"Hospital at Home" Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients

Problem Addressed

• Many potential complications due to hospitalization: Hospitalization results in a number of factors that can cause complications in seniors; these factors include enforced immobilization, reduction of plasma volume, accelerated bone loss, and sensory deprivation.¹ As a result, hospitalized seniors often experience morbidity including bedsores, muscular degeneration, and weakness resulting from extended immobilization. In addition, hospitalized seniors are at risk of falls, fractures, and medical/medication errors. According to the US Centers for Disease Control and Prevention, the increasing number of people over age 65 form a special population at risk for nosocomial and other health care-associated infections.² 
• Potential for functional decline and delirium as well: A study of 2,293 patients aged 70 and older found that 35 percent of hospitalized patients suffered declines in functional status, as measured by activities of daily living (ADLs); the oldest patients were at highest risk of functional decline, with ADL declines between baseline and discharge of 23 to 63 percent depending on the age range in question (not surprisingly, larger declines tended to occur in older patients).³ A study of 852 patients aged 70 and older who had been admitted to the general-medicine service at a teaching hospital found that delirium developed in 15 percent of patients who received usual care, lasting for an average of 161 days.⁴
• Traditional models of home-based care often cannot substitute for hospitalization: Several Hospital at Home models have been implemented in countries with single payer systems. Most are "early discharge" models and do not substitute entirely for acute care hospitalization.⁵

Description of the Innovative Activity

• Patient eligibility and consent: Patients who present in an emergency department or ambulatory site are assessed by clinicians for eligibility. Eligible patients include those who require hospitalization for a condition such as community-acquired pneumonia, exacerbation of chronic heart failure (CHF), exacerbation of chronic obstructive pulmonary disease (COPD), or cellulitis and who meet other general and disease-specific criteria. Common reasons for medical ineligibility include uncorrectable hypoxemia (insufficient oxygen in the bloodstream), suspected myocardial ischemia (heart attack), or presence of an acute illness (other than the target illness) that requires hospitalization. Patients deemed eligible for the program and who provide their consent to participate are transported home via ambulance.  
• In-home physician care: The patient receives an initial evaluation at home by a physician; this physician also provides subsequent daily home visits and is available 24 hours a day for urgent or emergent visits. Diagnostic studies, such as electrocardiography and radiography, and intravenous treatment, are provided at home.
• Nursing support: Initial one-on-one continuous nursing support is provided to the patient; the patient is visited at least daily by a nurse once continuous support is no longer required. Nurses use illness-specific hospital-at-home care maps and clinical outcome evaluations to determine what care is needed.
• Home health care support: Home health care services and equipment, including durable medical equipment, oxygen therapy, skilled therapies, and pharmacy support are provided by a home health agency and pharmacy support is provided by a hospital or home health agency.
• Emergency access: An emergency call button that can be used to contact a clinical staff member is provided to patients without a family member or other caregiver living in the home.
• Discharge: After the patient stabilizes, he or she is discharged from the program (discharge criteria are used to make this determination). The Hospital at Home physician orders any follow-up care required (such as physical therapy) and contacts the patient's primary care physician by phone, fax, or via EMR messaging to provide an update on patient status and schedule follow-up for the patient. The Hospital at Home physician may also do a follow-up phone call to the patient within 48-72 hours post discharge to check on the patient. 
• Medical record keeping: For this implementation of the program, the innovator used paper medical records maintained at the patients' homes. For future work, the organization is investigating the use of electronic medical record keeping, i.e., the hospital at home would be a virtual unit of the hospital and would be identified as such in the hospital's EMR, ordering system, laboratory reporting, and other systems. All interactions with the electronic systems would be done using laptops with secure remote connections.

References/Related Articles

Hospital at Home [Web site]. Available at: http://www.hospitalathome.org. 

