Improving Patient Care
6 December 2005

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

Publication: Annals of Internal Medicine
Volume 143, Number 11

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.

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Comments

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Jeremy M Jacobs 13 December 2005
Home Hospitalization: 15 years of experience.

To the Editor, We read with interest the report of Leff et al (1). Shorter length of stay, fewer medical complications, greater patient satisfaction and reduced cost are important additions to the mosaic of evidence supporting hospital at home (HH). They are also findings common to the Jerusalem Home Hospital program which, since initiation in 1991, has treated over 13,000 patients with intensive medical, sub-acute and palliative care at home instead of in hospital. We previously reported that decreased hospital utilization was attributable to the establishment of our home hospital service (2, 3).

Recent data confirmed these findings. When the chief HMO administrator cut HH spending by 60% (a reduction from 400 to 150 patients treated simultaneously), the opportunity arose to monitor the impact of withdrawing HH on geriatric and medical hospitalization rates. An analysis of the 45,000 target population of HMO beneficiaries over 65, showed that per capita in patient days (and spending) rose rapidly in the 12 months following HH cuts- far in excess of forecasts based on previous trends. Hospital days in medical wards increased by 7.2% in contrast to a projected decline of 2.9%, and days in geriatric wards increased by 16.9% as opposed to a forecasted rise of 4.4%. Our experience of a large, readily available HH service showed dramatic health spending repercussions at the macro level, and based on these data HH budget was reallocated to previous levels.

The criticism by Shepperd (4) cites the recent Cochrane review (5), however the models of HH varied and were not exclusively substitutive for inpatient care, thus dampening the effects of the intensive HH models. Shepperd addresses the difficulties of comparing and generalizing findings from different health care systems. However whilst structure of health service provision is fundamental in understanding health care delivery, it is but the context in which treatment modalities are provided. Successful treatment by HH is a robust finding which transcends health care structure. Finally the overwhelming majority of published literature supports either reduced overall spending or no overall difference. This is important since even in scenarios where savings were absent, HH did not incur greater costs than inpatient hospital care.

Beyond the medical and economic issues yet to be resolved is the resounding confirmation of those exposed to HH as either patients or health care professionals: HH is highly desirable and represents a uniquely humane face of modern medicine.

References

1. Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143:798-808.

2. Stessman J, Ginsberg G, Hammerman-Rozenberg R, Friedman R, Ronen D, Israeli A, et al. Decreased hospital utilization by older adults attributable to a home hospitalization program. J Am Geriatr Soc. 1996;44:591-8.

3. Maaravi Y, Cohen A, Hammerman-Rozenberg R, Stessman J. Home Hospitalization. J Am Med Dir Assoc. 2002; 3 (2): 114-8.

4. Shepperd S. Hospital at home: the evidence is not compelling. Ann Intern Med. 2005;143:840-1.

5. Shepperd S, Iliffe S. Hospital at home versus inpatient hospital care. (Review). The Cochrane Database of Systematic Reviews. 2005.

Conflict of Interest:

None declared

Jeffrey I. Farber 17 January 2006
Never ignore a tip from the jockey

Leff et al's feasibility study of a substitutive hospital at home model for older adults (Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients), compares two groups in a pre-post design: the observation group who met criteria for admission to the program the year prior to the program's existence, and the intervention group, those who met criteria the next year. The intervention group consisted of 3 subgroups: those who were treated with the program (n=84), those who were offered and refused (N=57), and those who were never offered because the program was not accepting patients at that time of day (N=73). Using an intention to treat analysis, while including all patients who met criteria and consented, effectively results in comparing apples with apples- since 61% of the intervention group received their care in hospital. This makes it much more difficult to show either benefit or harm from the intervention. Alongside the ITT analysis, it would be nice to see a per protocol analysis showing how the 84 older adults who received hospital at home care fared in comparison to the 130 subjects who were treated contemporaneously in the acute care hospital. Additionally, it would be helpful to understand the differences between the subjects who chose to be treated in the home program and those who chose hospital treatment. A mentor once told me to never ignore a tip from the jockey. In the end, some patients will prefer hospital at home care and others will not. We would be wise to heed the jockey's tip!

Conflict of Interest:

None declared

Francisco Rosell 18 January 2006
Hospital at Home. Economic impact of readmissions.

Dr Leff and cols have recently published a very interesting paper relating to the improvement of the patients' care during their admission at a Hospital at Home Unit (1).

Hospital at Home Unit provides the opportunity to make an educative intervention at patients' home. Educative intervention is a main step in the development of Disease Management Programs. There is a general agreement about how an educative intervention, with independence of its intensity, decreases readmissions of patients with chronic diseases. Literature reports the positive economic impact of the establishment of Disease Management Programs, specially when dealing with chronic heart failure (CHD) and pluripathologic patients, and their potencial to produce a positive return on investment from them (2).

Our experience switching Hospital at Home Unit and Disease Management Programs dates from eight years ago. The nexus point between both should be the educative home intervention during the patient admission at Hospital at Home. This home-based intervention and their persistence for years after its stablishment is also reported by other authors (3).

A domiciliary intervention because of a decompensation of a chronic disease while the patient is being attended at home by a multidisciplinary team has the advantage of a greater reception by patients and their families. We have demonstrated this fact with an educative intervention in CHD (4) and chronic obstructive pulmonary disease. As a final output we reported that the taxes of readmission and the visits to an Emergency Department were dropped spectacularly.

So, there's no doubt that Disease Manage Programs and Educative Domiciliary Interventions have a notable impact in the number of readmissions, and as a consequence, in the economic outputs. In our opinion, when evaluating cost-efficiency of alternative care services (such as Hospital at Home Units) specially addressed to elderly people with acute exacerbations of chronic diseases, the decrease of readmissions due to an educational intervention should be taken into account.

References

1.Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143:798-808.

2.Goetzel RZ,Ozminkowski RJ,Villagra VG, Duffy J. Return on investment in disease management:a review. Health Care Financing Review. 2005;26:1-19.

3.Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation. 2002;105:2861-2866.

4.Morcillo C, Valderas JM, Aguado O, Delás J, Sort D, Pujadas R, Rosell F. Evaluación de una intervención domiciliaria en pacientes con insuficiencia cardíaca. Resultados de un estudio aleatorizado. Rev Esp Cardiol.2005;58:618-625.

Conflict of Interest:

None declared

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 143Number 116 December 2005
Pages: 798 - 808

History

Published online: 6 December 2005
Published in issue: 6 December 2005

Keywords

Authors

Affiliations

Bruce Leff, 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.
Lynda Burton, ScD
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.
Scott L. Mader, 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.
Bruce Naughton, 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.
Jeffrey Burl, 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.
Sharon K. Inouye, MD, MPH
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.
William B. Greenough III, 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.
Susan Guido, RN
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.
Christopher Langston, PhD
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.
Kevin D. Frick, PhD
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.
Donald Steinwachs, PhD
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.
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.
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.
Disclosures: None disclosed.
Corresponding Author: 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, [email protected]; Web site, 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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Bruce Leff, Lynda Burton, Scott L. Mader, et al. Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients. Ann Intern Med.2005;143:798-808. [Epub 6 December 2005]. doi:10.7326/0003-4819-143-11-200512060-00008

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