than 70% of patients have major complication and comorbidity (MCC) or complication and comorbidity (CC).
DispatchHealth supports the CMS waiver program by partnering with hospitals and health systems to offer this service to their patients. In this model, patients must go to a brick-and-mortar emergency department or hospital first; based on clinical inclusion criteria, a provider at the hospital can then initiate the home-based transition and complete the hospitalization at home. Early data suggest just over half of patients covered by the CMS waiver agree to moving from hospital to home.3
3Study Record | ClinicalTrials.gov
In addition, DispatchHealth is the first provider in the country to also onboard patients directly into our alternative hospitalization program without the patient ever leaving home—a true differentiator that patients enthusiastically accept 98% of the time. Having a significantly higher acceptance rate, DispatchHealth’s community-based admission approach means a larger percentage of patients are admitted earlier in the cycle of their acute condition, leading to a positive impact on outcomes.
Clinical teams are led by hospitalist physicians and supported by a physician assistant or nurse practitioner, a 24/7 registered nurse command center, and other in-home care providers, such as registered nurses, alongside physical and occupational therapists, as needed.
The average initial in-home advanced care assessment lasts longer than two hours (120 minutes) after patients are seen in person, twice daily, by a nurse or advanced practice provider, totaling over 75 in-home minutes per day during the initial phase of treatment — at almost 390 in-home minutes per high-acuity episode, Advanced Care provides significant face time.
To further enhance the many in person touchpoints, the model offers additional remote nurse and provider care during the acute phase with social support and 24/7 RN-based monitoring for up to 30 days. On average, patients have 23.67 remote nurse connections through centralized resources during the transitional phase—all within the comfort of home. The combination of our high acuity and post-acute transition care is less costly than traditional inpatient hospitalization, even with these additional touch points that contribute significantly to our pioneering outcomes.
DispatchHealth executes our unique home-to-home onboarding model by leveraging mobile diagnostic services and software-enabled logistics management to power evidence-based risk stratification at the bedside. The key innovations that allow us to operate safely and efficiently include a point of care moderately complex lab, portable ultrasound, in-home imaging, and IV medication management — it is these advancements in tools and technology that gives DispatchHealth the ability to safely treat higher levels of complexity and acuity in the home.
Our proprietary technology platform uses real-time data insights to manage all aspects of the in-home care experience, including logistics, onboarding, risk stratification, care coordination, and analytics that elevate clinical practice and drive improved outcomes. While in the home, connectivity is powered by a specially designed connectivity hub, with reinforced, GPS-enabled mobile routers and enterprise-class security that leverage a combination of mobile Wi-Fi carriers to capitalize on the best signal available in any given geographical location. Eventually this will help facilitate expansion into more rural communities where wireless signals are harder to come by.
When 83 year old Jim of Denver, CO was diagnosed with pneumonia, didn’t hesitate when he was offered the choice of staying home for treatment, saying:
You can get good care in a hospital, but you never sleep really good. In plain English, there’s no place like home.
Measured outcomes
A closer look at a sample size of 1,000 patients across numerous national and regional payer partners and multiple health systems demonstrates that our in-home hospital alternative model successfully treats complex patients at home with no serious safety events and zero unexpected mortalities. Our study accounts for 4,000 bed days with twice daily in-person hospital-style rounding support from our providers, and 24-7 monitoring.
The average age of patients in our sample is 76, more than half of whom have been hospitalized in the last six months and, on average, come to our care with eight comorbidities.
Based on comparable national patient populations, * the average 30-day all-cause hospital readmission rate is 20%.4 In contrast, Advanced Care patients were re-hospitalized within a month of discharge, less than half that at an average of 9.3%.
Furthermore, as detailed later in this paper, heart failure and pneumonia are among the top five principal diagnoses with the highest number of 30-day all-cause readmissions for Medicare patients. Both conditions are ideal for care in the home, and with those in our sample experiencing nearly half as many readmissions, this represents a significant opportunity.
Another key metric is the improvement in hospital-acquired infections. On any given day, one in 31 facility-based patients will be diagnosed with a secondary infection, which, according to Centers for Disease Control and Prevention research, results in at least $28.4 billion in direct medical costs annually. There were no secondary infections among the >1,000 patients treated at home in our program.
In addition to the significant quality and safety benefits, the potential medical cost savings can be substantial. Data published in the Annals of Internal Medicine revealed an acute care episode treated in the home is 38% lower cost than a traditional brick-and-mortar setting. Patients had fewer laboratory orders (mean per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%).5 Among patients in our sample, we estimate the total medical cost saving at $500,000-$700,000, based on a calculated net savings value of $5,000-$7,000 per episode.
4Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018 (ahrq.gov) * data based on average among COPD, Pneumonia and Heart Failure Medicare patients. These patients represent more than half of those in our sample.
Age specific opportunities: Augmenting aging in place
As the healthcare landscape evolves, analyzing data-driven strategies that address the unique needs of aging populations, such as the “silver tsunami” of baby boomers, becomes crucial, particularly as aging in place has become a consumer premium and critical to supporting quality of life.
Studies suggest that 75% of patients 75 and older who are functionally independent at hospital admission will not be after6 — hospital-acquired infections and delirium contribute to the decline, as does hospital-imposed immobility. Often, new prescription drugs and changes in patient care plans cause confusion, and it is not unusual for doctors in hospitals lack insight into the realities patients face at home that may preclude well-intended care plans. Furthermore, 13% of US adults aged 70+ or 4.2M are homebound.7
Alternatively, meeting patients where they are at home affords a more seamless approach. With a growing decline in the availability of hospital beds, and because adults 65+ are hospitalized twice as often as middle-aged,8 our country is heading toward crisis-level capacity challenges unless the industry begins to reimagine care beyond the four walls of a hospital.
DispatchHealth’s Advanced Care program aligns perfectly with the growing needs of older Americans by offering personalized care for elderly patients in the comfort of their homes.
Among the 1,000 patients examined for this paper, the average patient age was 76. In addition to no severe safety events or unexpected mortality, only 3% of those in our program required post-discharge skilled nursing facilities care. This is a fraction of the 15% national average for seniors 75 and up.9 Moreover, the trust and continuity of an Advanced Care episode can help facilitate meaningful conversations around topics such as the transitions to palliative care modalities when preferred by patients and their families.
6https://www.msdmanuals.com/professional/geriatrics/providing-care-to-older-adults/hospital-care-and-older-adults
7Association of the COVID-19 Pandemic With the Prevalence of Homebound Older Adults in the United States, 2011-2020 | Geriatrics | JAMA Internal Medicine | JAMA Network
8Health, United States 2020–2021 (cdc.gov)
Condition specific opportunities
An Agency for Healthcare Research and Quality analysis sheds light on the most frequent inpatient principal diagnoses among nonmaternal, non-neonatal hospital stays.10 74% of the patients in our experience were treated for conditions on the agency’s top 20 list, accounting for nearly three million annual hospital inpatient stays and over $22 billion in medical spending. Success in treating these complex conditions at home underscores a significant opportunity for payors, risk-bearing entities, and health systems.
Furthermore, the frequency of readmissions for patients with congestive heart failure (CHF) and pneumonia is important to be considered. These illnesses account for 36% of those treated in advanced care and emphasize the value of comprehensive, condition-specific strategies that improve patient outcomes and reduce healthcare costs.
Heart failure is the most common cause of hospital readmissions among elderly and Medicare patients; more than 25% experience readmission within 30 days and 50% within six months.11 Heart failure patients treated in the Advanced Care program experienced nearly half as many readmissions at just 13.0%.
Hospital readmissions among patients with pneumonia are another significant issue, resulting in substantial costs and avoidable burdens. Research estimates that 17% to 25% of patients hospitalized for pneumonia experience readmissions within 30 days, amounting to a staggering $10 billion in expenses.12 Among patients in our sample, roughly three times fewer Advanced Care patients (7.9%) experienced an all-cause 30-day readmission.
By implementing targeted interventions and leveraging innovative approaches, such as alternatives to hospitalization in the home, stakeholders mitigate the financial burden associated with readmissions, alongside improved patient outcomes and an enhanced experience.
9Hospital Care and Older Adults - Geriatrics - MSD Manual Professional Edition (msdmanuals.com)
10Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals, 2018 (ahrq.gov)
11Trends in 30- and 90-Day Readmission Rates for Heart Failure | Circulation: Heart Failure (ahajournals.org)
12Predicting the Risk of Readmission in Pneumonia. A Systematic Review of Model Performance - PMC (nih.gov)
Quality of life: Patient and caregiver experience
Industry research tells us Americans are both ready for and want to experience healthcare in their environment — 85%13 of those who have received clinical care at home would recommend it to family and friends. Among patients in this analysis, the overwhelming majority reported an unprecedented experience. Average net promoter scores topped 93; more than 30 points higher than a typical healthcare patient satisfaction score. But this number alone demonstrates only a fraction of the added benefits.
