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家中客厅或将成为医院护理的未来

家中客厅或将成为医院护理的未来

Julie Appleby, Kaiser Health News 2021年05月27日
经过十多年的发展,相对小众的医院级家庭护理模式正蓄势待发。

如今,各大医院都押下重注,认为居家护理模式将会变成医院护理的未来。

经过十多年的发展,相对小众的医院级家庭护理模式(其中一些通过互联网提供)正蓄势待发。这一方面是因为医院迫切希望缓解新冠疫情期间人满为患的局面,另一方面是保险公司越发希望降低医疗支出费用。不过,从决定应该收取多少费用到哪些病人可以安全受益,该模式也面临着诸多挑战。

然而在居家护理模式下,则能够为患有肺炎、心力衰竭甚至是中度新冠肺炎患者提供深入护理,同时提供全天候远程监测和医护人员日常访问等服务。

今年5月,凯撒医疗(Kaiser Permanente)和妙佑医疗国际(Mayo Clinic)两家大机构宣布进军该领域,计划向总部位于波士顿的Medically Home联合投资1亿美元,这家公司通过提供上述居家护理服务扩大规模并拓展业务。据这两家公司估计,目前全美国30%的住院患者有条件接受居家护理。

去年夏天,其他几家著名医院也启动了相关项目。在此之前,已经有20多家医院提供这项服务,其中包括位于巴尔的摩的约翰斯•霍普金斯医院(Johns Hopkins Medicine)、新墨西哥州的长老会医疗保健服务中心(Presbyterian Healthcare Services)和马萨诸塞州总医院(Massachusetts General Hospital.)。

但医院在财务方面还有其他考虑,而这些也都是需要计算的成本。在过去十年里,有不少医院通过浮动利率债券和贷款融资才可以建造新设施,所以它们需要病人支付高昂的医疗费,以偿还贷款并收回投资。

韦莱韬悦咨询公司(Willis Towers Watson)北美健康管理实践的联合负责人杰夫•莱温-舍茨博士说:“至于容量过剩的医院,不管是因为新床位过多、患者数量减少,还是被竞争对手抢去业务,对居家护理服务的兴趣都不会太大。”

去年11月,为了让非新冠肺炎患者在疫情期间不用住院就能够得到治疗,美国联邦医疗保险(Medicare)同意为此类医疗服务付费,从而助推了居家护理理念的发展。之后已经有100多家医院获得联邦医疗保险的批准参与该项目,但并非所有医院都准备充分。

今年3月,亚马逊(Amazon)和一个行业组织联盟宣布,计划游说改变联邦和州条例规定,支持提供更广泛的家庭医疗服务。

“发展势头迅猛。”约翰斯•霍普金斯医学院(Johns Hopkins Medical School)的老年病学专家布鲁斯•莱夫博士表示。自20世纪90年代中期开创美国最早的居家护理项目以来,莱夫就一直致力于研究并提倡在家就医。

莱夫和其他支持者称,各种研究表明,居家护理的安全性堪比住院治疗,有可能比住院治疗的效果更好,而且可以通过限制医院扩大规模的需求、减少再入院人数以及帮助患者避免住进养老院来节省开支。据预估,居家护理将比传统医院护理节省30%的费用。但是,要想真正减少美国人住院花费的1.2万亿美元,刚起步的居家护理项目还有很长的路要走。

这些项目的最终目标是将10%或10%以上的住院患者转移到家中,但现有的居家护理项目处理的病例数量很少,有些项目的患者人数只有数名。

穆迪投资者服务公司(Moody’s Investors Service)的副总裁兼高级信贷官迪恩•安加尔称:“从很多方面来说,推广居家护理只是愿望,现在还处于早期阶段。”安加尔一直关注保险和医院行业。不过,他预测“未来会逐渐变成需要手术和重症监护等深切治疗的患者才能够住院。”

然而,扩大家庭护理的规模面临着诸多挑战,既要实现快速增长又要维持现有良好的安全形象,还需要足够的医护人员,特别是上门为患者服务的护士、护理人员和技术人员。

该项目对保险公司的吸引力很明显,只要支付的医疗费用比医院低,并且效果良好,保险公司就可以省下开支。

莱温-舍茨表示:“对医院来说,处理财务问题有点棘手。”

