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Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients

Bruce Leff, MD; Lynda Burton, ScD; Scott L. Mader, MD; Bruce Naughton, MD; Jeffrey Burl, MD; Sharon K. Inouye, MD, MPH; William B. Greenough III, MD; Susan Guido, RN; Christopher Langston, PhD; Kevin D. Frick, PhD; Donald Steinwachs, PhD; and John R. Burton, MD
[+] Article and Author Information

From Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, and The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Portland Veterans Administration Medical Center and Oregon Health & Science University, Portland, Oregon; State University of New York, Independent Health, and Univera Health, Buffalo, New York; Fallon Community Health Plan and Fallon Clinic, Worcester, Massachusetts; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and The John A. Hartford Foundation, New York, New York.


Note: Portions of this work have been presented at meetings of the American Geriatrics Society, May 2001, 2003, 2004; the Gerontological Society of America, November 2002, November 2003; and the American Academy of Home Care Physicians, May 2005.

Acknowledgments: The authors thank the following people without whom the study would not have been possible: Nurse Study Coordinators: Maggie Donius, Susan Saltzman, Christine Delano; Delirium Data Coordinators and other site personnel: Kristine Noonan, Lana McBride, Kathleen Chapman, Richard Harper, Wendy Wanlass, Carol Joseph, Nora Tobin, Jim Jackson, Joyce Holohan-Bell, Kay Schecter, Carol Baird, Sandie Taylor, Cleo Scribner, Kay Jenkins, Candace LaBlanc, Marcia Kirkpatrick, Diane Davies; Annette Hopkins for Confusion Assessment Method training and data review; Coordinating Center Data Safety Monitoring Board members: Anne Perkins, Knight Steel, George Taler, Stephanie Wilmer; Becky Clark for data management; Charles Rohde for advice on statistical methods; Curtis Meinert for advice on study design; Leslie Odendhal for coordinating center activities and manuscript preparation; Donna Regenstreif for her initial vision of the hospital at home; The John A. Hartford Foundation of New York for their ongoing support; Ronald Peterson for his support of hospital-at-home development at Johns Hopkins; and the patients, family members, and caregivers who participated in the study.

Grant Support: By a grant from the John A. Hartford Foundation of New York, grant no. 98309-G, and supplemented by the Portland Oregon Veterans Administration Medical Center by a Department of Veterans Affairs New Clinical Initiative Program grant no. 99-027. Dr. Inouye was supported, in part, by grant no. K24AG00949 from the National Institute on Aging.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Bruce Leff, MD, John Hopkins Bayview Medical Center, The Johns Hopkins Care Center, John R. Burton Pavilion, 5505 Hopkins Bayview Circle, Baltimore, MD 21224; e-mail, bleff@jhmi.edu; Web site, http://www.hospitalathome.org.

Current Author Addresses: Drs. Leff, Greenough, and Burton and Ms. Guido: Johns Hopkins Bayview Medical Center, The Johns Hopkins Care Center, John R. Burton Pavilion, 5505 Hopkins Bayview Circle, Baltimore, MD 21224.

Drs. Burton, Frick, and Steinwachs: Johns Hopkins University Bloomberg School of Public Health, Hampton House, 624 North Broadway, Baltimore, MD 21205.

Dr. Mader: P.O. Box 1035 (V-9-DIR), Portland Veterans Administration Medical Center, Portland, OR 97207.

Dr. Naughton: State University of New York, Buffalo, 100 High Street, Buffalo, NY 14203.

Dr. Burl: Fallon Clinic, 10 Chestnut Street, Worcester, MA 01609.

Dr. Inouye: Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, 1200 Centre Street, Boston, MA 02131.

Dr. Langston: 125 Park Avenue, New York, NY 10017.

Author Contributions: Conception and design: B. Leff, L. Burton, B. Naughton, W.B. Greenough, S. Guido, C. Langston, K.D. Frick, D. Steinwachs, J.R. Burton.

Analysis and interpretation of the data: B. Leff, L. Burton, S.K. Inouye, C. Langston, K.D. Frick, D. Steinwachs, J.R. Burton.

Drafting of the article: B. Leff, L. Burton, B. Naughton, K.D. Frick.

Critical revision of the article for important intellectual content: B. Leff, L. Burton, S.L. Mader, S.K. Inouye, W.B. Greenough, C. Langston, K.D. Frick, J.R. Burton.

Final approval of the article: B. Leff, L. Burton, B. Naughton, S.K. Inouye, W.B. Greenough, D. Steinwachs, J.R. Burton.

Provision of study materials or patients: S.L. Mader, B. Naughton, J. Burl, W.B. Greenough.

