CMS Launches ‘Unprecedented’ Hospital-at-Home Strategy to Manage Latest COVID-19 Surge

In an effort to increase hospital capacity amid the current COVID-19 surge, the U.S. Centers for Medicare & Medicaid Services (CMS) on Wednesday announced “unprecedented” flexibilities around providing hospital-level care for patients in their homes.

Similar to CMS’s recent allowances surrounding telehealth, the agency’s latest efforts are focused on lifting barriers that could potentially hinder care during the public health emergency, CMS Administrator Seema Verma said in a statement.

Wednesday’s flexibilities aren’t coming out of thin air. Instead, they build off the success and learnings of the nation’s existing hospital-at-home models, pioneered by organizations like Johns Hopkins and Mount Sinai.

“With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond,” Verma said.

Through CMS’s “Acute Hospital Care At Home program,” eligible hospitals will be granted “unprecedented” and “comprehensive” regulatory flexibilities to treat certain patients in their homes. The agency clarified the new flexibilities are aimed at acute care in the home and very different from “traditional home health services.”

In addition to building new capacity, CMS’s program is also a means to support established hospital-at-home programs, which have mostly had to rely on payment mechanisms outside of the Medicare fee-for-service world. CMS believes that with proper monitoring and treatment, acute conditions such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) can be treated in the home setting.

Wednesday’s move received praise from Dr. Bruce Leff, a hospital-at-home expert and the director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine.

“CMS made a terrific decision in recognizing the value of hospital-at-home care for the public health emergency,” Leff told Home Health Care News in an email. “Hospital-at-home is well proven to provide high-quality hospital-level care in patients’ homes for many acute conditions — and patients and their families love it.”

Similarly, the move drew applause from Contessa, a company that helps organizations provide hospital-level care in the home through its Home Recovery Care model.

“Given the tremendous strain COVID-19 is putting on our health care system, access to home hospital care has never been more important,” Travis Messina, CEO of the company, said in an email. “The teams at CMS and CMMI expertly executed this hospital-driven model. Hospital-level care requires appropriate clinical oversight from hospital leaders.”

Messina added that his team is “thrilled” Mount Sinai Health System, one of Contessa’s partners, was already approved for CMS’s new model due to its extensive experience with the hospital-at-home concept.

Under the program, participating hospitals will be required to implement screening protocols prior to delivering care in the home. Participants will need to screen for both medical and non-medical factors, including working utilities, assessment of physical barriers and screenings for domestic-violence concerns.

Participating hospitals will also need to provide in-person physician evaluation before starting care in the home.

Additionally, a registered nurse is required to perform evaluations on each patient — in person or remotely — daily.

“Acute Hospital Care at Home is for beneficiaries who require acute in-patient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis,” CMS noted.

Wednesday’s announcement from CMS has roots in its Hospitals Without Walls program, which was first established in March. CMS’s Hospitals Without Walls program loosened regulatory restrictions in order to enable hospitals to provide services in other settings.

Over the years, the hospital-at-home model has gained a reputation for providing better outcomes at a lower cost. Despite this, the model has still mostly existed as a niche service line for providers in the U.S.

Recently, the COVID-19 emergency has served as a catalyst for renewed interest in the model.

Currently, Brigham and Women’s Hospital, Huntsman Cancer Institute, Massachusetts General Hospital, Mount Sinai Health System, Presbyterian Healthcare Services and UnityPoint Health are being approved for CMS’s new program.

“We’re at a new level of crisis response with COVID-19, and CMS is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” Verma’s statement continued.

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Home-Based Medical Care Can Reduce Hospitalizations and Lower Costs — But It’s Still Underutilized

While home-based medical care has been shown to reduce hospitalization rates and lower costs for both homebound and non-homebound populations alike, it continues to be drastically underutilized in the current health care ecosystem.

As a result, there are millions of older Americans — especially those living in rural areas — who are going without the type of life-changing, in-home care they need.

That’s according to a new study published Monday in the journal Health Affairs.

To better understand the use of home-based medical care, a team of researchers from Mount Sinai, Johns Hopkins University, Wake Forest University, Massachusetts General Hospital and the University of Pennsylvania analyzed seven years’ worth of data from the National Health and Aging Trend Study (NHATS). Broadly, the NHATS is an annual comprehensive, population-based survey of late-life disability trends and trajectories.

Researchers looked at 7,552 community-based, fee-for-service Medicare beneficiaries who participated in the NHATS from 2011 to 2017. They then drilled down on that population to see how often home-based medical care was brought into the picture.