最有意愿进行尝试居家护理项目的是满载或接近满载的医院,它们亟需腾出空床位以缓解医疗资源的不足。

尽管如此,约翰斯•霍普金斯大学布隆伯格公共卫生学院(Johns Hopkins University Bloomberg School of Public Health)的卫生政策教授杰拉德•安德森指出,从长远来看,医院很可能发现居家护理能够节省大量成本和人员开支,有巨大的利润空间。

但安德森也对推广居家护理可能加剧医疗不平等问题表示担心。

“中上层家庭中实现不难,我担心贫困地区的家庭可能没有在家就医的条件。”安德斯说。

然而在郊区和农村地区,包括一些低收入的城市地区网络质量可能时好时坏,或者根本没有互联网,那么这些地区的患者如何参与此类项目?如何与远在医院的医生和医院工作人员交流?该项目的支持者们给出了解决方案,为此类患者提供互联网热点设备和备用电源,通过类似对讲机的手持设备和平板电脑实现即时沟通。

社会因素也会对此类项目产生很大的影响。独居的人会发现,如果需要很多人工帮助则很难实现在家就医,如果家庭成员众多则可能无法保证足够的空间或隐私。

另外还有潜在的问题,并非所有病人都可以找到人来帮助他们,比如搀扶上厕所、吃饭,甚至开门。

亚历山德拉•德雷恩表示,在患者与看护者同意参加居家护理项目之前,应该详细了解日常职责。德雷恩是营利集团Archangels的首席执行官,该公司以营利为主,主要与雇主合作,并为无薪看护者提供资源。

德雷恩说:“如果家庭财力足够,也有人能够承担照顾责任,就可以采用居家护理模式。但在很多情况下,这并不现实。假如我是全职工作,还有两个孩子,哪有时间做这些事情?”

对此,居家护理项目纷纷表示,会努力减轻家庭的负担。有些项目会协助患者洗澡或其他家庭护理事务,还提供餐饮。不少项目不需要家庭成员提供护理。由项目提供监控和通信设备,需要时还提供一张病床。

“我们能够看到患者在家的情况,家里的冰箱存放着哪些物品?他们的生活状况如何?我们可以改善这些状况吗?我们不会依赖病人家属提供护理。”莫尔•迪恩说,他是Adventist Health家庭就医项目的主席,该项目为加利福尼亚的大部分地区和俄勒冈的部分地区提供居家护理服务。

在通常情况下,每天都有不同的医护人员上门探访病人。部分居家护理项目的医生还会家访,但大多数项目都聘请医生从远程“指挥中心”监督护理,利用各种电子设备与患者交谈。

詹姆斯•克利福德位于加州贝克尔斯菲尔德的家中就有各种设备,在此之前,他刚刚决定参加Adventist的居家护理项目,离开医院在家完成感染治疗。各项工作都要协调安排,本来按照计划妻子要去医院接他,但后来不得不留在家中做准备,不过“安排妥当之后,在家就医就能够顺利进行。”

在家中,要连续几天每8小时使用抗生素治疗,“有次凌晨2点护士上门,吵醒了我妻子,不过没有关系,在家接受治疗感觉很安心。”70岁的克利福德说。

迪恩说,Adventist在一年前就推出了居家护理项目,目前规模还很小,没有实现节省资金。他最终的目标是“把居家护理变成Adventist Health的最大一块业务”,同时可以有500到1500名患者参与。

医疗保险决定为居家护理买单让迪恩距离自己的目标又进了一步,但疫情结束时医疗保险资助创建的居家护理项目也会结束。由于疫情期间情况紧急,医疗保险根据每个病人的诊断,报销的费用与住院治疗相同。如果未来区别对待,医院还会热情高涨吗?商业保险公司也不太可能为此买单,除非能够切实证明医疗费用降低,因为已经有人担心家庭护理被滥用了。

