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Sep 24, 2020

The Hospital at Home model of care is emerging as a promising concept to deliver acute care to patients with cancer outside of hospitals and clinics, especially in the era of COVID-19.  In this episode, Kathi Mooney, PhD, RN,  a distinguished professor of nursing at the University of Utah and co-leader of the Cancer Control and Population Sciences Program at the Huntsman Cancer Institute, discusses the significant impact of the her institution’s program, the first of its kind in the United States. This new frontier in care offers the oncology care community a chance to rethink its methods and to consider what can be done safely in the home that provides additional support during the cancer experience.  



ASCO Daily News: Hello and welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. I'm delighted to welcome Dr. Kathi Mooney to the podcast today Dr. Mooney is a distinguished professor of Nursing at the University of Utah and coleader of the Cancer Control and Population Sciences program at the Huntsman Cancer Institute.

Dr. Mooney will discuss the emergence of the hospital at home model of care in the oncology setting and the promise of this concept to deliver acute care to patients, reduce hospitalizations, ER visits, and cost. Dr. Mooney reports no conflicts of interest relating to the issues discussed in this podcast. Full disclosures relating to all Daily News podcasts are available on our episode pages. Dr. Mooney, it's great to have you on the podcast today.

Dr. Kathi Mooney: Thank you for inviting me, Geraldine.

ASCO Daily News: Dr. Mooney, you have done a great deal of research on hospital at home models including your work on the Huntsman at home trial, the first adult oncology hospital at home program in the United States, led by the University of Utah Huntsman Cancer Institute. The results were really impressive and were featured at the ASCO Virtual Scientific Program earlier this year. Can you tell us why you believe this concept could truly move the needle in adopting more innovative patient-centered models of care?

Dr. Kathi Mooney: Yes, thank you. Huntsman at home is a concept that is based on the hospital at home programs that are more widely known internationally in single-payer systems and have been in the United States mostly to support frail elderly at home and so has not previously been evaluated for oncology populations.

At the Huntsman Cancer Institute, we have been interested in providing more models and testing models of care that are in the community. And so we were very interested in whether the hospital at home concept could address some of the challenges we have in oncology care.

As you know, most oncology care is given on an outpatient basis. And so patients are at home for most of their treatment and extended survivor periods of time. And yet we don't have good models to reach out and support patients when they are at home. And as a result, we end up seeing very high levels of emergency department use and rehospitalization.

So we were interested in looking at the hospital at home model for oncology and began that program. And once we had a number of patients in it, we looked at evaluating how it impacted those health care utilization factors we were interested in, both emergency department and rehospitalization. We started by studying 169 patients that had been admitted to our Huntsman at home program and compared them with 198 cancer patients who would have been eligible to be admitted to Huntsman at home but lived outside of our 20-mile service radius.

And we found that indeed, it very much addressed the health care utilization issues and that, in the first 30 days after enrollment in the Huntsman at home or our comparison group, there was a 58% decrease in unplanned hospitalization. And for those who were hospitalized, they had a 1.2 less days of inpatient stay. We also found that it reduced emergency department visits by 48%. And the charges were also 48% less for the patients that were in Huntsman at home.

ASCO Daily News: Well, as you say, the Huntsman at home trial showed that patients can truly benefit from receiving oncology care in their homes. But are there any limitations to this model of care in the oncology setting in particular? What are some of the challenges that typically arise for oncology clinicians providing care at home?

Dr. Kathi Mooney: Well, one of the things is to really understand the care needs of oncology patients at home. And what we have found is that there is an initial acute care event for which Huntsman at home gets involved. And then once the patient is stabilized, then not too long afterwards, they may have an exacerbation of the problems that they were experiencing or new problems.

So one of the things in the model for oncology care is how we identify and give high-intensity care for a short duration and then how we do more remote monitoring of how the patient is doing so we can get back in there again if indeed they have an exacerbation of some of their symptoms.

ASCO Daily News: Is there a patient population that posed more challenges in this program in the trial than others?

Dr. Kathi Mooney: Well, we only had a small number of patients that were bone marrow transplant. But that is a challenging group to work with in terms of their stabilization needs. We also had some acute postsurgical cases that had extenuating circumstances that occur during the hospital at home period. But overall, I don't think one group particularly stands out. It's in being able to be available to monitor patients carefully and then to be able to jump back in when they need additional support.

