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

Service Delivery Innovation Profile

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

Snapshot

Summary

The Hospital at Home sm program provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions that are common among seniors. Studies have shown that the Hospital at Home program results in lower length of stay, costs, readmission rates, and complications than does traditional inpatient care, whereas surveys indicate higher levels of patient and family member satisfaction than with traditional care.

Evidence Rating

Strong: The evidence consists of multiple randomized studies of Hospital at Home, many of which are in the international literature. A Cochrane review of Hospital at Home showed reductions in clinical complications and mortality, better patient and family satisfaction, better functional outcomes, less caregiver stress, and lower costs when compared with the traditional inpatient care. Studies of Hospital at Home in the United States showed the same results.

Developing Organizations

Johns Hopkins Hospital

Baltimore, MD

Use By Other Organizations

  • The three pilot sites continue to use the model. In addition, the New Orleans VA started a hospital at home model in late 2007. The VA recently started to implement additional Hospital at Home Programs in Honolulu, HI, and Boise, ID. Presbyterian Health Systems, a large managed care organization in New Mexico, implemented the program, while United Healthcare is planning to pilot the model in its Arizona market. Other VA and Medicare managed care organizations are contemplating adoption.
  • After planning began in April 2007, Presbyterian Health Services, led by Lesley Cryer, RN, executive director of Presbyterian's Home HealthCare Services, succeeded in admitting its first patient to Hospital at Home in October 2008 and to date has treated more than 300 patients. Both the clinical and financial results were excellent.
  • Other health systems around the country have shown interest and expect several additional major adoptions. In addition, there has been strong international interest in the model.

Date First Implemented

2001

Problem Addressed

Hospitalization for older patients can result in complications such as nosocomial infections and medical errors, as well as functional decline and delirium. Home-based hospital-level care has the potential to reduce these adverse outcomes, but it is seldom available.

  • 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. 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 U.S. Centers for Disease Control and Prevention, the increasing number of people older than age 65 years form a special population at risk for nosocomial and other health care–associated infections.
  • Potential for functional decline and delirium as well: A study of 2,293 patients aged 70 years 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). A study of 852 patients aged 70 years 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.
  • 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.

Description of the Innovative Activity

The Hospital at Home sm program provides complete substitution of an acute hospital stay in the patient's home. Patient eligibility for in-home hospital care is assessed in the health care setting; eligible patients are transported home by ambulance and receive initial and daily visits by a physician, continuous nursing support, home health equipment and services, diagnostic testing, and other services. Features of the program include:

  • 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 (IV) 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 (e.g., physical therapy) and contacts the patient's primary care physician by phone, fax, or via electronic medical record (EMR) messaging to provide an update on patient status and schedule followup for the patient. The Hospital at Home physician may also do a follow up phone call to the patient within 48 to 72 hours postdischarge 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 EMRs—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.

Context of the Innovation

Johns Hopkins Bayview Medical Center, an urban hospital located in Baltimore, MD, has approximately 350 beds and has an average daily census of 250 patients and an average length of stay of 4.3 days. In the mid-1990s, approximately 20 percent of admissions to the medical center's medical wards (excluding the intensive care unit) were accounted for by CHF, COPD, pneumonia, and cellulitis. Johns Hopkins geriatricians who provided ongoing care to homebound seniors by making house calls observed that many of their patients requiring hospitalization expressed a desire to receive care at home instead. Patients were reluctant to be admitted because they had experienced adverse events during prior hospitalizations or because previous hospitalizations were otherwise difficult or unpleasant for them in some way. When patients refused to be admitted, the physicians found themselves patching together a care plan that might not have been optimally effective or efficient. To address this issue, the Hospital at Home sm program was designed and piloted at Johns Hopkins, and then implemented in a three-site national evaluation study in Buffalo, NY, Worcester, MA, and Portland, OR.

Results

Several studies have shown that the Hospital at Home program results in shorter length of stay and lower costs, readmission rates, and less complications than does traditional inpatient care, whereas surveys indicate higher levels of patient and family member satisfaction than with traditional care.

  • Reduced length of stay and costs: A prospective study conducted in 3 cities and including 455 community-dwelling seniors who required admission to an acute care hospital for 1 of 4 conditions (community-acquired pneumonia, exacerbation of CHF or COPD, or cellulitis) found that Hospital at Home care reduced length of stay and costs, due in part to use of fewer interventions and fewer complications.
    • Shorter length of stay: 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, IV antibiotics, nebulized bronchodilators) were similar for both inpatients and Hospital at Home patients. However, Hospital at Home patients were less likely to receive IV 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 (e.g., 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 randomized controlled trial (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 with 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

Strong: The evidence consists of multiple randomized studies of Hospital at Home, many of which are in the international literature. A Cochrane review of Hospital at Home showed reductions in clinical complications and mortality, better patient and family satisfaction, better functional outcomes, less caregiver stress, and lower costs when compared with the traditional inpatient care. Studies of Hospital at Home in the United States showed the same results.

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 whether 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 (VA) 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

Resources required depend on the size of the program in development. General resources required include:

  • 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 on 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: 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 on program size and include staffing and equipment; the major costs are the labor costs of physicians and nurses.

Funding Sources

Funding from John A. Hartford Foundation ended in 2009.
Some services offered by the program are reimbursed by Medicare.