“Home-based medical care is serving both clinically and socially complex homebound and non-homebound people, but the number of people who may benefit from this care is much greater than the number who receive it,” the researchers observed.

Generally, the team defined “home-based medical care” as longitudinal services like in-home primary care and palliative care. Any intermittent home-based medical care services — like home health care or physical therapy, for example — were filtered out.

Of the several thousand community-based Medicare beneficiaries surveyed, just 5% received any form of home-based medical care at any point during the study period.

Among the 2,486 homebound individuals in the group, just 11% received home-based medical care. Among the 5,066 non-homebound individuals, less than 2% received home-based medical care at any point during follow-up.

“It is apparent that the current system of community-based primary care does not adequately meet the needs of medically and socially complex homebound people,” researchers noted.

Homebound beneficiaries who received home-based medical care were more likely to live in a metropolitan area or in an assisted living facility compared to those who did not receive such services. They were also more likely to have dementia and to have had a hospitalization in the previous year, researchers found.

Meanwhile, the non-homebound beneficiaries who received home-based medical care typically had more chronic conditions, more functional impairments and a higher overall health care use. Additionally, they also had lower income, a higher use of Medicaid and less education.

“This suggests that home-based medical care may be an important care delivery approach that can address social determinants of health in patients with complex care needs,” the researchers wrote.

Non-homebound individuals that received home-based medical care were also more likely to be nonwhite.

Barriers to home-based medical care

There are 2 million or so older adults who rarely or never leave their homes living in the United States, according to some estimates. There are 5 million more who can only leave with the help of others or after “significant difficulty.”

“The homebound population is understudied and often is invisible to health care delivery systems, payers and quality-reporting programs,” the researchers pointed out.

Moving forward, the homebound population is likely to grow rapidly, particularly with more older adults opting for home- and community-based care instead of moving into a long-term care facilities. The coronavirus has only accelerated that trend.

Several in-home primary care companies and payers have positioned themselves to help meet an increased demand for home-based medical care.

At the end of July, for instance, Humana Inc. (NYSE: HUM) announced a strategic partnership with physician house call company Heal. As part of the partnership, Humana plans to invest $100 million into the Los Angeles-based startup.

Walgreens Boots Alliance (Nasdaq: WBA) and VillageMD also announced a five-year, $1 billion plan last month to expand the retailer’s full-service physician services at hundreds of stores.

On the government side, regulators have been exploring a home-based medical care payment model through the Independence at Home Demonstration. More than two dozen practices participate in the shared savings program, delivering home-based primary care services to high-risk, chronically ill patients across the country.

In its first two years, Independence at Home saved an average of $2,700 per beneficiary per year over expected patient costs. Projections suggest an expansion of home-based primary care could create savings of between $2.6 billion and $27.8 billion over a 10-year period.

Leading with value-based care

There isn’t a clear-cut avenue under fee-for-service Medicare to help pay for home-based primary care.

With that in mind, many home-based medical care providers have sought out value-based contracts to support their work.

“An important driver of the underuse of home-based medical care is the challenge of creating a financially sustainable model of such care within a fee-for-service model in which reimbursement for care of patients with complex chronic illness and functional impairments is limited,” the researchers stated.

But even in value-based contracts, challenges remain.

One big barrier to participation in more value-based care arrangements has been a lack of quality metrics specifically linked to the home setting or the needs of homebound older adults.

“Quality metrics relevant to home-based medical care are necessary to ensure that its providers can participate in the growing number of value-based reimbursement options within both Medicare Advantage and traditional Medicare,” researchers wrote.

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How to Treat Hiccups

Nearly everyone has experienced hiccups, but what exactly are they? It used to be thought that a hiccup is just a simple muscle spasm of the diaphragm, but that was apparently disproven more than 40 years ago. Instead, hiccups involve a complex, orchestrated pattern of muscle contractions. But, why?

Hiccups might be a leftover from the womb. During fetal life, “hiccups are universally present, their incidence peaking in the third trimester…[This] suggest[s] that hiccups might represent a necessary and vital primitive reflex” that would permit in-the-womb training of the breathing muscles without choking on amniotic fluid.

In adulthood, nearly anything can trigger hiccups. Case in point: A 19-year-old woman presented with persistent hiccups. Her physical exam was normal except for an ant crawling on her eardrum. Once the ant was removed, her hiccups stopped.

There appear to be as many cures for hiccups as there are causes, as I discuss in my video How to Stop Hiccups. As the famous Dr. Mayo put it, the less we know about something, the more treatments we seem to have for it—and perhaps “there is no disease which has had more forms of treatments…than has persistent hiccups.”

