Abstract
Background: Acute hospital care of older patients is often associated with adverse events including functional decline, iatrogenic illness, dissatisfaction with care among patients and family members, family stress related to caring for a family member, and high costs. Delivering acute medical care at home in a hospital at home (HaH) that substitutes for traditional acute hospital care may be associated with better outcomes in these domains.
Aim: Describe results of a national demonstration study of a HaH model of care in Medicare managed care and Veterans Administration (VA) settings.
Methods: Prospective, nonrandomized clinical trial, in which acutely ill older persons (age >65) who met required hospital level care for community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and cellulitis were followed through their usual hospital course during an observation phase (n=286) and were offered HaH care during an intervention phase (n=141). The study populations were from three Medicare managed care plans and one VA medical center.
Results: Subjects in the study groups had similar baseline demographic and health characteristics. Sixty percent of patients offered HaH care opted for it (n=84). Patients in HaH received types of treatments associated with hospital care. Length of stay was shorter for patients in HaH, 3.2 vs. 4.9 d, (P=0.001). Patients cared for in HaH had reduced risk of clinical complications including incident delirium, adjusted odds ratio 0.26 (0.12, 0.57) and use of sedative medications, adjusted odds ratio 0.49 (0.30, 0.81). HaH care was associated with trends towards better physical functional outcomes. Illness-specific quality of care standards were met in similar proportions in HaH and hospital-treated groups. Patient and caregiver satisfaction with HaH was better than that associated with hospital care across multiple domains (P<0.001). Family members of HaH patients experienced significantly less stress related to the caring for an acutely ill family member during the HaH episode compared with patients treated in the hospital (P<0.001). Costs of HaH care were lower for HaH patients.
Conclusions: HaH is an efficacious model of acute care delivery for selected older persons with certain medical illnesses. Dissemination of the HaH model into managed care settings is warranted.
- Received September 11, 2008.
