Home Is Where the Healing Is

When Dr. Eliza (Pippa) Shulman ’96 was in the second grade, some eighth grade boys pushed her off the top of a slide and she broke her arm. Far from being traumatizing, the experience led Shulman to her life’s work. “Sitting in the emer-gency room, I wasn’t scared at all,” she says. “I thought it was wonderful, and I was in awe watching the teamwork of the medical staff. That was the start of the path I have followed ever since.”

Shulman followed that path to the University of New England to become a doctor of osteopathic medicine and then to Dartmouth College for its Leadership Preventive Medicine Residency, which focuses on preparing physicians to lead change and improve systems of care. Today, she is a leader in the movement to decentralize the delivery of health care, championing a hospital-at-home model that provides acute hospital-level care in a patient’s home. A self-described “evangelist” for the home-hospital movement, Shulman is on a mission. “I think everyone is better off at home,” she says, citing instances in which physicians—herself included—do whatever it takes to prevent family members from being admitted to a brick-and-mortar hospital, steering them toward acute hospital-care treatment at home instead.

Shulman is the chief medical officer (CMO) of Medically Home, a Boston-based company that partners with health systems and hospitals across the country—including the Mayo Clinic, Kaiser Permanente, Cleveland Clinic, and Yale New Haven Health—to create and operate hospital-at-home programs. “We are there on-site, on a daily basis, truly co-operating these programs with these health system partners,” Shulman says. She is responsible for overseeing all of Medically Home’s clinical programs and works to ensure patients, physicians, and other health care leaders understand and are comfortable with the hospital-at-home model. “I believe the way the health system will be transformed is through organizations like ours that can laser focus on the mission and can free themselves from the constraints of having to operate in this legacy system,” she says.

“Her impact is profound,” says Dr. Linda DeCherrie, vice president for clinical strategy and implementation at Medically Home. “Hospital at home is a model of care that is here to stay, and Pippa is one of the reasons for that. She has also been instrumental in advocacy to allow this model to expand and be permanent.”

Triple board certified in family, preventive, and hospice and palliative medicine, Shulman was formerly the chief of geriatrics and palliative care at Harvard Vanguard Medical Associates and the medical director for health care innovation at Atrius Health, where she identified and implemented novel care-delivery solutions as part of the largest independent multispecialty medical group in the Northeast. In 2016, while at Atrius, she met the Medically Home team, and helped design, build, and launch its hospital-at-home care model. She joined the organization as CMO in 2017.

Shulman was recently named president of the American Academy of Home Care Medicine, which DeCherrie says is a “testament to the fact that Pippa is not only the CMO of Medically Home but is also seen nationally as the person representing the field of home-based medical care.”

Hospital at home is not a new idea. The term was first used in the 1970s, and the concept was implemented in the United Kingdom and several other countries to reduce costs and improve access and quality of care. Currently, home hospitals are in use in the U.K., Israel, Singapore, France, and Australia, though not at the acute level. The modern hospital-at-home model was introduced in the United States in 1995 at Johns Hopkins Hospital. Preliminary data showed promising results, with patients experiencing reduced recovery periods, decreased readmission rates and hospital-acquired infections, and increased satisfaction with their care. Today, it is generally accepted that between 20% and 30% of patients in a traditional hospital building could be safely cared for at home. “This is better care,” Shulman says, “and we should make sure that everyone has access to it.”

There are three components to Medically Home’s model. The first is a medical command center of physicians, nurses, nurse practitioners, and case managers who can communicate with and respond to patients 24 hours a day, seven days a week, as well as monitor patients’ vital signs and other medical markers around the clock through technology in the patient’s home. That technology includes a dedicated tablet and phone that connect with the patient’s care team. “Patients can speak to a member of their team usually within 18 to 20 seconds upon their request,” Shulman says, “which is much faster than a patient hitting a call bell for a nurse in a brick-and-mortar hospital.”

The second component is a rapid-response network of clinical in-person patient care, services, and supplies. “Think about everything a patient gets in a hospital,” Shulman says. “There’s a wide spectrum of requirements, from meals to IV medications. We must be able to provide all of that in the patient’s home in a time frame that’s equivalent to the hospital, which is a complex logistical undertaking.” If there is a change in a patient’s clinical condition, a rapid-response team can be at their bedside within minutes.

Technology is the third component, and it brings the command center and rapid-response team to life. Medically Home gives patients an in-home technology kit and can provide Wi-Fi as needed. “We monitor and record vital signs and quickly enact orders from the command center physician,” Shulman says. “If I order bloodwork, I can tell who is going into the home to take the blood sample and when they’re going to arrive.”

Shulman says at-home hospital care is inherently a team effort, which she loves. Staff are trained in how to provide care from a distance and in tandem with someone else at the bedside, simulating every element of the care journey for a patient. “We set up equipment in volunteer patients’ homes, and staff can do a run-through of the service they provide before they touch a single patient,” Shulman says. “They’ve logged onto the computer and learned how to work virtually or tethered to a clinician in the home.”