韦莱韬悦的莱温-舍茨说:“对社会而言,如果居家护理项目可以取代费用昂贵的住院治疗,那肯定是好事。”不过他也担心,如果居家护理服务接纳有些不需要去医院、在费用较低的门诊就能够治好的病人,借此实现增长,对社会就会形成负面影响。”(财富中文网)

凯泽健康新闻(Kaiser Health News)是覆盖全美的新闻机构,主要发布健康相关的深度新闻,与Policy Analysis and Polling同属凯泽家族基金会(Kaiser Family Foundation)的三大主营项目之一。凯泽家族基金会是依靠捐助的非营利组织,主要关注美国的医疗健康问题。

译者:李晓维

审校:夏林

如今,各大医院都押下重注,认为居家护理模式将会变成医院护理的未来。

经过十多年的发展,相对小众的医院级家庭护理模式(其中一些通过互联网提供)正蓄势待发。这一方面是因为医院迫切希望缓解新冠疫情期间人满为患的局面,另一方面是保险公司越发希望降低医疗支出费用。不过,从决定应该收取多少费用到哪些病人可以安全受益,该模式也面临着诸多挑战。

然而在居家护理模式下,则能够为患有肺炎、心力衰竭甚至是中度新冠肺炎患者提供深入护理,同时提供全天候远程监测和医护人员日常访问等服务。

今年5月,凯撒医疗(Kaiser Permanente)和妙佑医疗国际(Mayo Clinic)两家大机构宣布进军该领域,计划向总部位于波士顿的Medically Home联合投资1亿美元,这家公司通过提供上述居家护理服务扩大规模并拓展业务。据这两家公司估计,目前全美国30%的住院患者有条件接受居家护理。

去年夏天,其他几家著名医院也启动了相关项目。在此之前,已经有20多家医院提供这项服务,其中包括位于巴尔的摩的约翰斯•霍普金斯医院(Johns Hopkins Medicine)、新墨西哥州的长老会医疗保健服务中心(Presbyterian Healthcare Services)和马萨诸塞州总医院(Massachusetts General Hospital.)。

但医院在财务方面还有其他考虑,而这些也都是需要计算的成本。在过去十年里,有不少医院通过浮动利率债券和贷款融资才可以建造新设施,所以它们需要病人支付高昂的医疗费,以偿还贷款并收回投资。

韦莱韬悦咨询公司(Willis Towers Watson)北美健康管理实践的联合负责人杰夫•莱温-舍茨博士说:“至于容量过剩的医院,不管是因为新床位过多、患者数量减少,还是被竞争对手抢去业务,对居家护理服务的兴趣都不会太大。”

去年11月,为了让非新冠肺炎患者在疫情期间不用住院就能够得到治疗,美国联邦医疗保险(Medicare)同意为此类医疗服务付费,从而助推了居家护理理念的发展。之后已经有100多家医院获得联邦医疗保险的批准参与该项目,但并非所有医院都准备充分。

今年3月,亚马逊(Amazon)和一个行业组织联盟宣布,计划游说改变联邦和州条例规定,支持提供更广泛的家庭医疗服务。

“发展势头迅猛。”约翰斯•霍普金斯医学院(Johns Hopkins Medical School)的老年病学专家布鲁斯•莱夫博士表示。自20世纪90年代中期开创美国最早的居家护理项目以来,莱夫就一直致力于研究并提倡在家就医。

莱夫和其他支持者称,各种研究表明,居家护理的安全性堪比住院治疗,有可能比住院治疗的效果更好,而且可以通过限制医院扩大规模的需求、减少再入院人数以及帮助患者避免住进养老院来节省开支。据预估,居家护理将比传统医院护理节省30%的费用。但是,要想真正减少美国人住院花费的1.2万亿美元,刚起步的居家护理项目还有很长的路要走。

这些项目的最终目标是将10%或10%以上的住院患者转移到家中,但现有的居家护理项目处理的病例数量很少,有些项目的患者人数只有数名。

穆迪投资者服务公司(Moody’s Investors Service)的副总裁兼高级信贷官迪恩•安加尔称:“从很多方面来说,推广居家护理只是愿望,现在还处于早期阶段。”安加尔一直关注保险和医院行业。不过,他预测“未来会逐渐变成需要手术和重症监护等深切治疗的患者才能够住院。”

