When Cissy Gai began to feel unwell one day last month and her fever rose, she realized that she had no choice but to get to the emergency room. “I’m an oncology patient in treatment, and they explained to me that the moment my fever goes up I have to rush to the emergency room,” explains 62-year-old Gai, who lives in the Haifa suburb of Kiryat Bialik.
What awaited her there was worse than anything she had read about in the media. “We were there for hours and hours with all the sick people. My immune system is weak and I have to be in a sterile environment. At some point I lay down on the floor because I felt so ill that I was incapable of sitting on the chair, and I thought to myself – now I’m going to die.”
In the end, after many hours, it was decided to hospitalize her, but there was no vacancy in the oncology or internal medicine wards, and so Gai found herself in the corridor. “Towards morning they brought me to one of the internal medicine wards on a bed in the corridor. My daughter and I simply sat and cried like little girls. I told her: “I want to be home. I have no bathroom, I have no shower, I have no room. I don’t belong anywhere. I’m outside.”
She was rescued the following morning, in an unexpected way. “I signed a paper that I was switching to home hospitalization and went home in a taxi, where a doctor was already waiting for me. This provides me with a solution in my own home. What more do I get in the hospital than here? A doctor visits me once a day, I receive the medications, everything is organized, so why lie there with all the infections? It’s a brilliant solution.”
Gai was one of the first 280 patients in a project being conducted by the Maccabi health maintenance organization together with Sabar Health, and in cooperation with hospitals, to move patients from the crowded wards to internal medicine hospitalization at home. This concept has recently become the hottest topic of discussion in the search for solutions to the collapsing hospitalization system and soaring health costs.
Last month Finance Minister Moshe Kahlon announced that he would not join the next government unless home hospitalization, which replaces hospitalization in the internal medicine wards, increases at least ten-fold, from about 200 beds at present to 2,000 beds. Kahlon explained that home hospitalization prevents infections, returns the patients to the community, costs half the price of hospitalization in the wards or less, and is therefore the next revolution that he is planning.
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“Without revolutions it’s impossible to progress,” declared Kahlon. “During our next term in office we don’t intend to go the same way as everyone, because if we behave like them your grandmother will continue to sleep in the corridor.”
Kahlon is calling attention to a subject that has recently been increasingly on the healthcare agenda: A few months ago the Health Ministry launched a program that encourages the healthcare services, by means of monetary incentives, to increase and improve home hospitalization, and for the first time sets the required standard for such hospitalization. As of now, all the HMOs and several hospitals are in various stages of preparation for expanding home hospitalization.
What is the meaning of home hospitalization? There are various types of home care that have been offered by HMOs for years – for example in the field of palliative medicine (a home hospice that enables a dying person to remain in his home with supportive treatment, sometimes until the day he dies), home visits by doctors and nurses for the purpose of administering nutrition and medicines, and home rehabilitation.
Calanit Kay, the head of nursing in the community at Clalit Health Services, says that historically, home hospitalization in Israel began due to an urgent need created as a result of the Yom Kippur War: “During the war they had to release patients quickly in order to make room for the many wounded. Clalit organized quickly and in the 1970s the first continuing care units were established. The main purpose was to provide a home solution for people who still needed to be hospitalized.”
But the internal medicine home hospitalization, to which Kahlon is referring and which Gai experienced, is an upgrade in the area of home treatments: This is a total and complete substitute for hospitalization in the internal medicine ward – using the patient’s home instead of a bed in the ward.
Home hospitalization includes full medical coverage 24 hours a day, which is similar to the treatment administered in the ward: a daily visit by a doctor and a nurse, providing all the medications that the patient needs, blood tests and intravenous medication, and in the future even x-rays and ultrasounds at home. The HMO also places a medical hotline that is manned around the clock at the disposal of home patients.
“Being hospitalized today in an internal medicine ward is on the verge of something terrible. It borders on a lack of human dignity, a lack of compassion,” says Maccabi CEO Ran Saar, the man responsible for the health of two million Israelis. “It’s not because the staffs don’t want to provide service or that they lack compassion,” he says, “but because the situation in the internal medicine wards is such that people are normally hospitalized – not only in winter – in the corridors, in the kitchens, in the storage rooms.
“I spoke to a dermatologist who works with Maccabi and he told me how terrible it is to examine a patient in the corridor. He is forced to undress a man or a woman in the corridor in order to see their skin – it’s terrible, it’s humiliating. And at the same time a cart passes and bumps into the bed, and then there is the light, and the noise. All that leads to staff burnout. It’s very hard for them, and it’s entirely clear that ending up in the internal medicine ward is not advisable – unless it’s really essential.”
The patients who are sent to home hospitalization are those who suffer from infectious diseases such as urinary tract infections or pneumonia, chronic illnesses such as cardiac or respiratory diseases, and patients with metabolic problems who mainly need the supervision of a medical team and intravenous treatment. In short – most of the target population of the internal medicine ward.
Saar recounts that he did everything possible to make sure that his parents wouldn’t be hosptalized in the internal medicine ward. “My mother had very complex medical problems for eight years, with arrythmia, diabetes, epileptic seizures and a host of other problems,” he says. “She was small and fragile, weighed only 45 kilograms [99 pounds], and wasn’t hospitalized for a single day.
“Throughout those years she went to the emergency room twice when I was out of town, and then I arrived in the emergency room and took her out. I would tell her ‘Joke with your doctors’ so that they would see she was all right, and then I would get her out of there. At night I would bring a doctor and inject her with a sedative, and that’s it. I actually practiced independent home hospitalization.”