Tools and Resources

Develop Your “Hospital at Home” Program Web site. Available at: http://www.hospitalathome.org/develop-your-program/overview.php.

The Agency for Healthcare Research and Quality Resource Page on System Design can be found at http://www.ahrq.gov/professionals/systems/system/systemdesign/index.html

The Hospital at Home sm consulting team can provide expertise and technical assistance to help evaluate whether to adopt the program as well as to support implementation and reduce start up timelines through licensing and consulting engagements. The Hospital at Home national organization has developed planning, implementation, and evaluation tools to help encourage dissemination of the model.

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 VA, 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, frontline 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.

Use By Other Organizations

  • The three pilot sites continue to use the model. In addition, the New Orleans VA started a hospital at home model in late 2007. The VA recently started to implement additional Hospital at Home Programs in Honolulu, HI, and Boise, ID. Presbyterian Health Systems, a large managed care organization in New Mexico, implemented the program, while United Healthcare is planning to pilot the model in its Arizona market. Other VA and Medicare managed care organizations are contemplating adoption.
  • After planning began in April 2007, Presbyterian Health Services, led by Lesley Cryer, RN, executive director of Presbyterian's Home HealthCare Services, succeeded in admitting its first patient to Hospital at Home in October 2008 and to date has treated more than 300 patients. Both the clinical and financial results were excellent.
  • Other health systems around the country have shown interest and expect several additional major adoptions. In addition, there has been strong international interest in the model.

Lessons Learned

  • Medicare managed care plans and integrated/capitated delivery systems such as VA hospitals are currently in the best position to identify a positive business case for implementing Hospital at Home. This is especially true if their hospitals are operating at or near capacity. In the fee-for-service arena, the model will make more financial sense if a payment mechanism for Hospital at Home services can be developed. Johns Hopkins has submitted a proposal to test such a payment model under the Medicare Health Care Quality Demonstration (“Section 646”) Program. At present, hospital administrators with excess capacity working in a fee-for-service environment may be reluctant to adopt the program because patients would be moved out of reimbursable inpatient care.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Bruce Leff, MD
Professor of Medicine
Division of Geriatric Medicine
Johns Hopkins University School of Medicine
5505 Hopkins Bayview Circle
Baltimore, MD 21224
Phone: (410) 550-2654
E-mail: bleff@jhmi.edu



Innovator Disclosures

In addition to the external funders listed in the Funding Sources section, Dr. Leff reported that Johns Hopkins University received payments for consulting and licensing fees related to this program from Mobile Doctors 24/7 International, and that Johns Hopkins University and Johns Hopkins Health System received payments for consulting fees related to this program from Clinically Home, LLC. (Financial arrangements with both of these companies are now terminated.). Dr. Leff also reported receiving modest honoraria and reimbursement of travel-related expenses for speaking engagements related to this program.

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;143(11):798-808. [PubMed]

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

Leff B, Burton L, Guido S, et al. Home hospital program: a pilot study. J Am Geriatr Soc. 1999;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;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;49(8):1123-5. [PubMed]

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

Cheng J, Montalto M, Leff B. Hospital at home. Clin Geriatr Med. 2009;25(1):79-91, vi. [PubMed]

Leff B, Burton L, Mader SL, et al. Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care. J Am Geriatr Soc. 2009;57(2):273-8. Epub 2008 Dec 11. [PubMed]

Leff B. Defining and disseminating the hospital-at-home model. CMAJ. 2009;180(2):156-7. [PubMed]

Frick KD, Burton LC, Clark R, et al. Substitutive Hospital at Home for older persons: effects on costs. Am J Manag Care. 2009;15(1):49-56. [PubMed]

Marsteller JA, Burton L, Mader SL, et al. Health care provider evaluation of a substitutive model of hospital at home. Med Care. 2009;47(9):979-85. [PubMed]

Shepperd S, Doll H, Angus RM, et al. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009;175-82. [PubMed]

Footnotes

  1. Creditor MC. Hazards of hospitalization in the elderly. Ann Intern Med. 1993;118(3):219-23. [PubMed]

  2. Strausbaugh LJ. Emerging health care-associated infections in the geriatric population. Emerg Infect Dis. 2001;7(2):268-71.[PubMed] Also available at: http://wwwnc.cdc.gov/eid/article/7/2/pdfs/70-0268.pdf

  3. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc . 2003;51(4):451-8. [PubMed]

  4. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med . 1999;340(9):669-76. [PubMed]

  5. 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;143(11):798-808. [PubMed]

Funding Sources

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

Developers

Johns Hopkins Hospital

Baltimore, MD

Comments

By MLudwig on
This innovation apears to have remarkable promise. I noticed there is no mention of midlevel practitioners. It seems midlevel practitioners are the ideal candidates to work with patients in this environment leaving physicians to focus on the management of the rare or more complex illnesses their longer education better prepares them for. Has any organization who has implemented this care model used APRN's/PA's?

By The Editorial Team on
Readers may be interested in this 2009 study demonstrating cost savings for Hospital at Home care versus traditional inpatient care for older patients with community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of congestive heart failure, or cellulitis.The complete study can be found at:http://www.ajmc.com/files/articlefiles/AJMC_09jan_Frick_49to56.pdf
Original Publication: 08/18/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 04/09/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 12/09/13

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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