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"Hospital at Home" provides quality care at less cost
By LOIS BAKER
Contributing Editor
Being hospitalized can be a traumatic experience, especially for older persons. Hospitals are noisy, disorienting, full of strangers, and infections often spread among patients.
Now a new study has shown that for older persons with certain acute conditions, hospital-level care can be provided at home for less money and with fewer clinical complications than in-hospital care.
In addition, patients recovered sooner when "hospitalized" at home, the study found, and they and their families were more satisfied with the whole experience.
The program, called Hospital at Home, was carried out by UB, Yale University and Oregon Health and Science University. Bruce Leff from The Johns Hopkins University oversaw the project.
Results of the program appear in the current issue (Dec. 6) of Annals of Internal Medicine.
The program in Buffalo was a collaboration among four institutions—UB, Kaleida Health, Independent Health and Univera.
"The success of our collaboration provides a model for establishing home hospital programs within communities with multiple competing health-care organizations," said Bruce Naughton, principal investigator on the Buffalo project and director of the UB Division of Geriatrics.
"Work is continuing in Buffalo with the goal of establishing a sustainable home hospital program," added Naughton, associate professor of medicine.
The program was carried out in two consecutive 11-month phases. All patient participants came to a hospital suffering from one of four target illnesses: community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease or cellulitis.
The first phase—which included 60 patients in Buffalo—took place in participating hospitals. In this phase, 282 persons who met the study criteria, consented to participate and allowed a review of their records served as the "hospital observation comparison group." Through interviews and review of medical records, a study coordinator collected information on the seriousness of illness, health status, medications used, laboratory results, type and course of treatment, complications and outcomes, and determined if the care met treatment standards.
In addition, a family member or person who knew the patient well was interviewed to determine the patient's dementia experience. Patients and family members were contacted two weeks after discharge to obtain information on the patient's ability to function and satisfaction with care.
In the second, or intervention, phase—which included 30 participants in Buffalo—patients who came to the hospital for admission for the target illnesses were evaluated in the emergency department and given the option of being admitted or taking part in the Hospital at Home project. Sixty-percent of eligible patients opted for Hospital at Home. They were taken home by ambulance and met there by a nurse. Hospital-equivalent treatment—medications, electrocardiograms, X-rays, intravenous fluids and medications, oxygen and respirators—was provided in the home setting.
The nurse stayed with the patient for 8-to-24 hours initially, depending on the protocol of the project site, and then visited at least once a day until "discharge." The Hospital At Home physician made daily visits and was available 24 hours for emergencies. When the patient was ready for discharge, care reverted to the primary care physician.
Extensive evaluation of the process of care and treatment outcomes in both settings showed that, in addition to the fact that the majority of patients chose Hospital at Home when given the choice, care in that setting was timely and of high quality. Substituting at-home care entirely for hospital care resulted in fewer important clinical complications, including delirium, greater satisfaction and lower total costs, the analysis showed.
Naughton noted that this home treatment program differs from other community-based treatment plans in several respects: extensive physician involvement and one-on-one nursing care (for an average of nearly 17 hours per patient); intensive medical services, including providing oxygen and intravenous therapy, which were excluded in previous studies of in-home care; and in-depth analysis of a wide range of outcomes, including clinical, patient and family satisfaction, patient function, delirium experiences and costs.
"Our experience with home-hospital and similar programs gives Western New York the opportunity to develop innovative health-care services for its aging population," Naughton said. "There are alternatives to hospitalization for older adults that can increase patient safety and reduce costs."
The study was funded by a grant from the John A. Hartford Foundation.