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Ding Dong: The Doctor Will See You (at Home) Now

May 19, 2023

June 2023

Increasingly, patients are able to receive treatment for hematologic malignancies from the comfort of home.

Leah Lawrence

Leah Lawrence is a freelance health writer and editor based in Delaware.

Home-hospital services provide patients with nursing visits or oversight at home instead of having to visit a clinic, emergency department (ED), or other hospital setting. Unlike in single-payer systems, these programs have been slower to gain a foothold in the U.S., which is a majority fee-for-service-based system. However, in the years since the COVID-19 pandemic started, home-hospital programs are receiving renewed attention due, at least in part, to a November 2020 announcement from the Centers for Medicare & Medicaid Services (CMS) that detailed “flexibilities” aimed at providing eligible patients with acute hospital care in their homes.1

“These waivers [from CMS] allowed hospital systems to use telehealth, digital tools like remote monitoring, and hospital-at-home programs in ways that were more flexible than they previously were,” said Justin E. Bekelman, MD, founding director of the Penn Center for Cancer Care Innovation at Penn Medicine’s Abramson Cancer Center and professor of radiation oncology in the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “Now, as those waivers expire, the big question becomes ‘How do we maintain the regulatory and reimbursement landscape to keep patients safe but also continue to encourage innovation that has been shown to be successful?’”

ASH Clinical News spoke with Dr. Bekelman and other experts about the ongoing paradigm shift in health care from inpatient to outpatient to home-hospital options, including those for hematologic malignancies, as well as the pros and cons of using these programs now and in the future.

Acute Care

Acute care hospital-at-home programs did not begin among patients with cancer, according to Kathi Mooney, PhD, RN, FAAN, distinguished professor at the University of Utah College of Nursing in Salt Lake City.

“Mainly, the model was designed for frail, elderly patients or those dealing with chronic disease exacerbations,” Dr. Mooney said.

Early studies of this type of care looked at the feasibility of hospital-level care for community-​dwelling elderly adults and found that patients treated at home had a shorter length of stay, and the at-home care had a lower mean cost than acute hospital care.2

In 2018, Dr. Mooney and colleagues tested at-home acute care in patients with cancer and compared outcomes with those seen with usual care.3 To be eligible for home-hospital care, patients had to live within 20 miles of Huntsman Cancer Institute in Salt Lake City. Patients admitted to the home-hospital program required continued acute-level medical care after hospitalization or had continuing unstable symptoms related to treatment or disease progression that would normally require ED evaluation. Compared with a group of patients who would have qualified for the home-hospital program but lived outside of the required geographic area, home care reduced the odds of an unplanned hospitalization by 55%, ED visits by 45%, and health care costs by 47%.3

“In addition to the acute episode program, which is maybe three to five days long, we have a subacute program where we follow patients for about 30 days to proactively see if the condition is going to recur,” Dr. Mooney said.

The program is led by advanced practitioners (APs) who partner with a local home health agency. APs go to the patients’ homes to perform assessments, draw labs, and provide treatment. If a patient isn’t responding to treatment or if a case becomes too complicated, the AP consults with the medical director of the hospital-​at-home program.

“The AP also interacts with the patient’s oncology team to update and coordinate care either with a phone call or simply by inputting information into a messaging system,” Dr. Mooney said.

Despite the positive outcomes seen in the trial, Dr. Mooney acknowledged that reimbursement is a real barrier to scaling this type of program and making it sustainable.

Chemotherapy

In November 2019, Penn Medicine launched its Cancer Care at Home program. The program’s at-home administration of cancer drugs is rare in the U.S., according to Dr. Bekelman.

“Sometimes, and rightfully so, there has been an innate conservatism of the oncologic specialists who take care of patients with hematologic malignancies,” Dr. Bekelman said. That has been slow to change.

“For example, patients with some types of lymphoma used to receive the EPOCH chemotherapy regimen [etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin] in the hospital one week a month for six months,” he said. “Then, 10 to 20 years ago it was shown that patients could safely receive it as an outpatient regimen.”

Today, EPOCH is one of the regimens that Penn provides to patients at home, without any outpatient visits or hospitalizations.

Clinicians at Penn work to identify both the drug regimens and the patients who would be considered suitable for at-home infusions.

“We think about the characteristics of patients that would be conducive to care at home, which might include disease state or comorbidities,” Dr. Bekelman said. “Next, we think about the drug. Is the drug stable to be transported? Can the drug be stored within the temperature range of a home refrigerator?”

A patient can expect to receive a call ahead of time to set up the appointment for the infusion. Once the appointment is scheduled, equipment – such as an IV pole – is scheduled to be delivered. The day of the infusion, an oncology-certified infusion nurse arrives with the appropriate personal protective equipment and delivers the drug. The nurse always carries an anaphylaxis bag to manage any potential adverse events.

