Outcomes of Home-Based Primary Care for Homebound Older Adults

A Randomized Clinical Trial

Alex D. Federman MD, MPH; Abraham Brody PhD, RN; Christine S. Ritchie MD; Natalia Egorova PhD; Arushi Arora MPH; Sara Lubetsky MPH; Ruchir Goswami MBBS, MPH; Maria Peralta BA; Jenny M. Reckrey MD; Kenneth Boockvar MD; Shivani Shah MPH; Katherine A. Ornstein PhD; Bruce Leff MD; Linda DeCherrie MD; Albert L. Siu MD, MSPH

Disclosures

J Am Geriatr Soc. 2023;71(2):443-454.

Abstract and Introduction

Abstract

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.

Introduction

Over 2 million Americans 65 years and older are homebound,^[1] and live with high levels of multimorbidity, physical and cognitive impairment, and socioeconomic vulnerabilities that place them at risk for poor outcomes,^[2] including hospitalizations rates that are over three-times that of non-homebound older adults.^[1] 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.^[3]

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.^[4] 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.

1 2 3 4

Next Section

Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

Table 1. Baseline characteristics of patients by study group
	All Subjects N = 226 N (%)	Intervention N = 114 N (%)	Control N = 112 N (%)	p
Proxy respondent	94 (41.6)	46 (40.4)	48 (42.9)	0.70
Age, mean (SD)	82 (9.0) years	82 (8.8) years	81 (9.1) years	0.64
Age, years				0.53
65–74	54 (23.9)	26 (22.8)	28 (25.0)
75–84	83 (36.7)	39 (34.2)	44 (39.3)
≥85	89 (39.4)	49 (43.0)	40 (35.7)
Male	58 (25.7)	33 (29.0)	25 (22.3)	0.25
Race/ethnicity				0.27
White, non-Hispanic	64 (28.7)	34 (30.4)	30 (27.0)
Black, non-Hispanic	78 (35.0)	44 (39.3)	34 (30.6)
Hispanic	72 (32.3)	31 (27.7)	41 (36.9)
Education				0.30
<High school	45 (20.2)	19 (17.0)	26 (23.4)
High school graduate	72 (32.3)	39 (34.8)	33 (29.7)
Some college	42 (18.8)	25 (22.3)	17 (15.3)
College graduate	64 (28.7)	29 (25.9)	35 (31.5)
Monthly household income <$1350	92 (50.0)	45 (49.5)	47 (50.5)	0.88
Has a paid caregiver	166 (73.4)	83 (72.8)	83 (74.1)	1.00
Married/partnered	54 (24.0)	30 (26.6)	24 (21.4)	0.37
Lives alone	85 (37.6)	44 (38.6)	41 (36.6)	0.75
Type of residence				0.07
Private apartment	139 (61.0)	78 (68.4)	61 (53.5)
Public housing	68 (29.8)	28 (24.6)	40 (35.1)
Other	21 (9.2)	8 (7.0)	13 (11.4)
Social isolation (Lubben score <12)	111 (49.1)	46 (40.3)	65 (58.0)	0.004
General health, poor-fair	143 (63.6)	68 (60.2)	75 (67.0)	0.29
ADL impairment score, mean (SD)	15.7 (3.9)	15.7 (3.9)	15.7 (3.8)	0.84
IADL impairment score, mean (SD)	5.4 (2.0)	5.4 (2.0)	5.3 (2.0)	0.66
Use of assistive device
Cane	128 (59.8)	62 (57.4)	66 (62.6)	0.47
Walker	170 (78.7)	82 (75.2)	88 (82.2)	0.21
Wheelchair	103 (47.5)	48 (43.7)	55 (51.4)	0.25
Motorized wheelchair/scooter	16 (7.4)	8 (7.3)	8 (7.5)	0.95
Cognitive status				0.98
Normal	26 (11.8)	13 (11.8)	13 (11.8)
Mild cognitive impairment	35 (15.9)	17 (15.5)	18 (16.4)
Dementia	159 (72.3)	80 (72.7)	79 (71.8)
No. of hospitalizations, preceding 12 mos.
Total	162	107	55
Per patient, mean (SD)	0.7 (1.2)	0.9 (1.5)	0.5 (0.8)	0.02
No. of ED visits, preceding 12 mos.
Total	127	67	60
Per patient, mean (SD)	0.6 (1.2)	0.6 (1.3)	0.5 (1.1)	0.91

