Shirley, an elderly woman with chronic lung disease, had just returned home after a month in the hospital and a rehab facility following hip surgery. Her two daughters who’d been caring for her were exhausted. Shirley was also dehydrated, suffering from the effects of pneumonia, a urinary tract infection, a potassium deficiency, and unstable blood pressure. Her stay at rehab had not rehabilitated her; in fact, she became more ill there. Her primary care doctor told her and her daughter Kyle that she needed to be readmitted to the hospital right away. Shirley felt so awful, she would have agreed to anything. But Kyle feared her mother would not survive another round of hospital and rehab. She insisted to the doctor that Shirley would not be going back.
To their astonishment and relief, the doctor informed them that there was another option: the hospital could be brought to Shirley’s home. Less than two hours later, a nurse practitioner, a nurse, and an emergency medical technician arrived to get her room set up — complete with a hospital bed, an IV, and monitors like you’d find in an intensive-care unit.
Shirley, who is my stepmother’s mother and asked that her last name stay private, became the 32nd of about 50 patients who have been served by a Boston-based company called Medically Home. Next to her bed, the company placed a phone and iPad. Shortly after, the face of Eliza “Pippa” Shulman appeared on the iPad screen. Shulman, Medically Home’s chief medical officer, introduced herself as the doctor who would be coordinating Shirley’s care throughout her “hospitalization.” With a touch of a button, Shirley or one of her family members could teleconference with her physician or nurse practitioner, any time, day or night. “It literally is a hospital at home,” says Kyle, “with fresh breezes through her windows and a fluffy comforter and sheets.”
Shirley also received in-person visits from a nurse, an occupational therapist, and a physical therapist. Another health care worker would knock and then let herself in at 8 a.m., five days a week. For five hours a day, she helped Shirley dress and bathe, cooked meals, and even did laundry.
It says a lot about the economics of operating a hospital that this model can make sense even with the costs of transporting people and equipment in and out of patients’ homes.
Bringing hospital equipment and personnel to someone’s home isn’t totally new. It’s somewhat common in Australia, and Johns Hopkins School of Medicine has been developing hospital-at-home programs for two decades. But the idea hasn’t caught on widely because of “payment, attitudinal, and scalability issues,” as researchers who studied an earlier incarnation of Medically Home wrote in the American Journal of Managed Care in 2015. Now Medically Home is betting it can substantially expand the concept, as the costs of running hospitals continue to rise and as hospital-borne infections make hospital stays riskier.
Providing better service for less money sounds like an obvious premise in most industries, but it is radical in health care. Now Medically Home just has to prove it. Shirley’s insurance provider is one of only two payers in the Boston area that cover Medically Home’s program on a pilot basis. Medicare does not.
Medically Home’s CEO, Richard Rakowski, is an energetic entrepreneur who has worked in multiple industries. He turned his focus toward new forms of health care delivery about 10 years ago, when he lost his father to a medical error in a hospital. In 2010, he launched a company called Clinically Home, which showed in a clinical pilot that combining hospital care at home with telemedicine was cheaper and reduced the likelihood of hospital readmission. The trial caught the eye of Atrius Health, a nonprofit health care provider based in Massachusetts. Clinically Home relaunched as Medically Home and moved from Connecticut to Boston to pursue a collaboration with Atrius.
Now, the Medically Home headquarters is one block from Fenway Park, in a sixth-floor space that the team calls Mission Control. The room has more in common with NASA than a hospital, Rakowski tells me. “Think of a rocket going into space. You have to be wired to all of the things going on in the rocket, to the astronaut,” he says. “Everything happening in the home we have to be able to see, monitor, communicate to and from.”
At Mission Control, nurses, doctors, and other care providers are bunched in the center of the room at desks that form a “pod.” All members of the pod work together, caring for up to 14 patients at a time. As the company expands, the room will be filled with more of these pods, each one a team in charge of its own set of patients from the beginning of their care to the end. “We don’t really believe that much in handoffs,” says Rakowski. Any time a patient or their family calls, the people in the pod should never have to say, “I don’t know, let me see if I can find a doctor and get back to you.”
The room buzzes with the low murmur of providers speaking with patients just quietly enough to protect their privacy. One exception is when the team celebrates something — like a previously homebound patient getting well enough to attend a grandchild’s graduation — with takeout lunch from a barbecue joint.
On the left wall are two rows of large curved screens, where employees can monitor the weather, the conditions of the roadways, and the status of deliveries to patients’ homes. Anywhere from one to five providers will visit a patient daily for laboratory testing, physical therapy, and even x-rays and meal delivery, just like in a hospital. The service is capped at one month, and the company will only deliver care in a socially stable environment, Rakowski says. For example, the home must be heated and the patient must be safe from violence.
It says a lot about the economics of operating a hospital that this model can make sense even with the costs of transporting people and equipment in and out of patients’ homes. A small 2005 study showed that for patients with certain conditions, caring for them at home was 32 percent cheaper than a hospital stay. “The fixed costs of hospitals are just utterly gargantuan,” says Ira Wilson, professor of health services, policy, and practice at Brown University. Though he was not familiar with Medically Home specifically, Wilson believes hospital-at-home care is not only viable but necessary. “One of the things we’ve got to figure out how to do in health care is to give people care in settings that provide all the resources that are necessary to treat the problem that they have — but not more,” he says.
Providing better service for less money sounds like an obvious premise in most industries, but it is radical in health care.
Medically Home also says its care is about 30 percent less expensive than a typical hospital stay. Yet even if the logic of the idea is clear, scaling it up remains one of the main challenges. Doug McCarthy, senior research director at the Commonwealth Fund, a health care research organization, cautions that a “cultural shift” will be needed for doctors to be confident enough to refer their patients to a company like Medically Home. “It’s going to take time and it’s going to take effort to integrate it successfully in our current system,” he says.
Medically Home has raised $14 million from investors and is now planning on expanding to Indiana and New Jersey. As for Shirley, three weeks were all she needed to get up and walking again. On her last day, Mission Control probably smelled like BBQ.