From late March 2020 to April 2020, Penn’s at-home program logged a 700% increase in the number of participating patients, from 39 to 310.4 As of 2023, Dr. Bekelman estimated that about 3,000 patients take advantage of at-home cancer drug administration annually. The program continues to expand and add new therapies for at-home administration.

Early evaluation of the program showed largely positive patient feedback.

Transplantation

Researchers, including Anthony D. Sung, MD, associate professor of medicine at Duke University in Durham, North Carolina, have spent several years developing and testing the feasibility of an at-home transplant program.

“Patients undergoing autologous transplant are typically at the transplant center for three to four weeks during the course of transplant. They receive one or more days of chemotherapy followed by stem cell infusion and then wait two to three weeks for engraftment,” Dr. Sung said. “Allogeneic transplant runs a similar course, with up to three months at the transplant center for follow-up care.”

The at-home transplant program allows patients to receive pre-transplant conditioning and stem cell infusion in a medical setting before being discharged to their home immediately after transplantation.

First developed more than 20 years ago by the Karolinska Institute in Sweden, at-home transplantation care includes daily visits from an experienced nurse and daily phone calls from a physician. Compared with patients who chose hospital care, patients treated at home were “discharged” earlier, had fewer days on total parenteral nutrition, less grade 2-4 acute graft-versus-host disease, and lower transplantation-related mortality, as well as a lower cost of care.5

Dr. Sung and colleagues conducted a phase I study of home transplant care at Duke University from November 2012 to March 2018. To be included, patients had to live within a 60-minute driving distance of the medical centers and have a caregiver for the duration of the transplant and recovery.6

“Patients underwent a home inspection to make sure the home was a safe environment,” Dr. Sung said. “If it was, patients were discharged day 1 post-transplant and we made house calls after that.”

Once home, the patient received a morning visit from an AP who performed a full physical examination and drew labs for processing. If needed, a transplant nurse returned later in the day to deliver appropriate care based on that morning’s assessment. Patients then video-conferenced with the attending physician.

Clinical outcomes were not significantly different from standard-of-care treatment, but patients treated at home had a decreased incidence of relapse within one year and preserved their pre-transplant quality of life.6

Dr. Sung said that distance from the treating center is a limitation of this approach, but he noted all patients undergoing transplant are typically asked to temporarily relocate closer to the center for the duration of the transplant.

From the patient perspective, Dr. Sung has heard very few drawbacks to this approach.

“The feedback from the patients has been overwhelmingly positive. They love being at home,” Dr. Sung said.

There are also benefits to home transplant programs from a health care system perspective, he added. The first is freeing up beds in the hospital and chairs in the outpatient settings. The second benefit is a potential decrease in infections and other complications, which Dr. Sung expects to see with home transplant care.

One area of concern is whether home transplant care increases caregiver burden. Dr. Sung said he doesn’t think home transplant care will necessarily increase caregiver burden, but it may shift the burden from things like providing transportation to and from appointments to the requirements of at-home care.

Supportive Care & More

There are many more academic centers that are developing home-based care treatment programs for acute care, transplantation, and more. Areej El-Jawahri, MD, associate director of the Cancer Outcomes Research and Education Program and director of the Bone Marrow Transplant Survivorship Program at Massachusetts General Hospital in Boston, is working with a team to evaluate home interventions, including one trial to look at hospital-at-home care models for symptom assessment and management and another to investigate the feasibility of at-home interventions for hospitalized patients with advanced cancer.7

“A lot of intensive chemotherapy results in side effects like nausea, vomiting, or diarrhea that result in dehydration or failure to thrive,” Dr. El-Jawahri said. “Managing these symptoms and supportive care does not necessarily require hospital-level care. This could be an example of a safe home-hospital admission.”

Jennifer Holter-Chakrabarty, MD, chair of the ASH Committee on Practice and professor of medicine at the University of Oklahoma, is working to develop an at-home blood transfusion program. In 2022, she presented the results of a trial testing a home-based transfusion system that allowed patients to receive blood and platelet transfusions while enrolled in hospice. These infusions were prompted based on symptoms rather than the standard complete blood count triggers.8

All of the included patients had hematologic malignancies and were transfusion-dependent. Patients received a unit of packed red blood cells or platelets each week based on symptoms. The at-home transfusion program proved feasible and safe, with high enrollment and no transfusion reactions.9

“We partnered with different groups: our Stephenson Cancer Center, two hospice groups, and the Oklahoma Blood Institute,” Dr. Holter-​Chakrabarty said. “It was these partnerships that made the trial successful.”