Note: Hospitalization and emergency department data were obtained from the New York State Statewide Planning and Research Cooperative System mandatory discharge database; all other data were self-report.
Abbreviations: ADL, activities of daily living; IADL, instrumental activities of daily living; ED, emergency department.

Table 2. Quality of life, symptom burden, and satisfaction with care at baseline and 12 months, within and between group differences
	N	Baseline mean (SD)	N	12 months mean (SD)	Within group difference at 12 months		Between group differences at 12 months
	N	Baseline mean (SD)	N	12 months mean (SD)	Δ, 95% CI^a	p	Δ, 95% CI^a	Model-based p^a	Worst rank score p
Quality of life
Intervention	82	30.6 (6.2)	77	32.7 (7.1)	1.76 (0.66, 2.86)	0.002	1.25 (−0.39, 2.89)	0.13	0.77
Control	83	30.2 (5.5)	88	30.4 (5.9)	−0.01 (−1.03, 1.02)	0.99	1.25 (−0.39, 2.89)	0.13	0.77
Symptom burden
Intervention	113	30.7 (12.4)	76	27.9 (11.3)	−3.53 (−5.53, −1.53)	0.001	−1.92 (−5.22, 1.37)	0.25	0.48
Control	112	29.8 (12.1)	88	29.3 (10.9)	−0.69 (−2.59, 1.21)	0.48	−1.92 (−5.22, 1.37)	0.25	0.48
Physical domain
Intervention	113	20.8 (8.6)	76	19.6 (8.0)	−1.38 (−2.93, 0.17)	0.08	−0.95 (−3.39, 1.39)	0.79^b	0.37
Control	112	20.8 (8.7)	88	20.5 (7.9)	−0.50 (−1.97, 0.98)	0.51	−0.95 (−3.39, 1.39)	0.79^b	0.37
Emotional domain
Intervention	113	9.9 (5.6)	76	8.3 (5.5)	−2.10 (−3.10, −1.10)	<0.0001	−0.89 (−2.46, 0.68)	0.79^b	0.40
Control	112	9.0 (5.6)	88	8.8 (5.8)	−0.23 (−1.18, 0.72)	0.64	−0.89 (−2.46, 0.68)	0.79^b	0.40
Satisfaction with care
Intervention	112	6.5 (2.7)	74	7.6 (2.8)	1.14 (0.53, 1.76)	0.001	2.26 (1.46, 3.06)	<0.0001	0.007
Control	109	5.7 (3.1)	84	5.5 (2.9)	−0.22 (−0.81, 0.38)	0.47	2.26 (1.46, 3.06)	<0.0001	0.007
Doctor's attention
Intervention	112	1.4 (0.6)	74	1.6 (0.6)	0.15 (−0.07, 0.38)	0.18	0.27 (0.03, 0.52)	0.002^b	0.14
Control	109	1.3 (0.7)	83	1.2 (0.7)	−0.04 (−0.28, 0.20)	0.75	0.27 (0.03, 0.52)	0.002^b	0.14
Information about tests
Intervention	110	1.4 (0.6)	71	1.5 (0.6)	0.08 (−0.15, 0.31)	0.47	0.23 (−0.01, 0.48)	0.001^b	0.28
Control	106	1.2 (0.7)	81	1.3 (0.7)	0.03 (−0.22, 0.27)	0.83	0.23 (−0.01, 0.48)	0.001^b	0.28
Symptom assessment
Intervention	109	1.5 (0.7)	71	1.5 (0.7)	0.03 (−0.21, 0.26)	0.82	0.25 (0.01, 0.51)	0.0001^b	0.26
Control	103	1.2 (0.8)	79	1.2 (0.6)	0.01 (−0.25, 0.26)	0.93	0.25 (0.01, 0.51)	0.0001^b	0.26
Follow-up
Intervention	110	1.3 (0.7)	71	1.5 (0.7)	0.21 (−0.03, 0.44)	0.09	0.39 (0.13, 0.65)	0.001^b	0.02
Control	105	1.2 (0.7)	80	1.1 (0.7)	−0.09 (−0.35, 0.17)	0.49	0.39 (0.13, 0.65)	0.001^b	0.02
Doctor availability
Intervention	110	1.1 (0.7)	74	1.6 (0.6)	0.35 (0.11, 0.60)	0.005	0.48 (0.20, 0.73)	0.001^b	0.006
Control	106	1.1 (0.7)	80	1.0 (0.7)	−0.05 (−0.32, 0.23)	0.74	0.48 (0.20, 0.73)	0.001^b	0.006

