Comfort zone

Johnny Baker has been admitted to the hospital before, and he's in no rush to go back. "It's no fun being in the hospital," he says, giving a quick pat to his 17-year-old dog, Puppy.

Except by most measures, Baker, 49, should be back again. He had a flare-up of chronic obstructive pulmonary disease in November, and he called his doctors and nurses for help. They admitted him to Presbyterian's Hospital at Home program, giving him the same care he would have had in Presbyterian's Downtown Albuquerque hospital, but from the comfort and familiarity of his home in Los Lunas.

"I love it," Baker says. "It's a lot more comfortable here."

Baker is one of many Presbyterian patients to be admitted to the program since it started a little more than three years ago, and, if Presbyterian has its way, he will be far from the last to experience what doctors and administrators are calling an effective and efficient substitute for traditional hospitalization. In some ways, such as length of stay and individual attention from doctors, it might even be superior.

Hospital at Home started in October 2008 as a partnership between Presbyterian and Johns Hopkins University, and has since treated about 555 patients, says Lesley Cryer, executive director of Presbyterian Home Healthcare Services, which encompasses Hospital at Home as well as six other services like home hospice care and medical house calls.

In the program, doctors and nurses visit patients at home throughout the day to give medication, adjust equipment and assess patients' progress. They also call patients on the phone to check in, and some patients have video-conferencing devices to keep in direct contact with nurses.

During rough weather, doctors and nurses make every reasonable effort to get to patients' houses, and, if it proves too difficult, Presbyterian has a network of employees who volunteer the use of their four-wheel drive vehicles that can take doctors where they need to go.

The average length of stay in Hospital at Home is 3 1/2 days, where a traditional hospital stay is often a half a day to a day more. Hospital at Home patients typically cost $1,000-$2,000 less to care for than traditional hospital patients, Cryer says, and patients report a 95 percent satisfaction rating with the program, about 5 percent more than traditional patients.

Because the program has had such success, Cryer says Presbyterian (along with Johns Hopkins) is planning to create a comprehensive report of how many patients are readmitted within two months of being released from the program. If the report shows low two-month readmission rates, as she expects, it will go a long way to having the program recognized by the Centers for Medicare and Medicaid as high-quality and affordable. It will probably be another year before that report is finished.

If Hospital at Home gets Medicare and Medicaid approval, it'll be available to many more patients than it is now.

Hospital at Home began as a service for Presbyterian Salud and senior care patients, so its clientele tended to be older at first. When it first started, the program catered to patients whose average age was 80, says Dr. Melanie Van Amsterdam, the program's lead physician.

Now, patients vary more widely, though they still fit the same sort of criteria: sick enough to be in the hospital, but not sick enough that they're in immediate danger.

Van Amsterdam says some of the most common diagnoses for people in the program are chronic obstructive pulmonary disease (COPD), congestive heart failure, community acquired pneumonia, cellulitis and pulmonary embolis/deep vein thrombosis.

All of these conditions have been studied and validated for treatment in these kinds of programs, she says. Each has a set of criteria that patients must meet in order to be considered for home treatment -- for instance, a patient should be able to maintain decent bloodoxygen levels without lots of help.

From the doctors' perspective, Hospital at Home offers far more patient interaction. In a traditional hospital setting, doctors see 20 or more patients in a single day, but Hospital at Home doctors see three to four patients a day, Van Amsterdam says.

Van Amsterdam says part of what she loves most about the work is seeing where her patients live. "Any time you go to somebody's house, it's hugely different than the hospital setting," she says. "You're on their territory. You find out a lot about your patients. You find out a lot about, in particular, why they're sick."

In the hospital, Van Amsterdam says, doctors will know that a patient has lung disease, but not that their CPAP machine is collecting dust in a closet somewhere, or that they aren't using their oxygen equipment correctly, or their nebulizer machine is broken.

Often, doctors address these problems by helping change their habits at home. In very rare circumstances, the doctors take more drastic measures.

"You can choose how to live," Van Amsterdam says, "but if we see a condition that is causing, or at least exacerbating their illness, and they're not willing to do anything about it, we have called adult protective services. But rarely."

And it's not just a matter of making sure people have good habits like properly using their oxygen equipment, Van Amsterdam says. Sometimes it's a matter of making sure patients have access to the medications they need. For instance, she says, a common gut infection is treated with a medication called vancomycin, which costs up to $200 per bottle without insurance (and it isn't covered by many plans). By connecting patients to the right programs to cover some of the cost, a bottle could be $35-$40.

Another advantage of having doctors spend more time with patients stems from the fact that all three of the doctors currently participating in Hospital at Home, including Van Amsterdam, are trained in primary care.

"A lot of hospitalists, they don't look at primary care issues, per se. They look at the acute issue and say, 'Oh well, let the primary care provider follow up with this,' " Van Amsterdam says.

"Since all three of us doctors are primary care by training, we tend to look at those problems and say, 'well, why is your diabetes out of control?' " she said. "We're going to do something about it."

Albuquerque Journal (Albuquerque, N.M.) at www.abqjournal.com

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