At the American Society of Clinical Oncology (ASCO) Annual Meeting (May 29-31, 2020), researchers from the Huntsman Cancer Institute (HCI) and University of Utah (Salt Lake City, UT) gave the first ever evaluation report of a trial on an adult oncology Hospital at Home program. Huntsman at Home accepts referrals of cancer patients for acute-medical or post-surgical care at home. Researchers found strong evidence to suggest that the program led to reduced hospitalizations, emergency department (ED) visits, and costs.
Journal of Clinical Pathways spoke with Kathi Mooney, PhD, RN, FAAN, interim senior director of population sciences, HCI, to better understand the design of the program and the innovative ways in which it provides value through patient-centered care.
Can you provide some general background to the Huntsman at Home Program? When did it begin and why was it determined that this program would be offered? What was the inspiration behind it?
Dr Mooney: The concept of Huntsman at Home began in 2017 and we officially began enrolling patients in 2018. The inspiration came from HCI’s desire to improve care to cancer patients outside of the walls of our facilities. Most of our patients receive their treatment in infusion centers, so on an outpatient basis. Then, they return home.
Given that the treatment impact and progression of disease occurs in-between clinic visits when people are at home, HCI has been interested in better ways to provide care at the time that it is needed and in a way that is most supportive to patients – keeping in mind that they are frail and often not feeling well.
We have already done some work in this area. A colleague and I developed and deployed a remote monitoring patient-reported outcome system (Symptom Care at Home) over the last 15 years that allows patients to report their symptoms on a daily basis. The system has embedded automated coaching about self-care for patients, and it also alerts providers of poorly controlled symptoms when intensified care is needed. We found that symptomatic patients often do not report symptoms to their provider. Instead, they often wait until the symptoms are no longer tolerable and seek care in ED with many of these visits resulting in rehospitalization. HCI is interested in interrupting this cycle and providing more care in the home, mitigating problems as they arise and providing care that might otherwise require ED evaluation or hospitalization.
Around this time, several of us learned about the hospital-at-home concept, which is more common in other countries – especially those with single payer health systems. It had yet to be tried in the cancer population, but we knew that many of the supportive care needs of patients could be provided at home on an acute-level basis rather than through ED visits and hospitalizations.
That is the concept of Hospital at Home in a nutshell – providing some of the care one would receive in the hospital, but instead receive it in the home.
HCI was interested in exploring ways to provide care more broadly in its “catchment area,” which includes Utah and parts of the four surrounding states. The idea of going beyond the walls of the cancer center was very appealing. The Institute has always been supportive of taking care into the community. The willingness to providing funding for a demonstration project was essential, as acute level home care is currently not sufficiently reimbursed in our fee-for-service system. The program needed to be evaluated in order to determine the value of the hospital-at-home model for cancer care.
Was the main idea behind the Huntsman at Home program to decrease costs for providers, increase patient-centered care and satisfaction, or a combination of both?
Dr Mooney: The main idea was a combination of both. Most important is offering quality cancer care that adds value. Cost reduction was not a primary driver, but it was noted that it would be important to the success of the program in terms of gaining new payment models. The idea was to provide patient-centered care that would translate to lower cost of care as a secondary benefit. Our hypothesis was patients would be less inclined to go to the ED and the rate of rehospitalizations would decrease, which in turn would cut costs.
Who is eligible to take part in the program? What are the criteria?
Dr Mooney: It is very much a clinically-driven admission. From the onset, we enrolled patients that were admitted, and that was by clinical determination.
The program has a variety of patients and patient needs. We have both medical and surgical oncology patients enrolled. We even have had a few bone marrow transplant patients.
We have some patients that had very complex surgeries with the potential for a high rate of complications afterwards. When they are followed at home, they do not have to stay as long and reduce the risk of rehospitalization.
We have patients who have infection that receive their antibiotic course intravenously at home. We have patients with advanced disease and have different pain needs that are not being adequately controlled, and require higher level evaluation and intervention. Another example would be patients who are dehydrated and require intravenous fluids.
Can you speak to the feedback you have received from individuals in the program – both patients and caregivers? Has the feedback largely been positive? What are some aspects of the program you hope to improve upon or refine?
Dr Mooney: We have received very positive feedback, especially now during the COVID-19 pandemic. Some patients have expressed reservations about coming to Huntsman for care during the pandemic, and have been delighted that Huntsman was able to provide needed care in their homes.
When reviewing the 186 patients who were offered Huntsman at Home care, there were 17 in total who turned it down, 14 of whom already had a relationship with a home health agency.
The remaining three patients simply did not want clinicians coming to their home. These data tell us that the program has been very well received. Not only have we found that patients accept it readily, they also report being very satisfied with the care and services they receive.
We have also queried our providers, and they have shared an overall positive experience, especially in adding that extra layer of support during the COVID-19 pandemic.
We are starting to collect patient-reported outcomes and family member-reported outcomes from the program. We want to do a deeper dive into the experience of Huntsman at Home from the patients’ and families’ experience. We will examine symptom burden and caregiver burden, and make comparisons with a usual care group. It will be 6 to 12 months before we anticipate having those data to share.
Results of the analysis presented at the ASCO Annual Meeting show reduced ED visits and hospital admissions that lead to cost savings. In other words, the Huntsman at Home program has successfully demonstrated value to multiple stakeholders. Do you believe a program like this is reproducible outside of HCI? What types of cancer care systems are most compatible with a program like this?
Dr Mooney: We intend to demonstrate value and reproducibility. We would love to see it rolled out to improve patient care all over the country. That is part of the intent of studying it and disseminating it, which is important to do in order to convince payers that it is a sustainable model worthy of reimbursement. There have been several hospital-at-home models in the US, but none have reported outcomes from an oncology-focused program. We believe this model of care offers clear value for cancer patients. Further evaluation is warranted to learn more about its application in both community oncology and academic cancer centers. We are eager to share our experience and believe that adoption by other cancer care systems will accelerate the development of new payment models.
We are also advancing our evaluation of Huntsman at Home and will be expanding to take patients directly from an ED visit as well as evaluating the program in rural settings. We plan expansion to three counties in southeastern Utah by fall 2020. The closest community will be 2 hours and the furthest will be 4 hours from our cancer center. We are going to take what we have learned to consider how we can combine telehealth and on-group visits in order to operationalize this for rural settings. This will allow HCI to advance its mission of taking cancer care beyond the walls of the cancer center.