^aLinear mixed models adjusted for time and baseline social isolation and hospitalizations.
^bAdjusted for multiple comparisons.

Table 3. Hospitalization and emergency department visits, intention to treat analyses
	12 months pre-randomization	12 months post-randomization	Within group difference		Between group difference^a
	12 months pre-randomization	12 months post-randomization	Δ, 95% CI	p	Δ, 95% CI	p
Hospitalizations
Patients with any event
Intervention	54 (47.4%)	17 (14.9%)	−35.4% (−43.0%, −23.1%)	<0.0001	−17.9% (−31.0%, −1.0%)	0.001
Control	37 (33.0%)	18 (16.1%)	−17.5% (−28.2%, −6.2%)	<0.0001	−17.9% (−31.0%, −1.0%)	0.001
No. of events per patient, mean (95% CI)
Intervention	0.94 (0.66, 1.22)	0.22 (0.11, 0.33)	−1.50 (−2.03, −0.98)	<0.0001	−0.54 (−1.35, 0.25)	0.18
Control	0.49 (0.34, 0.64)	0.20 (0.11, 0.29)	−0.94 (−1.51, −0.37)	0.001	−0.54 (−1.35, 0.25)	0.18
ED visits without hospitalization
Patients with any event
Intervention	32 (28.1%)	18 (15.8%)	−12.9% (−20.2%, −4.0%)	<0.0001	1.2% (−10.5%, 12.4%)	0.75
Control	32 (28.6%)	17 (15.2%)	−14.0% (−21.8%, −4.6%)	<0.0001	1.2% (−10.5%, 12.4%)	0.75
No. of events per patient, mean (95% CI)
Intervention	0.59 (0.36, 0.82)	0.26 (0.13, 0.40)	−0.85 (−1.36, −0.33)	0.001	−0.03 (−0.77, 0.70)	0.70
Control	0.54 (0.32, 0.75)	0.25 (0.11, 0.39)	−0.81 (−1.34, −0.28)	0.003	−0.03 (−0.77, 0.70)	0.70

Abbreviation: ED, emergency department.
^aGeneralized linear mixed models adjusted for time and baseline social isolation and hospitalizations.