然而,扩大家庭护理的规模面临着诸多挑战,既要实现快速增长又要维持现有良好的安全形象,还需要足够的医护人员,特别是上门为患者服务的护士、护理人员和技术人员。

该项目对保险公司的吸引力很明显,只要支付的医疗费用比医院低,并且效果良好,保险公司就可以省下开支。

莱温-舍茨表示:“对医院来说,处理财务问题有点棘手。”

最有意愿进行尝试居家护理项目的是满载或接近满载的医院,它们亟需腾出空床位以缓解医疗资源的不足。

尽管如此,约翰斯•霍普金斯大学布隆伯格公共卫生学院(Johns Hopkins University Bloomberg School of Public Health)的卫生政策教授杰拉德•安德森指出,从长远来看,医院很可能发现居家护理能够节省大量成本和人员开支,有巨大的利润空间。

但安德森也对推广居家护理可能加剧医疗不平等问题表示担心。

“中上层家庭中实现不难,我担心贫困地区的家庭可能没有在家就医的条件。”安德斯说。

然而在郊区和农村地区,包括一些低收入的城市地区网络质量可能时好时坏,或者根本没有互联网,那么这些地区的患者如何参与此类项目?如何与远在医院的医生和医院工作人员交流?该项目的支持者们给出了解决方案,为此类患者提供互联网热点设备和备用电源,通过类似对讲机的手持设备和平板电脑实现即时沟通。

社会因素也会对此类项目产生很大的影响。独居的人会发现,如果需要很多人工帮助则很难实现在家就医,如果家庭成员众多则可能无法保证足够的空间或隐私。

另外还有潜在的问题,并非所有病人都可以找到人来帮助他们,比如搀扶上厕所、吃饭,甚至开门。

亚历山德拉•德雷恩表示,在患者与看护者同意参加居家护理项目之前,应该详细了解日常职责。德雷恩是营利集团Archangels的首席执行官,该公司以营利为主,主要与雇主合作,并为无薪看护者提供资源。

德雷恩说:“如果家庭财力足够,也有人能够承担照顾责任,就可以采用居家护理模式。但在很多情况下,这并不现实。假如我是全职工作,还有两个孩子,哪有时间做这些事情?”

对此,居家护理项目纷纷表示,会努力减轻家庭的负担。有些项目会协助患者洗澡或其他家庭护理事务,还提供餐饮。不少项目不需要家庭成员提供护理。由项目提供监控和通信设备,需要时还提供一张病床。

“我们能够看到患者在家的情况,家里的冰箱存放着哪些物品?他们的生活状况如何?我们可以改善这些状况吗?我们不会依赖病人家属提供护理。”莫尔•迪恩说,他是Adventist Health家庭就医项目的主席,该项目为加利福尼亚的大部分地区和俄勒冈的部分地区提供居家护理服务。

在通常情况下,每天都有不同的医护人员上门探访病人。部分居家护理项目的医生还会家访,但大多数项目都聘请医生从远程“指挥中心”监督护理,利用各种电子设备与患者交谈。

詹姆斯•克利福德位于加州贝克尔斯菲尔德的家中就有各种设备,在此之前,他刚刚决定参加Adventist的居家护理项目,离开医院在家完成感染治疗。各项工作都要协调安排,本来按照计划妻子要去医院接他,但后来不得不留在家中做准备,不过“安排妥当之后,在家就医就能够顺利进行。”

在家中,要连续几天每8小时使用抗生素治疗,“有次凌晨2点护士上门,吵醒了我妻子,不过没有关系,在家接受治疗感觉很安心。”70岁的克利福德说。

迪恩说,Adventist在一年前就推出了居家护理项目,目前规模还很小,没有实现节省资金。他最终的目标是“把居家护理变成Adventist Health的最大一块业务”,同时可以有500到1500名患者参与。

