Home hospital programs are a safer, cheaper and more efficacious alternative to inpatient hospital admission for many medical conditions. Brigham and Women’s Hospital is at the forefront of efforts to extend this delivery model to perioperative care, including for gastrointestinal (GI) and bariatric surgery.
Thomas C. Tsai, MD, MPH, is the director of clinical care redesign in the Brigham’s Department of Surgery. He notes that providers have traditionally focused on what he calls “the infrastructure of surgery”—the operating room, technology, staffing and other elements that reside within the hospital walls.
“But as we think about improving patient satisfaction, patient experience and the value of health care, we need to bring that care outside of the hospital’s walls, into the patients’ communities and ultimately into their homes,” Dr. Tsai says. “That’s the goal of home hospital for surgery.”
Dr. Tsai and his team have begun enrolling patients in a randomized controlled trial to further establish the safety and efficacy of this emerging option for perioperative care.
Not Synonymous With Outpatient Surgery
Home hospital for surgery is not outpatient surgery, where patients are discharged postoperatively and primarily responsible for their own recovery and care. It is instead a model that brings an inpatient level of services spanning preoperative and postoperative care, including monitoring and treatment of complications, into the home.
Prior to surgery, patients receive home safety evaluation, surgical prehabilitation assessment, medication/pain management and other components. Following surgery, patients can go home with an IV for management of postoperative pain and nausea. Vital signs can be monitored 24/7 via remote telemetry units. Point-of-care lab testing and imaging (e.g., ultrasound) can be incorporated as well. Importantly, patients also receive in-person house calls by nursing, paramedic, and physician providers to monitor their postoperative recovery.
“We can give patients access to the same level of medical expertise through home visits as well as virtual consultations with our inpatient specialist teams,” Dr. Tsai says. “If a bariatric surgery patient needs a consultation from an endocrinologist to manage their diabetes or needs a postoperative dietitian consultation, those things can be done virtually.”
Dr. Tsai stresses that home hospital for surgery does not constitute a discharge but rather a transfer of the patient to the home setting. If at any point the patient requires a higher level of care, they should be transferred back to the hospital.
“This is a paradigm shift. Instead of designing our care model around the minority of patients who have complications, we’re designing it around the majority of our patients who do well after surgery,” he says. “But all the while, we’re remaining vigilant so we can rapidly assess, triage and manage any complications that do occur.”
Increasing Capacity, Reducing Costs
First and foremost, Dr. Tsai is bullish on the ability of home hospital for surgery to enhance the recovery of patients from GI and bariatric surgery. But he also sees this model as a remedy to the extreme capacity constraints that many hospitals have faced during the pandemic.
As he explains, a high census on the surgical wards has a variety of ramifications, including longer waiting times for patients to be seen, more patients boarding in the emergency room and post-anesthesia care units, and delays in getting patients into the operating room. Home hospital for surgery offers a safety valve.
“By bringing more hospital services into the home, we’re improving the care experience not only for our surgical patients, but also for all of our patients,” Dr. Tsai says. “We’re also increasing our capacity to deliver care in the hospital while potentially creating long-term cost savings.”
In the ongoing trial at the Brigham, patients who give their consent are randomized into either inpatient admission into the hospital or home hospital recovery after surgery. By exploring home hospital for surgery in a rigorous, data-driven manner, Dr. Tsai hopes to lead the way in creating two viable options for more surgical patients: recovery in the hospital or at home.
“We’re one of the first programs in the country to bring this model of care to our patients, especially for GI and bariatric surgery,” he says. “We’re really thinking about the hospital as a hub for services, not just a place to receive inpatient care.”