At-home Hospital-Level Care May Allow Some Frail Seniors to Remain in Their Homes

By Linda Carroll

April 21, 2021

(Reuters Health) - Hospital-level care provided at home to medically unwell seniors who had received a comprehensive geriatric assessment did not lead to worse outcomes at six months compared with hospitalization, a UK study finds.

In the trial, more 1,000 patients (average age 83) were randomly assigned 2:1 to receive hospital-at-home (HAH) care or to be hospitalized. At the six-month follow-up, 78.6% of participants in the HAH group versus 75.3% of the participants in the group assigned to hospitalization were living at home, while 16.9% of the HAH group and 17.7% of the hospitalized group had died.

Moreover, at follow-up 37 of 646 (5.7%) in the HAH group were in long-term residential care as compared to 27 of 311 (8.7%) of those who had been hospitalized, according to the results published in the Annals of Internal Medicine.

"Hospital-level healthcare in home delivered by a specialist in older people's medicine who works with nurse practitioners and a multi-disciplinary team can create additional capacity by relieving pressure on hospital beds, and provide a suitable alternative to hospital care to a select group of older people," said the study's lead author, Sasha Shepperd, a professor of health services research at the University of Oxford in the UK.

The patients assigned to receive hospital level healthcare at home did not have a healthcare worker living with them, Shepperd said in an email. "Healthcare was delivered as required," she added. "There were at least daily (Monday to Friday) virtual ward rounds and in some cases, these were repeated at the end of the day. A plan of action, visits for the day, investigations and adjustment to the management plans were agreed (upon) at these meetings."

For out-of-hours service, patients had access to the usual National Health Service telephone consultation, Shepperd said. They also had "access to acute hospital-based healthcare, such as diagnostics and transfer to hospital," she added.

To explore the option of hospital-level healthcare delivered at home for seniors, the researchers recruited 1,055 older patients who were medically unwell, physiologically stable, and who had been referred for a hospital admission. The patients had presented with a variety of diagnoses, including COPD, shortness of breath, injuries due to falls, urologic disorders, delirium, and gastrointestinal disorders.

"The group we recruited to the study was a selected sample of older people who were being assessed for a hospital admission, and were not at the extreme end of being acutely ill," Shepperd said. "Almost all the patients could feed themselves, most reported moving independently, and over half reported either requiring help with stairs or being unable to manage stairs. Health care in the home was led by a specialist physician (attending) in older people's medicine, who worked with the nurse practitioners and multi-disciplinary team."

The patients were not required to have a caregiver living with them, Shepperd said. "Patients who lived alone did not routinely have additional monitoring," she noted.

Patients were excluded if they lived in a residential care setting, had an acute coronary syndrome, required an acute surgical assessment, were suspected of having had a stroke, were receiving end-of-life care, declined admission to comprehensive geriatric assessment hospital at home service, or were considered by the clinical staff to be too high-risk for home-based care. Being too high-risk was sometimes a result of having an unsafe home environment, which the authors defined as "one in which a patient with delirium was at risk for falling, the house stairs were too steep or lacked a hand rail, there was no heating or hot water, or there was public health concern due to poor housing conditions."

The findings are most applicable to older people referred from a hospital short-stay acute medical assessment unit, the study authors note. Limitations include that episodes of delirium may have been undetected.

The hospital-at-home model has been tested and has worked in the United States, said John McHugh, an assistant professor of health policy and management at the Columbia University Mailman School of Public Health in New York City.

"I think the hospital-at-home modality continues to show efficacy and I think for patients at the margins it can be used as a tool to keep people safe in the home environment," McHugh said. "I'm struck by the results showing that there was no increased mortality for those at home, and the decrease in long-term residential care, especially after last year with all the issues around nursing homes and COVID-19."

SOURCE: https://bit.ly/3egovFl and https://bit.ly/3uWTZHc Annals of Internal Medicine, online April 19, 2021.

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