Obtaining of funding: B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, J.R. Burton.

Administrative, technical, or logistic support: B. Leff, L. Burton, B. Naughton, S.K. Inouye, J.R. Burton.

Collection and assembly of data: B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, S. Guido.


Ann Intern Med. 2005;143(11):798-808. doi:10.7326/0003-4819-143-11-200512060-00008
Text Size: A A A

The Figure shows patient groups by study phase and by site. During the observation phase, there were 1251 patients in the target sample. Three hundred forty-nine (28%) were medically eligible for the study, of whom 286 (82%) consented to data collection; these made up the acute care hospital observation group. During the intervention phase of the study, there were 985 patients in the target sample, of whom 214 (22%) were medically eligible for the study. Of these patients, 141 were approached about receiving their care in hospital at home. Eighty-four received their care in this setting (overall, 60% of those approached—71% at site 1, 29% at site 2, and 68% at site 3), 57 patients declined hospital-at-home care, and 73 patients were not approached to enroll in hospital-at-home during the intervention phase of the study because hospital at home was not open for admissions between 10:00 p.m. and 6:00 a.m. Treatment status in the intervention phase and data availability by study phase and site are described in Table 1. The consent and complete case rates probably reflect the relatively low incentive to participate in a study with a relatively high interview burden for patients in the observation group as a whole and for patients in the intervention group who were treated in the acute care hospital. Other operative factors may have included a more amenable research sample at the Veterans Administration medical center (site 3) and a higher proportion of African-American patients at site 1 who were less willing to participate in the research. Neither death nor active withdrawal from the study contributed to these rates. In addition, an analysis of characteristics of participants who completed all data collection through the 2-week follow-up interviews showed that they did not differ substantially from the characteristics of participants who declined any type of data collection at the site level or in the aggregate in each study phase.

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Figure.
Patient flow and data availability by study phase and site.

*Consented at least to medical record review and review of cost data. †Consented to review of medical records and cost data and completed baseline interview and 2-week follow-up interview. ‡Not approached for hospital-at-home treatment because hospital at home was not open for admissions between 10:00 p.m. and 6:00 a.m.

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Home Hospitalization: 15 years of experience.
Posted on December 12, 2005
Jeremy M Jacobs
Dept Geriatrics and Rehab, Hebrew University Hadassah Medical Center, Mount Scopus, Jerusalem
Conflict of Interest: None Declared

To the Editor, We read with interest the report of Leff et al (1). Shorter length of stay, fewer medical complications, greater patient satisfaction and reduced cost are important additions to the mosaic of evidence supporting hospital at home (HH). They are also findings common to the Jerusalem Home Hospital program which, since initiation in 1991, has treated over 13,000 patients with intensive medical, sub-acute and palliative care at home instead of in hospital. We previously reported that decreased hospital utilization was attributable to the establishment of our home hospital service (2, 3).

Recent data confirmed these findings. When the chief HMO administrator cut HH spending by 60% (a reduction from 400 to 150 patients treated simultaneously), the opportunity arose to monitor the impact of withdrawing HH on geriatric and medical hospitalization rates. An analysis of the 45,000 target population of HMO beneficiaries over 65, showed that per capita in patient days (and spending) rose rapidly in the 12 months following HH cuts- far in excess of forecasts based on previous trends. Hospital days in medical wards increased by 7.2% in contrast to a projected decline of 2.9%, and days in geriatric wards increased by 16.9% as opposed to a forecasted rise of 4.4%. Our experience of a large, readily available HH service showed dramatic health spending repercussions at the macro level, and based on these data HH budget was reallocated to previous levels.

The criticism by Shepperd (4) cites the recent Cochrane review (5), however the models of HH varied and were not exclusively substitutive for inpatient care, thus dampening the effects of the intensive HH models. Shepperd addresses the difficulties of comparing and generalizing findings from different health care systems. However whilst structure of health service provision is fundamental in understanding health care delivery, it is but the context in which treatment modalities are provided. Successful treatment by HH is a robust finding which transcends health care structure. Finally the overwhelming majority of published literature supports either reduced overall spending or no overall difference. This is important since even in scenarios where savings were absent, HH did not incur greater costs than inpatient hospital care.

Beyond the medical and economic issues yet to be resolved is the resounding confirmation of those exposed to HH as either patients or health care professionals: HH is highly desirable and represents a uniquely humane face of modern medicine.

References

1. Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, 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;143:798-808.

2. Stessman J, Ginsberg G, Hammerman-Rozenberg R, Friedman R, Ronen D, Israeli A, et al. Decreased hospital utilization by older adults attributable to a home hospitalization program. J Am Geriatr Soc. 1996;44:591-8.

