Moving Cancer Care into the Home with the Huntsman at Home™ Program
Moving care away from brick-and-mortar facilities and delivering the same high-quality care in a patient’s home is a model that is gaining broader adoption in the United States, with many major hospital systems paving the way. As part of the Regence Health Policy Center series on Care at Home, we spoke with Dr. Kathi Mooney.
Dr. Mooney co-leads Cancer Control and Population Sciences at the Huntsman Cancer Institute and is a Distinguished Professor in the College of Nursing at the University of Utah. She is a leader in cancer patient reported outcomes, technology-aided remote symptom monitoring and home-based models of cancer care. In the coming months, we will continue the conversation with Dr. Mooney to discuss her insights on the future of care at home, policy and industry recommendations to advance this model and more.
In 2021, you published your research on hospital at home services for cancer care. What was your reason for originally conducting the study?
For many years I have been conducting research on how to reduce adverse symptoms related to cancer and its treatment for people at home in between their normal clinic appointments. Since cancer treatment is primarily outpatient, people are at home when they experience symptoms and side effects. However, we have not had robust patient-centered care pathways to monitor and care for people at home. This is particularly a problem for people who are geographically distant from their cancer treatment facility. In 2017, I was part of a taskforce at the University of Utah, UHealth, looking at new care pathways that could decrease hospitalizations through receiving treatment at home rather than the hospital.
The hospital at home model of care is widely available in single payer countries but had not caught on in the United States primarily due to the lack appropriate reimbursement mechanisms and a favorable regulatory environment. While the UHealth system did not choose to move forward with a hospital at home program, Huntsman Cancer Institute did proceed and the Huntsman at Home™ program began in 2018 designed specifically for people with cancer. Because there had been few studies evaluating the hospital at home model in the U.S. and none that included people with cancer, we wanted to carefully evaluate and describe our model.
As you stated in your introduction in your publication, hospital at home services have in the past been focused on conditions such as pneumonia, cellulitis, and other chronic diseases. Why has cancer care at home not been considered in the past?
The original hospital at home model was primarily developed by geriatric providers dealing with recurring conditions other than cancer. In addition, I think people believed that cancer patients had complicated care including unpredictable disease progression that might not lend itself to care at home. However, we found the hospital at home model to work very well for the acute episodes that result from cancer treatment side effects and also to shorten hospitalizations for treatment of issues related to disease progression.
We have found that a combination of home-based treatment of acute episode care (3-7 days for rehydration, IV antibiotics, lab monitoring, etc.) and a focus on prevention of acute episodes through 30-day subacute care monitoring for unstable symptoms that might escalate, is an excellent care model for cancer. I want to emphasize that home-based cancer care is a different care model from traditional home health visits for chronic conditions. The skill level and frequency of assessment and management is more akin to acute level hospital or clinic-based approaches than episodic home health visits. It is an entirely different care approach and philosophy.
What other acute conditions do you think should be considered for at home care in the future?
I think it requires a new look at place of care and a change from the automatic patterns of hospitalization or long emergency department stays to receive services. There are probably many conditions where treatment could be provided at home allowing the hospital to care for more patients who needed hospital-based diagnostics, procedures, and imaging that only the hospital and emergency department are equipped to do. Programs and providers need to assess what care they provide and what could be safely completed at home rather than default to hospitalization because those workflow pathways are established.
During the COVID-19 pandemic, health systems and providers did think about how to keep patients safely at home and there is a need to not forget those learnings and to bring new thinking to what care should be routinely provided in the home both in terms of hospital avoidance and shortened stays. We have shown that home-based acute episode and subacute care is safe and others have shown that some chemotherapy is safely given at home. Further study will allow us to examine other use cases, such as appropriateness and safety for CAR T-cell therapy, bone marrow transplant, clinical trials or early surgery discharge. As we get more experience with home-based care and new cancer treatments are available, it will become automatic to delineate appropriate home-based pathways.
Does the University of Utah have plans to study care at home services for other acute conditions?
Yes, the University of Utah, UHealth has a program called Heal at Home that offers some home-based care for selected conditions such as after certain orthopedic surgery. They also are now planning to open a hospital at home program.
Although it was not captured within the study, were there indications that showed improved patient outcomes, experience, and satisfaction?
Our anecdotal experience says both patients and families are highly satisfied with care in the home rather than hospitalization. We are currently conducting a study to address those exact questions. We are also including family caregiver experience to examine caregiver burden.
Your results demonstrated that unplanned hospitalizations and overall healthcare costs were considerably lower for at home patients, why do you think this is so?
Hospital care and emergency department care is expensive. Home-based care does not have the same base costs as supporting a tertiary level hospital. In addition, because we include monitoring to prevent further acute episodes, we decrease overall acute episodes preventing those further costs. In our study, we found a large reduction in emergency department use and hospitalizations that resulted in significant cost savings. So, the real savings comes in keeping symptoms under control so they do not escalate and having the capacity to quickly address the acute episodes that do occur.
The study required Hospital at Home patients to be within a 20-mile geographic service area of the Huntsman Cancer Institute. How will the at home model need to be adjusted for care further away from a hospital, especially in remote rural settings?
We are currently studying that. We have adapted our urban hospital at home model and in August 2021, implemented a rural Huntsman at Home™ program in southeastern Utah for the rural communities in Carbon, Emery and Grand counties. People in these counties drive anywhere from 2 to 5 hours, one-way, to receive their cancer care at Huntsman. While we operate with the same philosophy and goals as our urban program, we have incorporated aspects of rural culture and values and we have a nurse navigator that assists with coordination of care with the Huntsman oncology team to determine necessary in person Huntsman visits balanced with telehealth visits.
There is a greater need for communication and coordination between the oncology provider teams at Huntsman, the rural Huntsman at Home™ team, the local home health agencies we partner with, the local community of primary care providers and the local hospital. In addition, we find higher levels of economic impact on patients and their families- for example, income loss from time away from work for the patient and often a family member who accompanies them on Huntsman visits and significant out of pocket expenses for travel.
These compound the burden of cancer for those living at geographic distance from a cancer facility. Social determinants of health (SDOH) can impact patient outcomes and treatment choices and profoundly impact quality of life so we try to be very active and pull in community resources and other supports. We are evaluating this model just as we did for the urban program and hope to share what we learn in the next year.