M O L L Y M O N C R I E F FP H A R M . D . C A N D I D A T E

U N I V E R S I T Y O F G E O R G I A C O L L E G E O F P H A R M A C Y C L A S S O F 2 0 1 3

GERIATRIC HOSPITAL AT HOME

HOSPITAL AT HOME

• Developed by the Johns Hopkins University Schools of Medicine and Public Health• Innovative program that provides acute, hospital

level care and home based services to patients who would otherwise require inpatient care• Geared toward substituting for hospital care by

providing service that is highly satisfying to patients and their caregivers, associated with less complications and is less expensive

WHY HOSPITAL AT HOME?

• Patients run a high risk of debilitating complications during a hospital stay• Reduced muscle strength• Delirium• Hospital acquired infections• Psychological and functional decline

• Hospital stays are expensive • Patient and caregiver satisfaction is often during

hospital stays• Opens up hospital beds for patients with more

serious conditions

WHY HOSPITAL AT HOME?

• “It’s best to keep seniors out of the hospital whenever possible.”

–Bruce Leff, MDJohns Hopkins University School of Medicine

MIXED REVIEWS

• Hospital at home versus in-patient hospital care in Cochrane Database of Systemic Review, 2005• A systematic review of 22 randomized, controlled trials of

hospital-at-home care • Patients who received hospital at home care had

outcomes that were similar to those who were treated in the hospital

• Provided insufficient evidence of economic benefit

STUDY

• Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level care at Home for Acutely Ill Older Patients• Annals of Internal Medicine, 2005

OBJECTIVE

• To assess the clinical feasibility and efficacy of providing acute hospital level care in a patient’s home in a hospital at home• To assess patient and caregiver satisfaction• To assess the costs

PARTICIPANTS

• 455 community dwelling elderly patients who required admission to an acute care hospital for 1 of 4 conditions• Community acquired pneumonia• Exacerbation of chronic heart failure• Exacerbation of chronic obstructive pulmonary disease• Cellulitis

• Overall patients were elderly, white and had a high burden of functional impairments and comorbid illnesses

STUDY DESIGN

• Prospective quasi-experiment• Non-randomized• Intent to treat • Two consecutive 11 month phases• Phase 1: Observation phase• Patients were hospitalized

• Phase 2: Intervention phase• Patients received care in the home hospital setting

METHODS

• Patients were evaluated in the hospital at the emergency department• Patients who qualified and elected to proceed with

home hospital care were transported home by an ambulance• Patients were evaluated by the hospital at home

physician either in the ED or shortly after arriving home • The hospital at home nurse met the ambulance at the

patients home and provided direct nursing supervision for an initial period ranging from 8 to 24 hours

METHODS

• When direct nursing supervision was no longer required, the patient had intermittent nursing visits at least daily• The hospital at home physician made at least

daily home visits and was available 24 hours a day for urgent or emergency visits • Other components were provided such as DME,

oxygen therapy, skilled therapies and pharmacy support

RESULTS: PROCESS

• Process outcomes• Nurses and physicians arrived promptly• Systems to deliver oxygen & medications function

properly• Mean & median lengths of stay were shorter for hospital

at home patients• Hospital at home patients were less likely to receive IV

antibiotics, have a catheter, have a difficult procedure performed or have a consultation of any sort

RESULTS: PROCESS

RESULTS: CLINICAL

• Clinical outcomes• Delirium was reduced in the hospital at home patients• Patients in the hospital at home group were less likely to

have sedative medication prescribed • Reduction in the use of chemical restrains in the hospital

at home patients • Fewer critical complications for hospital at home patients• Hospital at home patients had a lower death rate

RESULTS: CLINICAL

RESULTS: SATISFACTION/FUNCTION

• Satisfaction of care outcomes• Satisfaction of patients and family members was greater

in the hospital at home group • Functional outcomes• No change in activities of daily living between the two

groups

RESULTS: ECONOMICAL

• Economical outcomes• The mean amount paid by hospitalized patients was

$7480 versus $5081 paid by hospital at home patients • 8 weeks after admission there was no difference in use of

health services between the two groups

LIMITATIONS

• Patients were not randomly assigned to treatment • Smaller proportion of patients consented to

interviews and contributed data to the analysis of outcomes, such as delirium, satisfaction and function• The recruitment experience at site 2 differed from

that of the other sites • Temporal trends may have affected the study • Influenza season

CONCLUSION

• The data suggests that this model is feasible and efficacious • Physician involvement is crucial in assuring

patient acceptance of hospital at home type care in the U.S. • Hospital at home can play an important role in

the health care system in the future

OTHER STUDIES

• Closure of a home hospital program: Impact on hospitalization rates in Archives of Gerontology and Geriatrics, 2007• This study describes an experiment that took place following

spending cuts and closure of a 400 patient Jerusalem hospital at home program

• The observed hospital utilization in the year following the hospital at home program closure cost $6.2 million U.S. dollars in excess of predicted expenditure

• Closure of the hospital at home program resulted in the saving of $1.3 million U.S. dollars

• The ratio of direct increased costs to savings was 5:1• Closure of the hospital at home program resulted in increased

hospital utilization rates among the local elderly population

TYPICAL HOSPITAL AT HOME PROGRAM

• Patient requiring admission for one of the target illnesses is identified in the ER. If the patient is eligible and consents, the hospital at home physician evaluates them and is they are then transported home

• Once home, the patient receives extended nursing care, and then at least daily nursing visits. Nurses are available 24 hours a day, 7 days a week

• The patient is evaluated daily by the physician. The physician is also available 24 hours a day,7 days a week

TYPICAL HOSPITAL AT HOME PROGRAM

• The clinicians use care pathways, including illness-specific care maps, clinical outcome evaluations, and specific discharge criteria.

• The patient can receive diagnostic studies such as electrocardiograms, echocardiograms, and x-rays at home, as well as treatments, including oxygen therapy, intravenous fluids, intravenous antibiotics, and other medicines, respiratory therapy, pharmacy services, and skilled nursing services.

• Diagnostic studies and therapeutics that cannot be provided at home are available via brief visits to the acute hospital.

• The patient is treated until stable for discharge

HOSPITAL AT HOME SITES

• Sites throughout the country• Presbyterian Health Services, Albuquerque, New Mexico• Veterans Affairs Medical Centers in• Boise, Idaho• Honolulu, Hawaii• New Orleans, Louisiana• Philadelphia, Pennsylvania• Portland, Oregon• Bend, Oregon

THE FUTURE

• Telemedicine enhancements will enhance the program• Accepting patients of all ages• Accepting more medical conditions • Extending the program to include early discharge

for patients who spend a few days in the hospital• Help to keep patients from being re-admitted• Will make reimbursement easier

BARRIERS

• No exact definition or guidelines to follow• There are only a few programs in the country • Attitudinal bias• Payment system that favors traditional hospital

care

REFERENCES • Leff B, et al. Hospital at Home: Feasibility and Outcomes of a

Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients. Annals of Internal Medicine. 2005;143:798-808.

• Jacobs JM, et al. Closure of a home hospital program: Impact on hospitalization rates. Archives of Gerontology and Geriatrics. 2007 September;45(2):179–189.

• Cheng J, et al. Hospital at Home. Clinics in Geriatric Medicine. 2009 February;25(1):79–91.

• Shepperd S, et al. Hospital at home versus in-patient hospital care. Cochrane Database of Systemic Review; 2005 July 20;

• Yasmine, I (2007). A new approach helps keep patients out of the hospital. Retrieved December 6, 2012, from Today’s Hospitalist. Website: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=415

• http://www.hospitalathome.org/