There are drugs, of course. There are always lots of drugs, from thorazine to apomorphine, but there are also a whole slew of non-pharmacological approaches—from breathing into a paper bag and drinking from the far side of a glass to smearing mustard on your tummy (as you can see at 1:24 in my video). “Many of these ‘remedies’ have not been tested and some appear to have been invented ‘purely for the amusement of the patient’s friends’.” One method, “forcible traction of the tongue” (which means pulling on someone’s tongue) was attributed to the great Dr. Osler, the first Chief Physician at Johns Hopkins Hospital, but the “therapy, however, is much older and (perhaps not surprisingly) of French origin.”

Another trick that might work to cure hiccups is “a modified Heimlich maneuver,” consisting of just three thrusts and moderate pressure. In one instance, it was so successful the patient’s “hiccups ceased immediately.” In general, however, “[t]reatment is notably disappointing, as is evidenced by the hundreds of remedies have been tried, none of which have been regularly curative.” You know doctors are starting to get desperate when they suggest things like chilling the ear lobe, and you know they are really getting desperate when they have to add prayer to the end of a miscellaneous hiccup cures list.

“Use of vinegar to relieve persistent hiccups in an advanced cancer patient” was the paper that started me down the hiccup rabbit hole. I was reviewing the latest research on vinegar and stumbled across a case where, “[a]fter the failure of common treatments for hiccups, the patient was given a sip of vinegar and his hiccups abated”—stopped after just a single sip. Evidently, sour tastes, such as vinegar and lemon, have been used to treat hiccups since the 1930s, but “nonpharmacological remedies such as vinegar…fell out of favor with the widespread use of pharmacotherapy,” that is, drugs. After all, how much can you charge for a sip of vinegar?

If worse comes to worst, there is the “phrenic nerve crush” surgery, which is as bad as it sounds. Before going that route, though, you may find it “surprising how many patients with hiccups respond to digital compression of the eyeballs.” Yes, we’re talking about digit as in finger, as in pushing your finger into someone’s eyes as a counter-irritation measure. That will get their mind off their hiccups!

If a finger in the eye somehow doesn’t distract them enough, doctors can try “digital rectal massage.” A 27-year-old man presented to the ER with “intractable hiccups.” Emergency staff tried massaging other places and even tried the digital eyeball compression, but nothing seemed to do it. So, bend over. “Digital rectal massage was then attempted using a slow circumferential motion”—and it worked! So, before giving patients drugs, maybe we would give them a massage. It’s “easy to perform” and may be less dangerous than sticking your fingers into people’s eye sockets, which, if you’re in medical school and have to memorize all these ridiculous names, is known as the Dagnini-Aschner Maneuver. (Medicine loves its eponyms.)

Speaking of maneuvers, how’s this for a pick-up line? “Hello. (Hic!) Want to help me (hic!) cure my hiccups?” In one case, on the fourth day of continuous hiccuping, the patient’s hiccups finally “suddenly and completely ceased,” with some spousal help, at the point of climax. “It is unclear,” the doctor wrote, “whether orgasm in women leads to a similar resolution, an issue that could be investigated further.” 

And it was, back in 1845. An infamous, disturbing case report that amounted to effectively bragging about sexual assault was published in what was to be become the New England Journal of Medicine. A young, religious woman with intractable hiccups fell into the hands of a Dr. George Dexter. He first attempted the best modern medicine could offer—bloodletting—but she continued to hiccup, until he pressed his hand on her genitals for a few minutes and that apparently worked. This went on for month after month, with the doctor frequently calling in his colleagues to show them this “singular phenomena.”

Who was this guy? “Although his interaction with the young female patient would not meet today’s ethical standards”—you could say that again!—“his medical observation was valid…” Even though rectal massage and sexual stimulation may help, “this kind of recommendation is reserved for carefully selected patients!”

DO NOT drink vinegar straight. In this blog, I talked about taking a tiny sip, not full-on drinking it. If you do drink instead of sip, you can make the problem worse, as I discuss in my video Vinegar Mechanisms and Side Effects. Vinegar can be great stuff, though. Check out my video series to find out why I include it in my own family’s daily diet:

There’s another way to treat hiccups—one that I’ve used myself since I was a kid. Since then, I’ve never had more than one or two hiccups because I can stop them in their tracks. Learn my trick in my video How to Strengthen the Mind-Body Connection.

In health,
Michael Greger, M.D.

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