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  • Posted December 16, 2019

Hospital-Level Care in Your Home? It Could Be the Future

The days of old-fashioned house calls may be over, but there is a growing trend toward providing some hospital care in the comfort of patients' homes. Now, a new study suggests it might end up being cheaper and, in some respects, better than traditional hospital care.

The study, done at Brigham and Women's Hospital in Boston, tested a "hospital at home" program -- where patients with certain medical conditions are eligible to receive "hospital-level" care at home.

Researchers found that compared with similar patients admitted to the hospital, those in the home program were less likely to return to the hospital within 30 days of their discharge. And their health care costs were, on average, 38% lower.

The study was small, with only 91 patients, and the home-hospital concept is still in its infancy in the United States.

But the results are "exciting," because they point to one way that health care can be "reimagined," said lead researcher Dr. David Levine, a physician at Brigham and Women's.

"In day-to-day practice," he said, "we look at certain [hospital] patients and think, 'You don't really need to be here.'"

That is, they could receive the care they need at home -- where they could likely sleep better, move around more and almost certainly eat better food.

Home hospital care is already offered in a few countries, such as Australia and Spain, according to Levine's team. And some academic health systems in the United States have launched projects, including Johns Hopkins in Baltimore and Mount Sinai in New York City.

But the new study, published Dec. 16 in the Annals of Internal Medicine, is the first randomized trial of a home program in the United States. Patients arriving in the ER were randomly assigned to either be admitted to the hospital or to the home program (with patients' informed consent).

Patients were eligible for home care if they had select conditions -- such as an infection or an exacerbation of a chronic disease like asthma, heart failure or emphysema.

"A critical point is that we knew exactly what the diagnosis was," Levine said.

If there was doubt -- a patient arriving in the ER with chest pain, for example -- home care was not an option.

Patients also had to have a certain amount of mobility -- needing no more than one person to help them to a bedside commode. And, Levine said, "they were all considered to be low risk for clinical deterioration."

The program involved at least one daily visit from a doctor and at least two visits from a nurse. If necessary, patients received services from a home health aide, physical therapist or social worker. Their vitals were monitored by a skin patch that could send alarms to their doctors' and nurses' smartphones, and any blood tests and imaging were done in their homes.

Overall, the study found, home patients underwent far fewer lab tests -- typically around three, versus 15 among hospital patients.

In the end, only 7% of home patients needed to be admitted to the hospital within 30 days of their discharge. In contrast, 23% of hospital patients were readmitted.

"We were frankly surprised there was such an impact on readmissions," Levine said.

Dr. John Wong, of Tufts University Medical Center in Boston, cowrote an editorial published with the study.

He said that a bigger-picture question is how well the results at Brigham and Women's -- a top academic medical center -- could be translated to other, smaller hospitals. The logistics -- including educating staff and partnering with a home health care company -- can be challenging even for a large hospital, Wong noted.

Payment is a major area that has to be worked out, too, he said: Currently, there is no "payment model" in place for insurance companies and Medicare/Medicaid to reimburse for home hospital care.

And then there are the family caregivers. Is it a help or a burden to have their loved one cared for at home?

"Some families would probably welcome this opportunity," Wong said, "while others might find it stressful."

But all of these questions are worth digging into, according to Wong.

One possibility, he noted, is that by caring for certain patients at home, hospitals would have more beds free for those with more-complicated or rare conditions.

"As a country," Wong said, "we should explore more opportunities to provide patients with the care they need, in the place they'd prefer to have it."

More information

The nonprofit Leapfrog Group has advice on hospital stays.

SOURCES: David Levine, M.D., M.P.H., physician, general internal medicine and primary care, Brigham and Women's Hospital, Boston; John Wong, M.D., primary care physician, and chief, Division of Clinical Decision Making, Tufts Medical Center, and professor, Tufts University School of Medicine, Boston; Dec. 16, 2019, Annals of Internal Medicine, online
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