Abstract and Introduction
Background: Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited.
Methods: We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients.
Results: The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46–3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (−17.9%, 95% CI −31.0% to −1.0%; p = 0.001; number needed to treat 6, 95% CI 3–100). There were no significant differences in quality of life (1.25, 95% CI −0.39–2.89, p = 0.13), symptom burden (−1.92, 95% CI −5.22–1.37, p = 0.25) or ED visits (1.2%, 95% CI −10.5%–12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001).
Conclusion: HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination.
Over 2 million Americans 65 years and older are homebound, and live with high levels of multimorbidity, physical and cognitive impairment, and socioeconomic vulnerabilities that place them at risk for poor outcomes, including hospitalizations rates that are over three-times that of non-homebound older adults. Their risks are compounded by limited access to care, especially geriatric and palliative care. A study of Kaiser Permanente members found that more than one quarter of frail older adults had no outpatient visits over 12 months while experiencing high rates of inpatient hospitalization, suggesting that functional challenges compromise proactive chronic disease management.
Home-based primary care (HBPC) circumvents many barriers to care for patients like these. HBPC typically involves multidisciplinary teams who provide care and the intensive care coordination required to keep severely ill adults at home and out of long-term care facilities. Observational studies suggest that HBPC improves outcomes and reduces spending,[5–8] as have three randomized trials in the U.S.[9–11] However, the randomized trials were conducted more than 25 years ago and two were from the Veterans Affairs system whose model of HBPC focused on patients transitioning from inpatient care to home.
To provide a contemporary evaluation of the effect of HBPC on homebound adults, we conducted a randomized controlled trial of HBPC versus office-based primary care and examined satisfaction with care, quality of life, symptom burden, and hospitalizations and emergency department (ED) visits.
J Am Geriatr Soc. 2023;71(2):443-454. © 2023 Blackwell Publishing