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Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients
- Bruce Leff, MD;
- Lynda Burton, ScD;
- Scott L. Mader, MD;
- Bruce Naughton, MD;
- Jeffrey Burl, MD;
- Sharon K. Inouye, MD, MPH;
- William B. Greenough III, MD;
- Susan Guido, RN;
- Christopher Langston, PhD;
- Kevin D. Frick, PhD;
- Donald Steinwachs, PhD; and
- John R. Burton, MD
- 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.
Abstract
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.
Article and Author Information
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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.
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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.
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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.
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Potential Financial Conflicts of Interest: None disclosed.
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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.
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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.
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Drs. Burton, Frick, and Steinwachs: Johns Hopkins University Bloomberg School of Public Health, Hampton House, 624 North Broadway, Baltimore, MD 21205.
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Dr. Mader: P.O. Box 1035 (V-9-DIR), Portland Veterans Administration Medical Center, Portland, OR 97207.
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Dr. Naughton: State University of New York, Buffalo, 100 High Street, Buffalo, NY 14203.
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Dr. Burl: Fallon Clinic, 10 Chestnut Street, Worcester, MA 01609.
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Dr. Inouye: Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, 1200 Centre Street, Boston, MA 02131.
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Dr. Langston: 125 Park Avenue, New York, NY 10017.
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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.
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Analysis and interpretation of the data: B. Leff, L. Burton, S.K. Inouye, C. Langston, K.D. Frick, D. Steinwachs, J.R. Burton.
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Drafting of the article: B. Leff, L. Burton, B. Naughton, K.D. Frick.
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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.
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Final approval of the article: B. Leff, L. Burton, B. Naughton, S.K. Inouye, W.B. Greenough, D. Steinwachs, J.R. Burton.
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Provision of study materials or patients: S.L. Mader, B. Naughton, J. Burl, W.B. Greenough.
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Obtaining of funding: B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, J.R. Burton.
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Administrative, technical, or logistic support: B. Leff, L. Burton, B. Naughton, S.K. Inouye, J.R. Burton.
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Collection and assembly of data: B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, S. Guido.
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