Suzanne's Mom's Blog

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New approaches in health care include meditation exercises and hospital care at home.

A couple of my doctors are convinced that people who are good at daily meditation are building new brain cells. I’m not convinced that I can do it, but I’m giving it the old college try. I go to a weekly class where we just sit and breathe. And I listen to an online meditation I like because it seems to give me permission to be “off duty” in so many ways. Trying to be good at meditation, for example, is out.

In another new approach to improving health care, hospitals are responding to both costs and the understanding that many acute-care patients fare better if they get the care they need at home, in their familiar surroundings.

Paula Span pursues the insights at the New York Times.

“Late last month, Raymond Johnson, 83, began feeling short of breath. ‘It was difficult just getting around,’ he recently recalled by phone from his apartment in the Jamaica Plain neighborhood in Boston. ‘I could barely walk up and down the stairs without tiring.’

“Like many older adults, Mr. Johnson contends with a variety of chronic health problems: arthritis, diabetes, high blood pressure, asthma, heart failure and the heart arrhythmia known as atrial fibrillation.

“His doctor ordered a chest X-ray and, when it showed fluid accumulating in Mr. Johnson’s lungs, told him to head for the emergency room at Faulkner Hospital, which is part of the Mass General Brigham health system.

“Mr. Johnson spent four days as an inpatient being treated for heart failure and an asthma exacerbation: one day in a hospital room and three in his own apartment, receiving hospital-level care through an increasingly popular — but possibly endangered — alternative that Medicare calls Acute Hospital Care at Home.

“The eight-year-old Home Hospital program run by Brigham and Women’s Hospital [is] one of the country’s largest and provided care to 600 people last year; it will add more patients this year and is expanding to include several hospitals in and around Boston.

“ ‘Americans have been trained for 100 years to think that the hospital is the best place to be, the safest place,’ said the program’s medical director, Dr. David M. Levine.

‘But we have strong evidence that the outcomes are actually better at home.’

“A few such programs began 30 years ago, and the Veterans Health Administration adopted them more than a decade ago. But the hospital-at-home approach stalled, largely because Medicare would not reimburse hospitals for it. Then, in 2020, Covid-19 spurred significant changes.

“With hospitals suddenly overwhelmed, ‘they needed beds,’ said Ab Brody, a professor of geriatric nursing at New York University and an author of a recent editorial on hospital-at-home care in the Journal of the American Geriatrics Society. ‘And they needed a safe place for older adults, who were particularly at risk.’

“In November 2020, Medicare officials announced that, while the federally declared public health emergency continued, hospitals could apply for a waiver of certain reimbursement requirements — notably, for 24/7 on-site nursing care. Hospitals whose applications were approved would receive the same payment for hospital-at-home care as for in-hospital care.

“Since then, Medicare has granted waivers to 256 hospitals in 37 states. … But Medicare’s waivers are not permanent. The public health emergency remains in effect until January; although the Biden administration will likely extend it, state health officials are anticipating its end at some point next year, perhaps by spring.

“What will happen to hospital-at-home care then? Twenty-seven percent of programs that participated in a poll by the Hospital at Home Users Group said that they were unlikely to keep offering the option without a waiver, and 40 percent were unsure; 33 percent said that their programs were likely to continue. …

“Studies have repeatedly documented the risks of hospital stays to seniors, even when the conditions that made the stay necessary are adequately treated. Older adults are vulnerable to cognitive problems and infections; they lose physical strength from inadequate nutrition and days of inactivity, and they may not regain it. Many patients require another hospitalization within a month. One prominent cardiologist has called this debilitating pattern ‘post-hospital syndrome.’

“Had Mr. Johnson remained in the hospital, ‘he would have been lying in bed for four or five days,’ Dr. Levine said, adding: ‘He would have become very deconditioned. He could have caught C. diff or MRSA’ — two common hospital-acquired infections. ‘He could have caught Covid,’ Dr. Levine continued. ‘He could have fallen. Twenty percent of people over 65 become delirious during a hospital stay.’

“Patients must consent to hospital-at-home care. Almost one-third of Brigham and Women’s patients decline to participate because the hospital setting feels safer or is more convenient. But Mr. Johnson was delighted to leave, when an attending doctor told him that his conditions were treatable through hospital-at-home care. …

“At home, a doctor saw him three times, twice in person and once by video. A registered nurse or a specifically trained paramedic visited twice daily. They brought the drugs and the equipment Mr. Johnson needed: prednisone and a nebulizer for his asthma, and diuretics (including one administered intravenously) to reduce the excess fluid caused by heart failure. All the while, a small sensor attached to his chest transmitted his heart and respiratory rates, his temperature and his activity levels to the hospital.

“Had Mr. Johnson needed additional monitoring (to ensure that he was taking medications as scheduled, for instance), food deliveries or home health aides, the program could have provided those. If he needed scans or experienced an emergency, an ambulance could have returned him to the hospital.

“But he recovered well without any of those interventions. About a week after he was discharged, Mr. Johnson said he was ‘much better, much better,’ and that he would recommend hospital-at-home care to anyone. …

“ ‘Are there people who need to be in a hospital?’ Dr. Leff said. ‘Absolutely.’ Surgeries, complex testing and intensive care still require a building and its staff. Nonetheless, he added, hospital-at-home initiatives demonstrate that more care could be provided outside bricks-and-mortar facilities.

“ ‘Hospitals in the future will be big emergency rooms, operating rooms and intensive care units,’ [Dr. Bruce Leff, a geriatrician at Johns Hopkins University School of Medicine] said. ‘Almost everything else will move to the community — or should.’ ”

More at the Times, here.

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