医疗保险决定为居家护理买单让迪恩距离自己的目标又进了一步,但疫情结束时医疗保险资助创建的居家护理项目也会结束。由于疫情期间情况紧急,医疗保险根据每个病人的诊断,报销的费用与住院治疗相同。如果未来区别对待,医院还会热情高涨吗?商业保险公司也不太可能为此买单,除非能够切实证明医疗费用降低,因为已经有人担心家庭护理被滥用了。

韦莱韬悦的莱温-舍茨说:“对社会而言,如果居家护理项目可以取代费用昂贵的住院治疗,那肯定是好事。”不过他也担心,如果居家护理服务接纳有些不需要去医院、在费用较低的门诊就能够治好的病人,借此实现增长,对社会就会形成负面影响。”(财富中文网)

凯泽健康新闻(Kaiser Health News)是覆盖全美的新闻机构,主要发布健康相关的深度新闻,与Policy Analysis and Polling同属凯泽家族基金会(Kaiser Family Foundation)的三大主营项目之一。凯泽家族基金会是依靠捐助的非营利组织,主要关注美国的医疗健康问题。

译者:李晓维

审校:夏林

Major hospital systems are betting big money that the future of hospital care looks a lot like the inside of patients’ homes.

Hospital-level care at home—some of it provided over the Internet—is poised to grow after more than a decade as a niche offering, boosted both by hospitals eager to ease overcrowding during the pandemic and growing interest by insurers who want to slow health care spending. But a host of challenges remain, from deciding how much to pay for such services to which kinds of patients can safely benefit.

Under the model, patients with certain medical conditions, such as pneumonia or heart failure—even moderate COVID—are offered high-acuity care in their homes, with 24/7 remote monitoring and daily visits by medical providers.

In the latest sign that the idea is catching on, two big players—Kaiser Permanente and the Mayo Clinic—announced plans this month to collectively invest $100 million into Medically Home, a Boston-based company that provides such services to scale up and expand their programs. The two organizations estimate that 30% of patients currently admitted to hospitals nationally have conditions eligible for in-home care. (KHN is not affiliated with Kaiser Permanente.)

Several other well-known hospital systems launched programs last summer. They join about two dozen already offering the service, including Johns Hopkins Medicine in Baltimore, Presbyterian Healthcare Services in New Mexico and Massachusetts General Hospital.

But hospitals have other financial considerations that are also part of the calculation. Systems that have built sparkling new in-patient facilities in the past decade, floating bonds and taking out loans to finance them, need patients filling costly inpatient beds to repay lenders and recoup investments.

And “hospitals that have surplus capacity, whether because they have newly built beds or shrinking populations or are losing business to competitors, are not going to be eager about this,” said Dr. Jeff Levin-Scherz, co-leader of the North American Health Management practice at consultancy Willis Towers Watson.

Medicare gave the idea a boost in November when it agreed to pay for such care, to help keep non-COVID patients out of the hospital during the pandemic. Since then, more than 100 hospitals have been approved by Medicare to participate, although not all are in place yet.

Tasting opportunity, Amazon and a coalition of industry groups in March announced plans to lobby for changes in federal and state rules to allow broader access to a wide range of in-home medical services.

“We’re seeing tremendous momentum,” said Dr. Bruce Leff, a Johns Hopkins Medical School geriatrician who has studied and advocated for the hospital-at-home approach since he helped establish one of the nation’s first programs in the mid-1990s.

Leff and other proponents say various studies show in-home care is just as safe and may produce better outcomes than being in the hospital, and it saves money by limiting the need to expand hospitals, reducing hospital readmissions and helping patients avoid nursing home stays. Some estimates put the projected savings at 30% over traditional hospital care. But ongoing programs are a long way from making a dent in the nation’s $1.2 trillion hospital tab.

While the goal is to shift 10% or more of hospital patients to home settings, existing programs handle far fewer cases, sometimes serving only a handful of patients.

“In a lot of ways, this remains aspirational; this is the early innings,” said Dean Ungar, who follows the insurance and hospital industries as a vice president and senior credit officer at Moody’s Investors Service. Still, he predicted that “hospitals will increasingly be reserved for acute care [such as surgeries and ICUs].”