Table 4. Process measures, 12-month period of observation
	Assignment				p
	N	Intervention N = 114	N	Control N = 112	p
No. of days to HBPC telephone triage, mean (SD)^a	72	25.8 (23.1)	-	-	-
No. of days to first home-based primary care visit, mean (SD)^a	74	86.3 (56.7)	-	-	-
No. of days in HBPC, mean (SD)^b	74	254 (82)	-	-	-
No. of days to any in-person clinical encounter, mean (SD)^a	93	57.3 (56.2)	87	59.8 (59.8)	0.95
No. of office-based clinical visits prior to first HBPC visit, median (range)	74	2 (0–5)	-	-	-
No. of home-based primary care visits, median (range)	74	6 (2–15)	0	0	-
No. of office-based primary care visits, median (range)	58	2 (1–14)	86	4 (1–13)	0.003
Among intervention patients with no HBPC visits	23	5 (1–14)	-	-	-
No. of telephone encounters with primary care, median (range)^c	87	6 (1–34)	64	3 (1–14)	<0.0001
Had specialty care referral	63	55.3%	49	43.8%	0.08
No. of specialty care referrals, median (range)		2 (1–13)		2 (1–8)	0.90
Had any social work encounter	84	73.7%	43	38.4%	<0.0001
No. of social work in-person encounters, median (range)	33	1 (1–6)	13	2 (1–7)	0.19
No. of social work telephone encounters, median (range)	82	7 (1–37)	38	3 (1–17)	<0.0001
Assessments
Falls	88	77.2%	73	65.2%	0.046
Cognition	45	39.5%	10	8.9%	<0.0001
Physical function	57	50.0%	30	26.8%	0.0003
Signed MOLST form in medical record
At baseline	9	7.9%	7	6.3%	0.63
At 12 months	28	24.6%	13	11.6%	0.01
Documentation of DNR or DNI order
At baseline	6	5.3%	8	7.1%	0.56
At 12 months	46	40.3%	23	20.5%	<0.0001
Documentation of do not hospitalize order
At baseline	0	-	0	-	-
At 12 months	7	6.1%	0	-	-

Note: p-values were calculated per intention-to-treat analysis.
Abbreviations: DNI, do not intubate; DNR, do not resuscitate; MOLST, medical outcomes of life sustaining treatments.
^aFrom date of randomization.
^bFrom date of randomization to study completion (12-month follow-up, death, or drop out).
^cIncludes physician, nurse practitioner, or nurse encounter.

Authors and Disclosures

Alex D. Federman MD, MPH¹, Abraham Brody PhD, RN^2,3, Christine S. Ritchie MD⁴, Natalia Egorova PhD⁵, Arushi Arora MPH¹, Sara Lubetsky MPH⁶, Ruchir Goswami MBBS, MPH¹, Maria Peralta BA¹, Jenny M. Reckrey MD⁶, Kenneth Boockvar MD^6–8, Shivani Shah MPH⁹, Katherine A. Ornstein PhD⁶, Bruce Leff MD¹⁰, Linda DeCherrie MD^1,6 and Albert L. Siu MD, MSPH^6,7

¹Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
²Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
³Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
⁴The Mongan Institute and Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
⁵Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
⁶Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
⁷Geratrics Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
⁸Research Institute on Aging, The New Jewish Home, New York, New York, USA
⁹Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, New York, USA
¹⁰Center for Transformative Geriatric Research, Division of Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Correspondence
Alex D. Federman, Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1087, New York, NY 10029, USA. Email: alex.federman@mssm.edu

Author Contributions
Dr. Federman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Federman, Brody, Ritchie, Reckrey, DeCherrie, Siu. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Federman. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Federman, Arora, Egorova. Obtained funding: Federman, Brody, Ritchie, DeCherrie, Siu. Administrative, technical, or material support: Lubetsky, Peralta, Goswami, Arora. Supervision: Federman.

Conflict of Interest
Dr Brody is an unpaid member of the Board of Directors of the Hospice and Palliative Nurses Association, and of MJHS Hospice Care. Dr Leff serves as an adviser to Medically Home, Dispatch Health, Chartis Group, Kenes, MedZed, Patina Healthcare, Honor/Home Instead, CVS, and koko. He receives grant support from the John A. Hartford Foundation, the Centene Foundation for Quality Healthcare, the Boye Foundation, and Humana. Dr Leff's relationships have been reviewed and approved by Johns Hopkins University in accordance with its conflict-of-interest policy. No other potential conflicts of interest to report.