At-Home Care
Physicians at the command center review patient
vitals and, depending on their findings, can deploy
X-ray technicians to visit patients at home or con-
nect with other doctors over video chat to assess
patient needs.
Another model, Clinically Home, is based in
Tennessee and was designed in collaboration with
staff at Johns Hopkins. It follows a similar approach:
Staff provide at-home hospital services, such as
managing intravenous (IV) lines and performing
diagnostic tests. 5 Although the model relies heav-
ily on physicians and nurses, doctors do not make
house calls. Instead, they engage with patients – or
with nurses and nurse practitioners making home
visits – through video technology.
“Hem/Onc, I’m Home!”
Home-based care has been implemented in many
disease settings, but Dr. Leff acknowledged that the
list of conditions that qualify for care through the
Hospital at Home program contains few hematology/
oncology diagnoses, and a small portion of patients in
the initial experiences had hematologic disorders.
“One of the more interesting areas of innovation
is the idea of broadening the scope of diagnoses that
are handled through the Hospital at Home program,
as well as broadening the use cases for Hospital at
Home,” he said.
“[At-home treatment]
has become much
more mainstream
because at-home
management of
DVT is easier and
involves less hassle
[than hospital-based
care].”
—MICHAEL STREIFF, MD
The transition to at-home care has already begun
in certain areas of hematology, and one of the most
substantial shifts in care has occurred in the care of
patients with DVT.
Home-based treatment of DVT appears to offer
substantial advantages over in-hospital treatment,
according to a meta-analysis of seven trials compar-
ing outcomes of patients who received initial treat-
ment with low-molecular-weight heparin at home
with those who received unfractionated heparin in
the hospital. 6 There were no statistically significant
differences between the groups for major bleeding,
minor bleeding, or mortality, but patients treated at
home were less likely to experience a recurrence of
DVT (relative risk = 0.58; p=0.007).
The availability of DOACs also has made more
patients eligible for home treatment of DVT.
“With the advent of these agents, [at-home treat-
ment] has become much more mainstream because
at-home management of DVT is easier and involves
48
ASH Clinical News
less hassle [than hospital-based care],” said Michael
Streiff, MD, a professor of medicine and pathology
at Johns Hopkins.
He also noted that DVT was an ideal candidate
for at-home management because it did not require
a major shift in how care is administered: Typically, a
DVT is diagnosed in a doctor’s office using a duplex
ultrasound. After receiving a prescription for a
DOAC, patients are sent home and scheduled for later
follow-up with their doctor.
While home treatment is becoming the norm
for patients diagnosed with DVT, Dr. Streiff noted
two exceptions to this rule: patients with extensive
clots that are causing significant pain or those who
need advanced therapies (such catheter-directed
thromboylysis or surgical thrombectomy) to remove
the clot and require hospitalization. “Hospitals are
great places if you are critically ill and require close
monitoring, but for patients who are not critically ill,
it is much better to be at home,” he said, adding that
hospitals can often be “petri dishes” of germs and
bacteria.
Researchers also are looking at other areas where
home-based treatment would be reasonable – and
preferable, in some cases, including for patients with
low-risk pulmonary embolism (PE). While U.S.
patients and practitioners readily embraced at-home
management of DVT, they have been slower to
warm up to at-home management of PE, Dr. Streiff
commented.
“In Canada and Europe, PE is managed more
frequently in the outpatient setting, but we take a
more conservative approach in the U.S.,” he said.
Home-based management of blood clots is being
addressed in the American Society of Hematology’s
(ASH’s) upcoming guidelines for the treatment of
venous thromboembolism. At the time of publication,
this chapter of the guidelines was not yet publicly
available, but, according to Kendall Alexander,
manager of practice guidelines in ASH’s Quality
Improvement Programs department, the recommen-
dations will provide guidance about which patients
should receive at-home or in-hospital treatment
based on disease severity, patient history, and patient
preference. ASH also is creating guidelines for the
management of immune thrombocytopenia, with
expected publication at the end of 2019, that will ad-
dress at-home care options and considerations.