Future Potential for the Home-Hospital Model

There is huge potential for the home-hospital model to enhance equity in care across rural settings and places with less access to high-quality care, according to Dr. El-Jawahri.

“With how it works today, a patient could drive to the oncology center for their high-dose chemotherapy, experience these effects, and end up in a local ED away from their oncology team,” Dr. El-Jawahri said. “Now imagine a care model where the patients are proactively managed with maximal supportive care at home to avoid the need to go to the local ED.”

Of course, there is no home-hospital program that will just “cut and paste” to new populations or geographies. Each will need to adapt. For example, Dr. Holter-Chakrabarty is partnering with a group in Boston to run a trial of at-home transfusions. She was surprised to learn that her colleagues in Boston were worried about the timing of transfusions and their ability to get to patients quickly.

“In Oklahoma, we get on a road and in 30 or 40 minutes we can drive 30 or 40 miles,” Dr. Holter-Chakrabarty said. “My colleagues said that in Boston, you may not be able to get across town in 30 to 40 minutes.”

Those types of differences have to be considered.

Although there are barriers to address, many people involved in developing at-home programs believe that it is part of the future of cancer care.

“It is going to expand,” Dr. El-Jawahri said. “Ultimately, we are talking about the care continuum and how to meet patients where they are by providing the best possible care in the home setting. That is not only where patients want to receive care but will probably be the most cost-effective model in terms of reducing cost of care and health care utilization.”

In fact, research from at-home programs in other countries seems to support the cost-effectiveness of these models.9,10 Although, clear information on how these programs will be reimbursed in the U.S. and whether they will be cost-effective for cancer care is lacking.

“In cancer care, and specifically in hematologic malignancies, we need a call to action to help clinicians, hospital systems, and payers to appreciate that when patients are exposed to truly high-quality care in the home, or through digital care, the patient experience is dramatically better,” Dr. Bekelman said. “We must move faster because our patients expect it of us. Health systems and insurers should make the necessary investments and moves to make these care delivery models truly available and effective nationwide.”

References

  1. Centers for Medicare & Medicaid Services. CMS announces comprehensive strategy to enhance hospital capacity amid COVID-19 surge. November 25, 2020. Accessed March 27, 2023. https://www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-strategy-enhance-hospital-capacity-amid-covid-19-surge.
  2. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143(11):798-808.
  3. Mooney K, Titchener K, Haaland B, et al. Evaluation of oncology hospital at home: unplanned health care utilization and costs in the huntsman at home real-world trial. J Clin Oncol. 2021;39(23):2586-2593.
  4. Laughlin AI, Begley M, Delaney T, et al. Accelerating the delivery of cancer care at home during the Covid-19 pandemic. NEJM Catalyst. July 7, 2020.
  5. Svahn B-M, Remberger M, Myrbäck K-E, et al. Home care during the pancytopenic phase after allogeneic hematopoietic stem cell transplantation is advantageous compared with hospital care. Blood. 2002;100(13):4317-4324.
  6. Sung AD, Giri VK, Tang H, et al. Home-based hematopoietic cell transplantation in the United States. Transplant Cell Ther. 2022;28(4):207.e1-207.e8.
  7. Nipp RD, Shulman E, Smith M, et al. Supportive oncology care at home interventions: protocols for clinical trials to shift the paradigm of care for patients with cancer. BMC Cancer. 2022;22(1):383.
  8. Saleem R, MacDougall K, Hassan A, et al. Novel home-based transfusion model of palliative care in malignant hematology. Blood. 2022;140(supplement 1):11024-11025.
  9. Tzala S, Lord J, Ziras N, Repousis P, Potamianou A, Tzala E. Cost of home palliative care compared with conventional hospital care for patients with haematological cancers in Greece. Eur J Health Econ. 2005;6(2):102-106.
  10. Megido I, Sela Y, Grinberg K. Cost effectiveness of home care versus hospital care: a retrospective analysis. Cost Eff Resour Alloc. 2023;21(1):13.

 

Therapies Available Through Penn Medicine’s Cancer Care at Home Program

Type of Therapy

Specific Type of Agents

Antineoplastic agents

Gonadotropin releasing hormone agonists

Estrogen receptor antagonists

PD-1 inhibitors

Proteasome inhibitor

Alkylating agents

Pyrimidine analogs

Topoisomerase II inhibitors

Vinca alkaloids

Monoclonal antibodies

Supportive agents

Bisphosphonates

Colony stimulating factors

Somatostatin analogs

Immune globulin

Pain management

Parenteral nutrition

Anti-emetics

Hydration

Anti-infective agents

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