Overview

A home hospitalization program was developed to provide care for acute illness in patients’ homes in order to improve cost-effectiveness, quality, and safety compared to traditional in-hospital care. 

Department

Department of Medicine

Division

Division of General Internal Medicine

Collaborators

David M. Levine, MD MPH MA
Kei Ouchi, MD MPH
Bonnie Blanchfield, ScD
Keren Diamond, RN MBA
Adam Licurse, MD MHS
Charles T. Pu, MD
Jeffrey L. Schnipper, MD MPH

Status/Stage of Development

Completed

Funding Sources

Funding sources for this project included:

Partners HealthCare Population Health Management, which funded the home hospital program
Institutional National Research Service Award (T32HP10251)
Ryoichi Sasakawa Fellowship Fund

Practice Setting

Academic Medical Center

National/Policy Context

• In the United States, the standard of care is for patients to seek care for acute illness in hospitals.
• In-hospital care often incurs high financial costs and puts patients at risk for secondary complications from their hospital stay, including hospital-acquired infections and permanent loss of functional status.

Patient Population Served and Payor Information

• The general breakdown for patients involved in the study is presented with data from Levine et. al. The intervention group was compared to a control group that received standard care in the hospital. 
  • There were a total of 20 patients that were enrolled in the pilot program study; 9 patients received home hospital care and 11 patients received standard hospital care. 
  • The median age for the home hospital care group was 65 and in the control group it was 60 (p=0.49).
  • The insurance coverage breakdown for the pilot program included (p= 0.17):
    • Private: 6 (67%) patients in intervention, 3 patients in control group (27%)
    • Medicare: 3 (33%) patients in intervention, 5 patients in control group (27%)
    • Medicaid: 0 (0%) patients in intervention, 3 patients in control group (27%)
  • The racial/ ethnic breakdown in the pilot included (p= 0.84):
    • White: 4 (44%) patients in intervention, 5 patients in control group (45%)
    • Latino: 4 (44%) patients in intervention, 3 patients in control group (27%)
    • Black: 1(11%) patients in intervention, 3 patients in control group (27%)

Tools or Products Developed

• Home hospital care: The intervention provided acute, hospital-level care for patients in their homes in order to model a safe and  cost-effective alternative to traditional acute care in emergency departments. 

Tech Involved

• Electronic medical record

Team Members Involved

• NPs
• Physicians

Workflow Steps

• Eligible patients for the pilot study were recruited in the emergency department; the inclusion criteria included age above 18 years and a primary diagnosis of “infection, heart failure exacerbation, COPD exacerbation, or asthma exacerbation” (Levine et. al).
  • The patients who gave consent to be involved in the pilot program study were judged to not be at risk for an imminently life-threatening complication. 
• The necessary medical equipment was brought to patients’ homes, such as intravenous medication pumps, oxygen tanks, point-of-care blood diagnostic equipment, in-home radiology equipment, and continuous vital signs monitors 
• The screened patients received at least one daily visit by an attending general internist and two daily visits from a registered nurse.
  • These patients also had access to other healthcare team members, including a social worker, physical therapist and occupational therapist. 
• During home visits, patients received respiratory therapy, intravenous therapies, in-home radiology, and point-of-care blood-based diagnostic testing. 
• The patients wore a small skin patch (manufactured by physIQ, Chicago, IL; VitalConnect, San Jose, CA) that monitored vital signs, falls, and sleep patterns
• Providers communicated with patients via encrypted video messages and by telephone; the providers were available 24 hours a day for urgent calls. 
• The home care patients were “discharged” from the pilot program and recommended for follow-up care at the discretion of the attending physician. 

Outcomes

• Costs: The direct cost of acute care episode:
  • The median direct cost was 52% (p = 0.05) lower than that for the control group.
  • Including the immediate cost of the acute episode and 30 days later, the home hospitalization patients incurred a median cost that was 67% lower than the hospital patients (p <0.01).
• Utilization: The utilization of medical resources included laboratory and radiology studies, and length of stay:
  • The median length of stay was the same for both groups – 3 days (p = 0.8).
  • The home care patients had fewer laboratory orders, 6, compared to 19 in the hospital patients (p < 0.01).
• Safety: The safety of the intervention was measured by the number of adverse events (falls) and complications requiring re-hospitalization:
  • There were no reported adverse events or re-hospitalization in the home health group. 
• Quality: The quality of the intervention was measured through surveys, including the pertinent Center for Medicare and Medicaid Services (CMS) inpatient quality measures, sleep, pain scores, and physical activity (Levine et. al):
  • Home health patients had more minutes of physical activity (median minutes, 209 vs. 78; p < 0.01), and then tended to have more sleep.  
• Patient experience: Patients in the home hospitalization group reported high satisfaction with the intervention model.

Future Outcomes

• The pilot team anticipated more definitive results from a larger trial. 

Benefits

• The intervention showed that acute care provided in patients’ homes can be more cost-effective, decrease the use of medical resources, and is equally safe when compared to traditional in-hospital care. 
• The intervention program was more patient-friendly, allowing patients to receive care in a comfortable setting.
• The patients receiving home hospital care were largely satisfied with the level of care they received and were more likely to follow-up with a primary care physician after the acute care episode. 

Intervention-Specific Challenges

• The pilot study had a small sample size which made it difficult to adjust for the clinical difference between the intervention and control patients.
• The pilot is also limited to the specific conditions studied (e.g. patients with COPD, heart failure, and asthma) might limit the generalizability of the study. 

Sources

• Levine DM, Ouchi K, Blanchfield B, Diamond K, Licurse A, Pu CT, Schnipper JL. Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial. J Gen Intern Med. 2018 May;33(5):729-736. doi: 10.1007/s11606-018-4307-z. Epub 2018 Feb 6. PubMed PMID: 29411238; PubMed Central PMCID: PMC5910347.
• Counsell SR, Holder CM, Liebenauer LL, Palmer RM, Fortinsky RH, Kresevic DM, Quinn LM, Allen KR, Covinsky KE, Landefeld CS. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000 Dec;48(12):1572-81. PubMed PMID: 11129745.
• Hung WW, Ross JS, Farber J, Siu AL. Evaluation of the Mobile Acute Care of the Elderly (MACE) service. JAMA Intern Med. 2013 Jun 10;173(11):990-6. doi: 10.1001/jamainternmed.2013.478. PubMed PMID: 23608775; PubMed Central PMCID: PMC3691362.