Hospital-at-Home Care Improved Outcomes, Patient Satisfaction

Tara Haelle

June 26, 2018

Patients receiving a new model of hospital-at-home (HaH) care had better outcomes, greater satisfaction, and no increased rate of adverse events compared with similar patients who received traditional inpatient care, a study has found.

Length of inpatient care stay, readmission rates, and emergency department revisits were nearly half as high in the HaH group compared with traditional inpatient care, the researchers write.

Alex D. Federman, MD, MPH, from the Icahn School of Medicine at Mount Sinai in New York City, and colleagues published their findings online June 25 in JAMA Internal Medicine. The study was limited, however, by its observational nature and its potential for selection bias.

The new model combined HaH care (acute hospital-level care in the patient's home instead of the hospital) with 30 days of transitional care after the acute event. The researchers estimate a cost savings of 19% to 38%.

They compared outcomes among 507 adult Medicare patients who had an acute medical illness requiring inpatient care between November 2014 and August 2017. The patients came from one of two New York City emergency departments or from home or physician referrals in the area.

The patients' average age was 74.6 years, and 68.6% were women. The only notable differences between the two groups was that those in the HaH group tended to be older and more often had a functional impairment before the acute event.

All the patients qualified for HaH care, and 295 chose it; the remaining 212 turned it down or required care in the emergency department when HaH intake was not available.

In addition, the study excluded patients who were "clinically unstable, needed required cardiac monitoring or intensive care, lived in an unsafe home environment, or resided outside of Manhattan," the authors explain.

HaH care involved a physician or nurse practitioner providing acute care services at the patient's home, including exam, vital signs, illness monitoring, intravenous fluids, wound care, and patient education. A nurse visited the patient at least once a day, and a physician or nurse practitioner visited in person or by video call at least once a day. Necessary equipment was brought to the home, and a social worker made at least one house call per patient.

Significantly Shorter Length of Stay

During 30 days of follow-up after the acute episode, HaH patients had an average 3.2 days of acute inpatient care compared with 5.5 days among those who received traditional inpatient care. The 2.3-day difference in length of stay was statistically significant (95% confidence interval [CI], 1.8-2.7 days; weighted P < .001).

HaH patients also had nearly half the rate of readmissions and emergency department revisits as the control inpatients. HaH patients had an 8.6% readmission rate compared with 15.6% in control inpatients, and 5.8% of HaH patients visited the emergency department again compared with 11.7% of control inpatients (weighted P < .001).

Admissions to skilled nursing care were substantially lower in HaH patients (1.7%) compared with inpatients (10.4%). No significant difference existed between the groups in home health agency referrals or adverse events. Urinary catheter insertion rates were low in both groups but higher in the HaH group.

HaH patients were also happier with their care. More than half (68.6%) rated their hospital care highly compared with 45.3% of inpatients. However, they rated pain management care lower than control patients.

"Some features of the HaH model, such as fewer opportunities to titrate pain medications and more physical activity by patients in their homes, may challenge pain control," the authors write.

This study's findings match those of several past HaH randomized controlled trials and other studies, "which demonstrated positive effects of HaH care on readmissions, mortality rates, costs, and patient and caregiver experiences," the authors write.

This study is larger and included a broader range of admitting diagnoses (19 in total) than previous studies.

"Providing hospital-level care for a broad set of clinical diagnoses enhances value for health care systems and patients because of the flexibility to treat more patients," the authors write. Further, this study's HaH program "bundled a 30-day postacute period of home-based transitional care with the acute care episode to improve care coordination, facilitate access, enhance postacute illness self-management, and reduce 30-day readmission rates," they add.

Selection bias, however, may have affected the results, as noted in an accompanying commentary by Joshua M. Liao, MD, MSc, from the University of Washington School of Medicine in Seattle, and colleagues.

"The challenge of valid controls may arise from the fact that the program selected patients in part based on patient preferences, which could be highly correlated with study outcomes," they write. "For example, patients who preferred traditional hospitalization rather than HaH services may have had less social support, thereby increasing their likelihood of requiring readmission or referral to skilled nursing facilities."

They also note clinical differences between the groups, such as more frequent urinary tract infection in the HaH group and more frequent congestive heart failure in the control group.

"These 2 conditions can have very different trajectories, management strategies, and care utilization patterns in the acute and postacute settings," write the editorialists.

Before widespread HaH programs are implemented, quality and safety considerations mandate that standards and requirements be developed that are comparable to those in traditional hospitals, they add. Further, "any bundled payment for HaH care should account specifically for potential unintended consequences," they write.

They also point out the need to design a truly bundled HaH payment model (reimbursements were not fully bundled in this study) and coordinate those payments with other programs. Liao and colleagues recommend a "rigorous test of the HaH-Plus payment model in select conditions" that address the aforementioned considerations before wide scale implementation. "A test of HaH-Plus should also include private payers to elucidate the applicability of HaH care to a broader patient population and to align incentives across payers," they add.

The research was funded by the US Department of Health and Human Services, Centers for Medicare & Medicaid Services, National Institute on Aging, Claude D. Pepper Older Americans Independence Center, and The John A. Hartford Foundation. One coauthor previously worked at the Centers for Medicare & Medicaid Services, but not in the program described in the study. Another coauthor has received fees from Navvis & Company, Navigant Inc, Lynx Medical, Indegene Inc, and Sutherland Global Services as well as fees and equity from Nava Health. He reports a past grant from Oscar Health. The remaining authors have disclosed no relevant financial relationships.

JAMA Internal Med. Published online June 25, 2018. Article full text, Commentary full text

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