Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients

6 December 2005 | Volume 143 Issue 11 | Pages 798-808

Background: Acutely ill older persons often experience adverse events when cared for in the acute care hospital.

Objective: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home.

Design: Prospective quasi-experiment.

Setting: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center.

Participants: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis.

Intervention: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital.

Measurements: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care.

Results: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care ($5081 vs. $7480) (P < 0.001).

Limitations: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences.

Conclusions: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.

Editors' Notes Context Hospital care for older people often means iatrogenic complications and a decline in function. Home hospital care might reduce these adverse outcomes. Content Patients were 65 years of age or older and required hospital care for pneumonia, heart failure, chronic obstructive pulmonary disease, or cellulitis. In phase I, they were hospitalized. In phase II, they could choose home hospital care (continuous nursing care followed by at least daily visits from a nurse and a physician). Sixty percent of patients chose home hospital care. Patients who received this type of care had shorter stays; fewer procedures, consultations, and indwelling devices; less delirium; greater satisfaction; and similar functional outcomes. Cautions The study was nonrandomized, and data were missing. Conclusion Home hospital care may be a good alternative for selected patients. —The Editors

 

Author and Article Information

From Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, and The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Portland Veterans Administration Medical Center and Oregon Health & Science University, Portland, Oregon; State University of New York, Independent Health, and Univera Health, Buffalo, New York; Fallon Community Health Plan and Fallon Clinic, Worcester, Massachusetts; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and The John A. Hartford Foundation, New York, New York.

Note: Portions of this work have been presented at meetings of the American Geriatrics Society, May 2001, 2003, 2004; the Gerontological Society of America, November 2002, November 2003; and the American Academy of Home Care Physicians, May 2005.

Acknowledgments: The authors thank the following people without whom the study would not have been possible: Nurse Study Coordinators: Maggie Donius, Susan Saltzman, Christine Delano; Delirium Data Coordinators and other site personnel: Kristine Noonan, Lana McBride, Kathleen Chapman, Richard Harper, Wendy Wanlass, Carol Joseph, Nora Tobin, Jim Jackson, Joyce Holohan-Bell, Kay Schecter, Carol Baird, Sandie Taylor, Cleo Scribner, Kay Jenkins, Candace LaBlanc, Marcia Kirkpatrick, Diane Davies; Annette Hopkins for Confusion Assessment Method training and data review; Coordinating Center Data Safety Monitoring Board members: Anne Perkins, Knight Steel, George Taler, Stephanie Wilmer; Becky Clark for data management; Charles Rohde for advice on statistical methods; Curtis Meinert for advice on study design; Leslie Odendhal for coordinating center activities and manuscript preparation; Donna Regenstreif for her initial vision of the hospital at home; The John A. Hartford Foundation of New York for their ongoing support; Ronald Peterson for his support of hospital-at-home development at Johns Hopkins; and the patients, family members, and caregivers who participated in the study.

Grant Support: By a grant from the John A. Hartford Foundation of New York, grant no. 98309-G, and supplemented by the Portland Oregon Veterans Administration Medical Center by a Department of Veterans Affairs New Clinical Initiative Program grant no. 99-027. Dr. Inouye was supported, in part, by grant no. K24AG00949 from the National Institute on Aging.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Bruce Leff, MD, John Hopkins Bayview Medical Center, The Johns Hopkins Care Center, John R. Burton Pavilion, 5505 Hopkins Bayview Circle, Baltimore, MD 21224; e-mail, bleff{at}jhmi.edu; Web site, http://www.hospitalathome.org.

Current Author Addresses: Drs. Leff, Greenough, and Burton and Ms. Guido: Johns Hopkins Bayview Medical Center, The Johns Hopkins Care Center, John R. Burton Pavilion, 5505 Hopkins Bayview Circle, Baltimore, MD 21224.

Drs. Burton, Frick, and Steinwachs: Johns Hopkins University Bloomberg School of Public Health, Hampton House, 624 North Broadway, Baltimore, MD 21205.

Dr. Mader: P.O. Box 1035 (V-9-DIR), Portland Veterans Administration Medical Center, Portland, OR 97207.

Dr. Naughton: State University of New York, Buffalo, 100 High Street, Buffalo, NY 14203.

Dr. Burl: Fallon Clinic, 10 Chestnut Street, Worcester, MA 01609.

Dr. Inouye: Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, 1200 Centre Street, Boston, MA 02131.

Dr. Langston: 125 Park Avenue, New York, NY 10017.

Author Contributions: Conception and design: B. Leff, L. Burton, B. Naughton, W.B. Greenough, S. Guido, C. Langston, K.D. Frick, D. Steinwachs, J.R. Burton.

Analysis and interpretation of the data: B. Leff, L. Burton, S.K. Inouye, C. Langston, K.D. Frick, D. Steinwachs, J.R. Burton.

Drafting of the article: B. Leff, L. Burton, B. Naughton, K.D. Frick.

Critical revision of the article for important intellectual content: B. Leff, L. Burton, S.L. Mader, S.K. Inouye, W.B. Greenough, C. Langston, K.D. Frick, J.R. Burton.

Final approval of the article: B. Leff, L. Burton, B. Naughton, S.K. Inouye, W.B. Greenough, D. Steinwachs, J.R. Burton.

Provision of study materials or patients: S.L. Mader, B. Naughton, J. Burl, W.B. Greenough.

Obtaining of funding: B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, J.R. Burton.

Administrative, technical, or logistic support: B. Leff, L. Burton, B. Naughton, S.K. Inouye, J.R. Burton.

Collection and assembly of data: B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, S. Guido.

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