Who are the 280 Israelis who have already participated in the project, and were hospitalized at home? They are aged 20 to 93, more than 70% are over 65, and the leading causes for hospitalization are skin infections, pneumonia, urinary tract infections and heart failure. The results reported by Maccabi are impressive: The average number of home hospitalization days was 6.3, compared to a nationwide figure of 6.4 days in hospitals, and the number of repeat hospitalizations, which is considered an index of failure, is significantly lower. Only 4% of those hospitalized at home required repeat hospitalization within a week, compared to a nationwide figure of 8% in hospitals; 13% required repeat hospitalization within 30 days, compared to 20 percent in hospitals.
Patients prefer home
The satisfaction of those hospitalized at home is also high. In a survey, about 80% expressed great or very great satisfaction. In addition, Maccabi reports that 90% of their clients who were offered home hospitalization instead of going to the hospital consented; in other words, there is great demand for the home solution.
The big question is whether this experiment, as successful as it may be, can grow into a national project of sufficient scope to affect the hospitalization problem and save money for the system. Saar is convinced that it can: “The potential is enormous because we know that 30% of those hospitalized in the internal medicine wards don’t have to be there. It’s entirely clear that a significant percentage of them can be hospitalized at home, or be discharged from the hospital after a day or two. We’re just starting out, but it’s clear to me that within a few years it will be very significant.”
Dr. Itamar Offer, CEO of Sabar Health, which has been involved in various types of home care and hospitalization for many years and operates the project with Maccabi, is convinced that home hospitalization can account for a fifth of the beds in the system within only three years. “Home hospitalization can enter the mainstream and become the form of hospitalization for 20% of the patients who are now in internal medicine wards, within three years,” he says. “There are about 4,000 beds in the wards in Israel, so that 800-900 people could be hospitalized at home at any given moment – about 60,000 people a year.”
According to Offer, “There’s no need to bring architects to build the hospital under discussion in Be’er Sheva in order to solve the problem of the internal medicine wards. We can open an internal medicine ward in Be’er Sheva in the patients’ homes within two months, and the new hospital will start out as a hospital that begins from the home. It’s a matter of perception: When they actually build the hospital in Be’er Sheva it will be directed towards intensive care, surgery, and things for which you really need a hospital.”
The advantages of home hospitalization are numerous: convenience, reduction of infections and patients’ preference for remaining at home during an acute illness. But what is really likely to encourage the HMOs and the entire system to develop home hospitalization is the financial savings. As Kahlon stresses, home hospitalization is far less expensive.
“A hospital is an expensive place,” says Offer. “You only start the year and already there are tens of millions of shekels of fixed expenditures. At home we deal almost solely with clinical work – treating the patients, training the staffs and staff meetings. There aren’t expenses that exist in the hospital, such as training students, inventory for times of emergency, or property tax and support staff. And there’s future savings as well: The moment you lower the percentage of repeat hospitalizations, the HMO saves a great deal of money.”
How much money do the healthcare services save with home hospitalization? The rates of Sabar and its agreements with the services are confidential, but the sums are quite clear: The price of a day of hospitalization that Sabar collects from the HMOs is tens of percentage points lower than the list price of hospitalization in the internal medicine ward - 2,240 shekels ($620). The healthcare services actually pay less than the list prices in the hospitals as well.
In addition, under the Health Ministry program, the healthcare services receive a refund of about 1,250 shekels a day for every person hospitalized at home, with a larger incentive for elderly patients and those in communities in outlying areas. The bottom line is that home hospitalization is substantially cheaper both for the HMOs and for the entire system compared to hospitals.
Choosing the right patients
Before we transfer the entire healthcare system from the hospital to the home, it’s worth noting that this is not a magical solution. For the move to work it must target the right patients – not those who are so ill that they are likely to deteriorate quickly and to require resuscitation or intensive care, and not those who are “too healthy” and not really in need of hospitalization in the first place.
“It’s a challenge to choose the right patients,” says Dr. Vered Ezra, head of the medical administration in the Health Ministry. “Since home hospitalizations in Israel are a new and developing field, at this stage we have defined when it’s inappropriate: in situations where there is a fear of respiratory failure, patients in need of intensive care, patients who have had a stroke and need intensive intervention, cardiac events – all these are conditions that require the acute care provided by the hospital and are not suitable for home hospitalization.”
So at the moment you’re choosing the healthier and stronger patients?
“Not at all, on the contrary,” says Ezra. “A significant percentage of the patients are elderly or have dementia, meaning the harm and suffering caused by hospitalization is far greater. Of those over 70 who are hospitalized, 41% develop functional deterioration due to deficient nutrition, irregular bowel movements and an absence of movement. As long as we believe that the service is right for a certain person, we aren’t deterred by a long list of illnesses, or by social or psychosocial complexity. Actually the people who have slight mental health problems are those who suffer most if they are removed from their framework.”
The other criteria needed for home hospitalization to work is the presence of a companion, usually a family member, who is at home with the person receiving treatment 24 hours a day. That’s an essential condition for home hospitalization – and also the greatest obstacle for many. “It’s not suitable for everyone,” explains Ezra. “In terms of the family’s ability to function, and also in terms of what there is in the house, whether the house is sufficiently accessible, whether there’s someone who will cook the patient’s meals, and even whether the elderly person has heating at home.”
Cissy Gai is still hospitalized at home. But there’s no question that she was saved by avoiding the hospital. “I’m disappointed with the healthcare system in Israel – it has collapsed and will continue to collapse. It’s unacceptable for a cancer patient to lie in the corridor and be in the emergency room together with so many patients who [have diseases that are] contagious. It’s not sensible. It’s more than humiliating. For patients like me, who can avoid bacteria and who can be spared the suffering - it’s a life saver.”