Leff B, Burton L, Mader SL, 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 Dec;143(11):798-808. [PubMed]

Leff B, Montalto M. Home hospital—toward a tighter definition [Letter]. J Am Geriatr Soc. 2004 Dec;52(12):2141. [PubMed] 

Leff B, Burton L, Guido S, et al. Home hospital program: a pilot study. J Am Geriatr Soc. 1999 Jun;47(6):697-702. [PubMed]

Leff B, Burton L, Bynum JW, et al.  Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital. J Am Geriatr Soc. 1997 Sep;45(9):1066-73. [PubMed]

Leff B. Acute? care at home. The health and cost effects of substituting home care for inpatient acute care: a review of the evidence. J Am Geriatr Soc. 2001 Aug;49(8):1123-5. [PubMed]

Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev. 2005 Jul;(3):CD000356. [PubMed]

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Results

• Reduced LOS and costs: A prospective study conducted in three cities and including 455 community-dwelling seniors who required admission to an acute care hospital for one of four conditions (community-acquired pneumonia, exacerbation of CHF or COPD, or cellulitis) found that Hospital at Home care reduced LOS and costs, due in part to use of fewer interventions and fewer complications. 
  • Shorter LOS: Patients receiving Hospital at Home care experienced shorter average lengths of stay (3.2 vs. 4.9 days) than patients receiving usual hospital care.
  • Lower average costs of care: Costs of care were lower for Hospital at Home patients than for hospital inpatients ($5,081 vs. $7,480).
  • Fewer interventions: Care processes typically associated with inpatient care (e.g. oxygen therapy, intravenous antibiotics, nebulized bronchodilators) were similar for both inpatients and Hospital at Home patients. However, Hospital at Home patients were less likely to receive intravenous fluids, sedatives (which can lead to complications such as delirium and falls), urinary catheters, or chemical or physical restraints, and were less likely to undergo expensive diagnostic testing (such as magnetic resonance imaging, stress test, computerized tomography scans, and endoscopy).
  • Fewer complications: The rate of incident delirium was lower for Hospital at Home patients (9 vs. 24 percent), as were bowel complications (9 vs. 16 percent) and emergency situations (6 vs. 11 percent).
• Fewer readmissions and higher quality of life: A small RCT (104 elderly patients with COPD) reported the following results 6 months after discharge from the program or hospital: 
  • Lower hospital readmission: Hospital readmission rates were 42 percent for Hospital at Home patients, compared to 87 percent of hospital inpatients.
  • Better quality of life: Hospital at Home patients experienced improvements in depression and quality-of-life scores, while hospital inpatients experienced no such improvements.
• Lower costs: The cost per patient day was approximately 30 percent lower for Hospital at Home patients than for hospital inpatients.
• Higher patient and family satisfaction, lower family member stress:
  • Higher satisfaction: A 40-item survey administered to 214 community-dwelling elderly patients  and their families found that Hospital at Home patients were 4 times more likely than acute care inpatients to be satisfied with their physician; 6.5 times more likely to be satisfied with the convenience of care; 4 times more likely to be satisfied with the admissions process; and 3 times more likely to be satisfied with the overall care experience. Family members of Hospital at Home patients were also more likely to be satisfied with each of these measures of care.
  • Lower family member stress: A 15-item survey administered to the family members of 214 community-dwelling elderly patients found that the number of experiences that caused stress for family members of Hospital at Home patients was significantly lower than for family members of acute care inpatients (1.7 vs. 4.3).  