Sickle cell disease (SCD) is another area of
exploration for at-home treatment. Adopting
a home-based treatment model would overcome
one of the largest barriers to treatment for the SCD
population: transportation.
Many patients do not live close to a specialized
SCD center and instead may seek treatment for
SCD-related complications at an emergency de-
partment. “By providing some of these services at
home, practitioners have reported fewer missed
appointments and are able to offer better care,” said
Ifeyinwa Osunkwo, MD, MPH, director of SCD
Enterprise at the Levine Cancer Institute/Atrium
Health in Chapel Hill, North Carolina.
In this home-based program, staff identify
patients who live far from the clinic and may have
difficulty traveling to the center for care. The program
also was designed to lessen the burden on overloaded
staff: Physicians follow up through virtual house calls,
while nurse practitioners and emergency medical
technicians are recruited to visit patients to perform
basic assessments or check vital signs.
Patients with cancer have also started to receive
therapy in the comfort of their own homes – if
not for treatment of the malignancy itself, then for
management of adverse events that can occur during
treatment.
One such target is febrile neutropenia. While the
condition typically has been treated in the emergency
department followed by an inpatient stay, recent
evidence suggested that low-risk patients with febrile
neutropenia can be safely treated with oral antibiotics
and discharged. In a review of three studies, the
proportion of patients who were re-admitted to the
hospital after discharge ranged from 17 to 21 percent,
and the mortality rate ranged from 0 to 4 percent.
“Low-risk” factors in the studies included living near
the hospital, having a caregiver living in the home,
and having a temperature lower than 100.3 degrees; a
diagnosis of a hematologic malignancy was consid-
ered a low-risk exclusion criterion. 7
“Treatment outcomes of low-risk febrile neutro-
penic patients in the inpatient and outpatient setting
are comparable,” the authors concluded.
At-Home Stem-Cell Transplants?
HCT is a demanding undertaking that, while extend-
ing patients’ survival, also disrupts their lives. Patients
undergoing an HCT spend four weeks or even longer
in the hospital. Patients often undergo immunosup-
pression before and after the procedure, so they are
placed under strict isolation protocols while in the
hospital and after discharge.
“Over time, the medical community has become
aware that hospitals aren’t the cleanest of environ-
ments,” said Anthony Sung, MD, an assistant
professor of medicine at Duke University School of
Medicine in Durham, North Carolina.
This realization led to the emergence of “day
hospitals,” or outpatient facilities where patients
can receive treatment or undergo assessment and
then return home each night. Keeping the patient
at home also decreases risks of other complications
related to lengthy hospital stays, like delirium, inac-
tivity, poor diet, and hospital-acquired infections.
In an initial, small phase I study, Dr. Sung and
colleagues evaluated the complications, effects on
quality of life, and resource use associated with
at-home HCT. 8 To be eligible for the trial, patients
had to live within a 30-minute drive of a transplant
center and have a suitable living environment that
passed a home inspection (free from black mold,
fall risks, etc.). Participants followed the normal
pretransplant procedures and received conditioning
at the hospital or day hospital, then were discharged
after receiving their stem cell infusion.
Per study protocol, nurse practitioners or
physician assistants made house calls each morn-
ing to conduct assessments, examine patients, and
draw blood for laboratory studies. Another nurse
would return in the afternoon to provide IV fluids,
electrolytes, or antibiotics or to perform home blood
transfusions or other interventions as necessary.
Complications from the HCT were managed in
the home as much as possible, but patients returned
to the clinic for treatment of events like febrile
neutropenia and for routine procedures like IV
administration of methotrexate for graft-versus-
host disease prophylaxis. As a preventive measure,
patients received their first post-HCT blood transfu-
sion in the day hospital.
Twenty-two patients were involved in the study.
Those who received allogeneic HCT were able to
spend 72 percent of their days entirely at home,
May 2019