The requirements for patients’ homes are minimal: electricity, running water, and access to a bathroom. In fact, Shulman has seen at-home hospital care provided in recreational vehicles and says it can work in all types of environments. Treating patients at home enables the care team to gain significant information about their lives. “When we see patients in the hospital, we don’t know what kind of home we’re sending them back to, but they are going home,” she says. “Being in that patient’s home allows us to create a care plan that is tailored to what the patient needs, and, ultimately, will result in more effective care with better outcomes.”

During program design and development, plans are made for emergencies, including severe weather, power outages, and local events that could impact patients in their homes. Every patient technology kit includes an uninterruptible power supply as well as an alerting system for power and other outages to ensure patients are safe, even in a natural disaster.

The benefits of hospital at home are well documented. One big advantage is being able to redirect money from the fixed costs of running a physical hospital to paying for patient care in the home. “Much of the cost of treating patients in a brick-and-mortar hospital is the overhead and maintenance of that facility, not patient care,” Shulman says. “In this country, it costs between $3 million and $10 million to build one hospital bed. When you leverage those resources to care for the patient in the home, you’re able to provide a lot more care for a lot less.”

Also, patients tend to be more comfortable in their own homes with family and friends around them. Hospitals can be noisy and cold. Patients—who are often alone—may be scared, and they are rarely able to sleep very well. Delirium and falls, especially for older patients, happen all too frequently. Nurses are understaffed and overworked, and often cannot meet patients’ needs in a timely manner. Patients may wait for days to speak with a physician.

As hospital at home becomes more widespread, data shows that this model provides better overall patient care; higher patient satisfaction; lower readmission rates; and reduced risk of infection, delirium, falls, and mortality. “We now have 20 health system partners and have seen nearly 27,000 patients,” Shulman says, “so we can stand by our own data as well as the data in literature—both from our partners and colleagues around the country—that hospital at home is safe and effective.” Data also shows that medical staff report a much higher rate of job satisfaction, citing reasons such as working within a team structure and better identifying patients’ needs at home versus at a hospital facility.

The types of acute patients who can be considered for hospital at home are also growing. “I see a future where hospitals are for multitrauma, surgery, or the intensive care unit [ICU],” Shulman says, “but once patients have been downgraded from the ICU or can be on a medical surgical floor, many of them could finish their hospitalization at home.” One of Medically Home’s partners, the Mayo Clinic—one of the world’s leading hospitals, with locations across the globe—is even treating kidney transplant patients using hospital at home. Such patients need a lot of monitoring and intervention to avoid the risk of infection, Shulman says, “but they don’t need a new surgical procedure so we can do all the monitoring and intervention at home. You start to really see the possibilities.”

Another advantage of hospital at home is the potential for better medical care for patients from disadvantaged and marginalized communities. “These patients distrust the medical system, and there is documented evidence that they often receive substandard care,” Shulman says. “When a person doesn’t trust their medical team, and when the medical team has some implicit biases that make that care challenging, it’s not a surprise to see these troubling outcomes.” Shulman says hospital at home “shifts the paradigm” because medical staff are guests in a patient’s home. “The trust and relationship created is very different,” she says. “Suddenly, the patient is on a much more equal footing with the medical staff. When I am in a patient’s home, I see the full spectrum of their human experience. I may see books, a painting, and I might ask about those things. This helps me understand more about a patient’s life. That’s what creates great medical care and improves justice in the health care system.”

Shulman sees the biggest obstacle to hospital at home as reimbursement and the regulatory environment. The Centers for Medicare & Medicaid Services (CMS) will pay for Medicare patients who are in hospital-at-home programs through December 31, 2024, but CMS does not have full control over Medicaid reimbursement; that’s up to the individual states. Many states—but not all—have agreed to reimburse hospital-at-home costs for Medicaid patients. It is expected that the waivers will be extended and continue for the foreseeable future. Meanwhile, some private insurance companies in some states also reimburse for home hospital care.

“Does every state, with all their systems, have a contract for hospital at home? No,” Shulman says, “but what encourages me is that most payers are supportive of hospital at home and reimbursement in some way. But it is still very much a patchwork.”

Despite the hodgepodge reimbursement process, hospital at home is growing. Some hospital systems are seeing more than 10% of patients being cared for in a home hospital versus a facility. And those numbers are projected to climb to 15% or 20% in certain states. “We are committed to home hospitals having an impact on the health system as a whole,” Shulman says. “I think getting to that 20% threshold is going to be really important over the coming years.”

To find out whether you qualify for a hospital-at-home program, start with your insurance company. Despite the fact that the bill that allowed for the extension of the Medicare waivers was bipartisan in its introduction and passage, Shulman encourages voters to find out which candidates support hospital at home and which do not, and then make themselves heard at the polls. “It is going to be important as we hit 2024 to ensure this access is locked in for as many people as possible,” she says. “I want everyone in my family to be able to receive hospital care in the home, should they require hospitalization. And I want that for everyone. This care is better. It’s safer. I want to see this spread far and wide, and for as many people as possible.”

Cheryl Dellecese is a senior editor at Smith.

Photographs by Jessica Scranton