While not every home is conducive to healing, evaluation is part of the risk stratification process; those qualifying environments offer a more pleasant and comforting experience. Home is a quieter space in a more familiar area that feeds patients a sense of normalcy. Research supports the healing benefits of friends, family, and pets. Patients can eat their favorite meals at home, watch the movies they love, and relax to the music they enjoy on their schedule. Also, patients are measurably more active at home, Industry data tells us patients engaged in 1.3 to 5.9 times more physical activity and up to 67% less daily sedentary behavior at home.14
When you’re at home and together and life is the same, mostly without the pain, you heal faster and better. It’s important to be happy when you’re healing.
While some have voiced concerns that home-based high acuity care models may shift undue burden to in-home caregivers, recent research conducted by DispatchHealth shows that caregiver perceptions of Advanced Care are exceedingly positive (NPS +85). Of those surveyed, 71% lived with the patient during the care episode; among the others, one stayed with the patient during the treatment window, four visited multiple times daily, and two less than once daily. 96% of caregivers preferred our at-home model of care over traditional hospitalization, and 93% said that the in-home model was less stressful.
Qualitative reasons caregivers provided for the benefits of this home-based alternative included: the comfort of the home environment, the convenience of seeing their loved one vs. navigating hospital visitation, the ability to reach caregivers any time, day or night, and communication. Ongoing surveying is underway to expand the scope of these initial results.
At-home hospital care keeping loved ones together (denver7.com)
13PowerPoint Presentation (movinghealthhome.org)
14Levels of Physical Activity and Sedentary Behavior During and After Hospitalization: A Systematic Review - PubMed (nih.gov)
A new vital sign: home-life context
Research tells us health inequities account for approximately $320 billion in annual health care spending, and if unaddressed, could grow to US$1 trillion or more by 2040.15 While as an industry, healthcare is catching on to the positive economics tied to addressing the social needs of patients, researcher underscores the roadblocks – one study found that even though health plans work diligently to address members’ needs, understanding those individualized needs is still a significant challenge.16 However, by sending providers into patients’ homes, we now have the real-life context that can help pull back the curtain and align resources tailored to a patient’s care plan.
Among patients reviewed in this 1,000+ sample, 32% faced a significant social need that impacted their health, the majority of which (22%) were identified as experiencing food insecurity. The Centers for Disease Control looked at the direct impact of food insecurity on healthcare costs and found hunger adds an astonishing $51.8 billion17 annually. Medical transportation negatively impacted more than 100 patients in our study (11%). This is something the American Hospital Association found prevents 3.6 million people from receiving medical care each year.18
Ideal to the most promising innovations is the notion that what is good for humanity can also have appealing economics. By empowering clinicians to solve issues beyond a single acute event, the potential exists to free up billions of healthcare dollars with decreased hospital readmissions and improved longitudinal health of patients. While in-home care programs do not inherently enhance health equity – and in fact, some worry that poorly designed models may widen the care access gap – a tenant of the DispatchHealth Advanced Care efforts is deliberate design to meet the needs of the communities we serve across levels of social and environmental needs whenever possible.
Conclusion
Few healthcare offerings truly encapsulate a win-win-win opportunity. For health insurance companies and their members, Advanced Care offers a better experience, with superior outcomes, while reducing net costs by upwards of $5,000 per episode. For health systems, the model also improves hospital capacity and throughput – as well as community reach. For patients and their families, the model enhances the healing experience and facilitates a meaningful transition back to the patient’s medical home.
Advanced Care is at the forefront of transformation as healthcare shifts towards a home-based focus. Backed by substantial investment and partnerships among prominent venture capital investors, the DispatchHealth model of care represents a promising component of a more effective healthcare system.
About the author
Patrick Kneeland
MD, SFHM
Vice President of Medical Affairs - DispatchHealth
Dr. Patrick Kneeland is the vice president of medical affairs at DispatchHealth and leads the organization’s Advanced Care and Extended Care service lines that bring hospital and skilled nursing facility-level care to wherever patients call home. Previously, Patrick served as the Executive Medical Director for Patient and Provider Experience at UCHealth, where he led the development of a system-level interdisciplinary patient and provider experience team and strategic blueprint. He is an Associate Clinical Professor of Medicine at the University of Colorado Anschutz Medical Campus and a founding faculty member of the Institute for Healthcare Quality, Safety, and Efficiency (IHQSE). He is an award-winning educator at Tulane University’s Master of Medical Management program. After completing training in internal medicine at the University of California-San Francisco, Patrick completed a fellowship in Hospital Medicine where he focused on the transformation of clinical delivery systems. He is a certified Patient Safety Officer and has advanced training in human-centered design from Stanford.