3. Maaravi Y, Cohen A, Hammerman-Rozenberg R, Stessman J. Home Hospitalization. J Am Med Dir Assoc. 2002; 3 (2): 114-8.

4. Shepperd S. Hospital at home: the evidence is not compelling. Ann Intern Med. 2005;143:840-1.

5. Shepperd S, Iliffe S. Hospital at home versus inpatient hospital care. (Review). The Cochrane Database of Systematic Reviews. 2005.

Conflict of Interest:

None declared

Never ignore a tip from the jockey
Posted on January 13, 2006
Jeffrey I. Farber
Mount Sinai School of Medicine
Conflict of Interest: None Declared

Leff et al's feasibility study of a substitutive hospital at home model for older adults (Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients), compares two groups in a pre-post design: the observation group who met criteria for admission to the program the year prior to the program's existence, and the intervention group, those who met criteria the next year. The intervention group consisted of 3 subgroups: those who were treated with the program (n=84), those who were offered and refused (N=57), and those who were never offered because the program was not accepting patients at that time of day (N=73). Using an intention to treat analysis, while including all patients who met criteria and consented, effectively results in comparing apples with apples- since 61% of the intervention group received their care in hospital. This makes it much more difficult to show either benefit or harm from the intervention. Alongside the ITT analysis, it would be nice to see a per protocol analysis showing how the 84 older adults who received hospital at home care fared in comparison to the 130 subjects who were treated contemporaneously in the acute care hospital. Additionally, it would be helpful to understand the differences between the subjects who chose to be treated in the home program and those who chose hospital treatment. A mentor once told me to never ignore a tip from the jockey. In the end, some patients will prefer hospital at home care and others will not. We would be wise to heed the jockey's tip!

Conflict of Interest:

None declared

Hospital at Home. Economic impact of readmissions.
Posted on January 18, 2006
Francisco Rosell
Hospital Universitari Sagrat Cor. Barcelona. Spain
Conflict of Interest: None Declared

Dr Leff and cols have recently published a very interesting paper relating to the improvement of the patients' care during their admission at a Hospital at Home Unit (1).

Hospital at Home Unit provides the opportunity to make an educative intervention at patients' home. Educative intervention is a main step in the development of Disease Management Programs. There is a general agreement about how an educative intervention, with independence of its intensity, decreases readmissions of patients with chronic diseases. Literature reports the positive economic impact of the establishment of Disease Management Programs, specially when dealing with chronic heart failure (CHD) and pluripathologic patients, and their potencial to produce a positive return on investment from them (2).

Our experience switching Hospital at Home Unit and Disease Management Programs dates from eight years ago. The nexus point between both should be the educative home intervention during the patient admission at Hospital at Home. This home-based intervention and their persistence for years after its stablishment is also reported by other authors (3).

A domiciliary intervention because of a decompensation of a chronic disease while the patient is being attended at home by a multidisciplinary team has the advantage of a greater reception by patients and their families. We have demonstrated this fact with an educative intervention in CHD (4) and chronic obstructive pulmonary disease. As a final output we reported that the taxes of readmission and the visits to an Emergency Department were dropped spectacularly.

So, there's no doubt that Disease Manage Programs and Educative Domiciliary Interventions have a notable impact in the number of readmissions, and as a consequence, in the economic outputs. In our opinion, when evaluating cost-efficiency of alternative care services (such as Hospital at Home Units) specially addressed to elderly people with acute exacerbations of chronic diseases, the decrease of readmissions due to an educational intervention should be taken into account.

References

1.Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, 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;143:798-808.

2.Goetzel RZ,Ozminkowski RJ,Villagra VG, Duffy J. Return on investment in disease management:a review. Health Care Financing Review. 2005;26:1-19.

3.Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation. 2002;105:2861-2866.

4.Morcillo C, Valderas JM, Aguado O, Delás J, Sort D, Pujadas R, Rosell F. Evaluación de una intervención domiciliaria en pacientes con insuficiencia cardíaca. Resultados de un estudio aleatorizado. Rev Esp Cardiol.2005;58:618-625.

Conflict of Interest:

None declared

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Summary for Patients

The Feasibility of Home Treatment instead of Hospitalization for Older Patients with Acute Illness

The summary below is from the full report titled “Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients.” It is in the 6 December 2005 issue of Annals of Internal Medicine (volume 143, pages 798-808). The authors are B. Leff, L. Burton, S.L. Mader, B. Naughton, J. Burl, S.K. Inouye, W.B. Greenough III, S. Guido, C. Langston, K.D. Frick, D. Steinwachs, and J.R. Burton.

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