ASCO Daily News: Right. Well, there are significant costs to staff a hospital at home program. Can you tell us about the payment model challenges that are associated with this model of care?

Dr. Kathi Mooney: Yes. There are significant challenges in the US because most home care is based on a traditional home health model that restricts to several registered nurse visits over a period of time. And that, of course, does not fit at all with an acute care model of care rather than a home care model care.

And so part of our demonstration of the hospital at home concept in oncology is to carefully evaluate and get data so that we can work with payers about alternate payment systems. To make the model sustainable, we can't have a fee for service or a traditional home health model of care.

Our particular Huntsman at home model is led by oncology nurse practitioners. And we also work with a home health agency for registered nurse care. We also have backup by a medical director. And we have other interdisciplinary team members such as physical therapists involved. They work very closely with the patient's ongoing oncology team.

ASCO Daily News: Well, the hospital at home model of care seems especially timely in the era of COVID-19. It was actually introduced in the United States more than 20 years ago but hasn't been widely adopted or tested in the oncology setting specifically. So why do you think it has taken a while for this concept to receive the attention it deserves?

Dr. Kathi Mooney: Well, I think a couple of reasons. One as we just mentioned, the issue of reimbursement, makes it very difficult for a program and oncology center to start it and have adequate reimbursement for it.

But also the model began really out of general hospitals, out of the focus on geriatrics. And therefore, there was a lot of thinking that it may not apply to oncology or cancer centers or cancer programs. And so it was more developed within the geriatric and also for health centers that had a broad number of other kinds of conditions for which they were providing hospital-level care. So it just was not focused on within the oncology community until now.

ASCO Daily News: So what's next for this model of care following the Huntsman at home trial? What are the next steps for you? And how do you see the path forward for this model of care?

Dr. Kathi Mooney: We were very excited about the response we got from the oncology community to the work we've done with Huntsman at home. We've been contacted by a number of people who are interested in learning more. And we hope that based on that that we can involve additional people in evaluating and piloting this new form of care for cancer patients.

We're very interested in continuing to study and advance this model of care. And one of the things being in Utah is the fact that we have many rural communities. And one of the things that the Huntsman Cancer Institute is interested in is how we extend care into communities, rural communities, frontier communities.

So the next thing that we are going to do is to extend the program into three rural counties in Utah. And this will be very interesting and definitely follows up on the idea of how do you provide care and outreach during a pandemic.

And so we will use a lot of telehealth. We'll have home health nurses in the community, so a combination of people on the ground and also telehealth, in order to work with communities around providing better support to cancer patients when they're back in their rural communities. And we hope to decrease the amount of travel that is required to receive high-quality cancer care.

ASCO Daily News: Absolutely. It'll be interesting to see how this concept evolves in a rural setting. Is there anything you'd like to add, Dr. Mooney, before we wrap up the podcast today?

Dr. Kathi Mooney: I would just like to add that this is an exciting concept that I am hopeful that others' programs will consider adopting, piloting, also evaluating. I think we need an movement in oncology to look about how we provide comprehensive care not just here in clinics and hospitals and so how we can establish ourselves in the community by using a combination of telehealth and care within the site to improve the outcomes for cancer patients.

It's been exciting to see how much we can address the problems we have in oncology with rehospitalization and emergency department. And yet for families, it's wonderful to be able to get their care locally and to be able to have support when they're at home.

There is also some interest that we'll see how it develops that has come out of the COVID experience. We haven't specifically done that with the Huntsman at home program yet. But it's also to look about, is there safe chemotherapy that could be given at home and thus not have patients who are vulnerable have to come in to cancer centers or community oncology clinics to provide care?

So there is a great opportunity for us to rethink about how we deliver care and rethink what can be safely done in the home that provides additional support during the cancer experience.

ASCO Daily News: Absolutely. Well, thank you, Dr. Mooney, for sharing your insight with us today on this innovative patient-centered model of care.

Dr. Kathi Mooney: Thank you very much for inviting me.

ASCO Daily News: And thanks to our listeners for joining us today. If you're enjoying the content on the podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.

COI:  Dr. Kathi Mooney

No conflicts of interests 

Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.