Challenges to scaling up include maintaining the current good safety profile in the face of rapid growth and finding enough medical staff—especially nurses, paramedics and technicians—who travel to patients’ homes.

The attraction for insurers is clear: If they can pay for care in a lower-cost setting than the hospital, with good outcomes, they save money.

For hospitals, “the financials of it are, frankly, a little tough,” said Levin-Scherz.

Those most attracted to hospital-at-home programs run at or near capacity and want to free up beds.

Even so, Gerard Anderson, a health policy professor at Johns Hopkins University Bloomberg School of Public Health, said hospitals likely see the potential, long term, for “huge profit margins” through “saving a lot of capital and personnel expense by having the work done at home.”

But Anderson worries that broad expansion of hospital-at-home efforts could exacerbate health care inequities.

“It’s realistic in middle- and upper-middle-class households,” Anderson said. “My concern is in impoverished areas. They may not have the infrastructure to handle it.”

Suburban and rural areas—and even some lower-income urban areas—can have spotty or nonexistent Internet access. How will that affect the ability of those areas to participate, to communicate with physicians and other hospital staff members miles away? Proponents outline solutions, from providing patients with “hot spot” devices that provide Internet service, along with backup power and instant communication via walkie-talkie-type handsets and computer tablets.

Social factors play a big part, too. Those who live alone may find it harder to qualify if they need a lot of help, while those in crowded households may not have enough room or privacy.

Another possible wrinkle: Not all patients have the necessary human support, such as someone to help an ill patient with the bathroom, meals or even answering the door.

That’s why both patients and their caregivers should get a detailed explanation of the day-to-day responsibilities before agreeing to participate, said Alexandra Drane, CEO of Archangels, a for-profit group that works with employers and provides resources for unpaid caregivers.

“I love the concept for a resourced household where someone can take this job on,” said Drane. “But there’s a lot of situations where that’s not possible. What If I have a full-time job and two children, when am I supposed to do this?”

The programs all say they aim to reduce the burden on families. Some provide aides to help with bathing or other home care issues and provide food. None expects family members to perform medical procedures. The programs supply monitoring and communication equipment and a hospital bed, if needed.

“We see the patient in their home setting,” said Morre Dean, president of Adventist Health’s hospital at home program, which serves a broad area of California and part of Oregon. “What is in their refrigerator? What is their living situation? Can we impact that? We aren’t reliant on the family to deliver care.”

Patients are typically visited in their homes daily by various health workers. Physicians make home visits in some programs, but most employ doctors to oversee care from remote “command centers,” talking with patients via various electronic gadgets.

All of that was delivered to James Clifford’s home in Bakersfield, California, after he opted to participate in the Adventist program so he could leave the hospital and finish treatment for an infection at home. It required coordination—his wife had to be at their house for the set-up team even as she was scheduled to pick him up—but “once it was set up, it worked well.”

At home, he needed treatment with antibiotics every eight hours for several days and “one nurse came at 2 a.m.,” said Clifford, 70. “It woke up my wife, but that’s OK. We had peace of mind by my being at home.”

Adventist launched its program a year ago, but it hasn’t achieved the scale needed to save money yet, said Dean. Ultimately, he envisions the hospital-at-home option as “our biggest hospital in Adventist Health,” with 500 to 1,500 patients in the program at a time.

Medicare’s payment decision gave momentum to such goals. But the natural experiment it created with its funding ends when the pandemic is declared over. Because of the emergency, Medicare paid the same as it would for in-hospital care, based on each patient’s diagnosis. Will hospitals be as enthusiastic if that is not the case in the future? Commercial insurers are unlikely to pay unless they see lower rates, since there are already concerns about overuse.

“From a societal perspective, it’s great if these programs replace expensive inpatient care,” said Levin-Scherz at Towers. But, he said, it would be a negative if the programs sought to grow by admitting patients who otherwise would not have gone into the hospital at all and could have been treated with lower-cost outpatient services.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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