Hospital at Home for Older Patients With Underlying Comorbidity

Abstract

Hospital at home (HAH), a model of acute hospitallevel care at home, is beginning to be adopted as evidence of the model s efficiency and safety accumulate (1–3). In their article, Shepperd and colleagues (4) contribute to this growing body of research with the report of their trial of HAH. This multisite trial done in the United Kingdom evaluates the outcomes of HAH combined with comprehensive geriatric assessment (CGA) for older patients experiencing an acute event requiring hospital-level care. Participants were randomly assigned to either HAH with CGA or traditional hospitalization with CGA when available. Comprehensive geriatric assessment evaluates medical, psychosocial, and functional limitations common in older adults that affect well-being and contribute to frailty. The goal of CGA is to maximize overall health in older adults, and the goal of HAH is to treat an acute episode of illness. This research shows how combining 2 care approaches benefits older persons with frailty while keeping them at home. Across the developed world, there has been a proliferation of HAH models that represent a significant shift in the delivery of acute medical care. Countries including Canada, Japan, Spain, the United Kingdom, and Australia have published studies documenting the benefits associated with shifting acute medical care services from the hospital to the home (5, 6). Such programs are often initiated to control burgeoning health care costs, address hospital capacity, and avoid common in-hospital complications, such as nosocomial infections and delirium. The development of HAH programs has accelerated worldwide with the emergence of COVID-19 and the pressure to reduce the demand on acute care hospitals and decrease risk for COVID-19 transmission to vulnerable older persons. Shepperd and colleagues show that older persons are not worse off when they receive care at home, echoing prior research that has shown outcomes equivalent to or better than inpatient care. Benefits have included decreased mortality, increased efficiency, decreased readmissions, and higher patient and family satisfaction (7, 8). These potential benefits are especially pertinent for the population included in the current trial—persons with a mean age of 83.3 years who had an infective episode and who also had cognitive decline and mobility issues. Unique aspects of this study include the randomized design, the inclusion of 9 sites in the United Kingdom, and the combination of HAH with CGA. This allowed the specific expertise of the multidisciplinary geriatric team to contribute to the care pathway of the HAH program. The study s primary outcome was whether participants still lived at home 6 months after the event requiring hospital care. The results showed that 78.6% who received HAH and 75.3% who received traditional hospital care were still living at home at 6 months (relative risk, 1.05 [95% CI, 0.95 to 1.15]), and mortality was similar in both groups. There was a slight decrease in the risk for moving to a long-term care facility for the HAH group (relative risk, 0.58 [CI, 0.45 to 0.76]). These findings concur with Beswick and colleagues (9) meta-analysis, which concluded that complex interventions can help elderly persons avoid the need for nursing home care. Participants in this study had complex medical problems. The main presenting problems for the participants in this study were acute functional deterioration (37.01%); falls (21.2%); shortness of breath (11.8%); and delirium, confusion, or dementia (6.5%). Most (72.3%) had cognitive impairment and reported moderate to severe problems with mobility (60%). Yet, compared with patients in the traditional hospitalization group, HAH participants reported higher levels of satisfaction with their care, length of waiting time for care to start, understanding the aims of care, knowing how to contact staff, and discussions on further care. Again, this is consistent with other trials of HAH that consistently show high satisfaction with this model of care. There were some significant challenges to the design of this trial that should be noted. Although a randomized trial was planned, 22% of those randomly assigned to hospitalization either declined hospital admission and received HAH services or were diverted to HAH because of issues with bed capacity. While underscoring the desirability and need for HAH to address settings with limited bed capacity, this tempers confidence in the study s findings because it represents more of a real-world evaluation than a controlled experiment. In addition, the primary outcome of living at home at 6 months may be more of a reflection of the CGA than of the single HAH admission for acute care. Specifying outcomes more directly attributable to each component of the intervention could provide more insight into the value of a combined approach. The observation that participants in the HAH group had a 32% increased likelihood of admission to the hospital in the month after HAH admission suggests that further support to older patients beyond the brief HAH episode could prevent readmission. Other studies have shown a clear decrease in hospital admissions and emergency department visits the month after HAH admission (10). The most distinctive feature of this study compared with others of HAH is the addition of CGA. Further study of the value of combining CGA with HAH associated as a strategy to improve outcomes among older patients requiring acute hospital-level care is warranted. Although HAH programs serve persons of all ages who have an acute illness requiring hospital-level care, this study contributes to the literature on the appropriateness of this model even for older patients with underlying comorbidity when combined with CGA.