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps in the planning and development process included the following:

• Model design and eligibility criteria: A study team of geriatricians developed the basic clinical model for Hospital at Home care, as well as medical eligibility criteria for participation. The team conducted a literature review and applied common sense to develop clinical criteria that physicians could use to determine if a patient was appropriate for Hospital at Home care. Specific clinical practice guidelines were not used, but the team consolidated information from various well-accepted sources and then adapted existing clinical pathways to what would happen in a home situation.
• Pilot study: The Hospital at Home program was first piloted with 17 patients at the Johns Hopkins Bayview Medical Center; the pilot demonstrated that the program was feasible, safe, and cost effective.
• Prospective four-site study: To evaluate the efficacy of Hospital at Home in a broader range of settings, a National Demonstration and Evaluation Study was conducted to test the feasibility of Hospital at Home care in three cities: two in Medicare managed care organizations in Worcester, MA and Buffalo, NY, and one in a Veterans Administration health center in Portland, OR.
• Program expansion: The project team is working to disseminate the model to would-be adopters; it is also developing protocols for Hospital at Home treatment for additional conditions, including urinary tract infection, urosepsis, volume depletion/dehydration, and deep vein thrombosis/pulmonary embolism.

Resources Used and Skills Needed

• Staffing: Staffing for the program includes the following:
  • Physician time: Physician visits are a critical piece of the model. Participating physicians (geriatricians, internists, or family physicians) should be identified who are willing to travel to the patient's home. Physicians can make approximately 7 to 10 visits per day, depending upon the program's geography.
  • Nurse staffing: For the pilot study, the Johns Hopkins Bayview Medical Center Institution Review Board required that a nurse be in the home for at least the first 24 hours, but this may be more conservative than needed. In the national evaluation study, researchers found that most Hospital at Home patients do not need 24 hours of nursing care, but could probably be served safely with an initial nurse visit of 4 to 6 hours, followed by daily visits thereafter. Although new nurse hires are likely to be needed, the marginal change in nurse staffing depends on the organization’s ability to float hospital nursing staff between Hospital at Home patients and inpatient units. 
  • Home aides: The program requires the use of aides who can visit Hospital at Home patients who need help with ADLs.
  • Nurse coordinator: A nurse coordinator should be hired to run the program.  
• Equipment: Intravenous (IV) infusion capacity is needed so that IVs can be placed in the home. Additional equipment such as that required for oxygen therapy and bronchodilator therapy is often required by patients. Additional diagnostic studies that are performed in the home include basic radiography such as chest x-rays, electrocardiograms, and echocardiography. Some of these diagnostic services may be provided by independent service providers that contract with the Hospital at Home program.
• Costs: The costs of adoption depend upon program size, and include staffing and equipment; the major costs are the labor costs of physicians and nurses.

Funding Sources

National Institute on Aging; Portland VA Medical Center; John A Hartford Foundation

Tools and Other Resources

Getting Started with This Innovation

• Assess the financial implications: Given current payment structures, the model is more easily adopted by managed care organizations, integrated delivery systems like the Veterans Administration, and systems that have a health plan and providers organized under one umbrella organization. (See Additional Considerations and Lessons for more information.)
• Assess current capabilities: Would-be adopters ideally should care for a large senior population; have some experience with home health care; and have some physicians who are willing to make house calls.
• Recognize the program as a disruptive technology: Hospital at Home will disrupt normal patterns of care; organizations that are not willing to embrace and accommodate this type of disruption will have difficulty implementing the model.
• Elicit leadership support: Strong support from the hospital leadership is essential. The Johns Hopkins Bayview Medical Center hospital administrator had the vision to see Hospital at Home as a logical extension of hospital services, and he understood the need to expand service to older persons and to address future bed shortages.
• Assess staffing needs, taking geography and scale into account: Organizations that serve a geographically dispersed patient population will have greater staffing needs due to physician and nurse travel requirements.  

Sustaining This Innovation

• Maintain the commitment of key stakeholders: Sustaining the program requires ongoing commitment and support from senior leaders, front-line caregivers, and emergency department physicians (who often assess patients for program eligibility). 
• Expand capacity as program grows: Nurse staffing and home health capabilities must grow in step with the program. 
• Medical record keeping: Record keeping requirements can be complex, and will be dictated by the policies and procedures of the adopting organizations. The use of EMRs will facilitate record keeping for a Hospital at Home program.

Additional Considerations and Lessons

Use By Other Organizations