Bruce Leff

Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients

Context Hospital care for older people often means iatrogenic complications and a decline in function. Home hospital care might reduce these adverse outcomes. Content Patients were 65 years of age or older and required hospital care for pneumonia, heart failure, chronic obstructive pulmonary disease, or cellulitis. In phase I, they were hospitalized. In phase II, they could choose home hospital care (continuous nursing care followed by at least daily visits from a nurse and a physician). Sixty percent of patients chose home hospital care. Patients who received this type of care had shorter stays; fewer procedures, consultations, and indwelling devices; less delirium; greater satisfaction; and similar functional outcomes. Cautions The study was nonrandomized, and data were missing. Conclusion Home hospital care may be a good alternative for selected patients. The Editors Although the acute care hospital is the standard venue for providing acute medical care, it is expensive and may be hazardous for older persons, who commonly experience functional decline, iatrogenic illness, and other adverse events during care (1-3). Providing acute hospital-level care in a patients home is an alternative to hospital care (4, 5). Although several hospital-at-home models have been studied, there is controversy regarding the effectiveness of this method. In part, this reflects heterogeneity among hospital-at-home models (6). A recent Cochrane review examined surgical and medical early hospital discharge models, terminal care, and admission avoidance, that is, substitutive models. Overall, no differences were found in health outcomes. Patients, but not caregivers, had increased satisfaction with hospital-at-home care, and there was some evidence that substitutive models may be cost-effective (7). However, with some exceptions (8), most of these models would be difficult to distinguish from augmented skilled nursing services, community-based long-term care, or home-based primary care services in the United States. In addition, most studies have been done in countries with single-payer national health insurance systems (7-14). Previous research in the United States has been limited to a pilot study of a physician-led substitutive hospital-at-home model for older persons with acute medical illness (15). The aim of our study was to evaluate the safety, efficacy, clinical and functional outcomes, patient and caregiver satisfaction, and costs of providing acute hospital-level care in a hospital at home that substituted entirely for admission to an acute care hospital for older persons. Methods Patients The target sample was community-dwelling persons, age 65 years and older, who lived in a catchment area and who, in the opinion of a physician not involved in the study, required admission to an acute care hospital for 1 of 4 target illnesses: community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Patients were required to meet validated criteria of medical eligibility for hospital-at-home care (16), which were designed to identify patients who would be medically suitable for this type of treatment. The most common reasons for medical ineligibility were uncorrectable hypoxemia (oxygen saturation <90%), suspected myocardial ischemia, and presence of an acute illness, other than the target illness, for which the patient was required to be hospitalized. Study Design This study was a prospective quasi-experiment conducted in 2 consecutive 11-month phases. During the acute care hospital observation phase (1 November 1990 to 30 September 2001), eligible patients were identified and followed through usual hospital care. Study coordinators verified the patients eligibility for hospital-at-home care using a standard protocol at the time of enrollment. During this observation phase of the study, most patients were identified the morning after admission. These patients made up the acute hospital observation comparison group. During the intervention phase (1 November 2001 to 30 September 2002), eligible patients were identified at the time of admission and were offered the option of receiving their care in hospital at home rather than in the acute care hospital. Patients who chose hospital-at-home treatment were never admitted to the acute care hospital but received treatment, after initial evaluation (usually in the emergency department), in their home. The intervention group comprised all patients eligible for hospital-at-home care, irrespective of where they were treated. Approval The institutional review boards from each study site, the coordinating center, and officials at the Center for Health Plans and Providers at the Centers for Medicare & Medicaid Services (CMS) gave their approval for the study. All participants provided informed written consent. Study Sites The study was conducted in 3 Medicare managed care (Medicare + Choice) plans at 2 sites and at a Veterans Administration medical center. Univera Health and Independent Health, in Buffalo, New York, are Medicare + Choice plans that operate in an independent practice association model. These 2 plans collaborated to provide hospital-at-home care and made up 1 study site (site 1). The Fallon Health Care System (site 2), in Worcester, Massachusetts, operates a not-for-profit Medicare + Choice plan, and the Fallon Clinic, a for-profit multispecialty physician group, provides care on a capitated basis to Medicare + Choice beneficiaries. The Portland, Oregon, Veterans Administration Medical Center (site 3) is a quaternary care and teaching facility. Assessments Age, gender, and primary diagnosis were obtained for all eligible patients. Informed written consent was required for all additional data collection: medical record review, cost data review, and interviews. Staff trained at the coordinating center used standard procedures outlined in a detailed training manual to conduct all interviews, assessments, and medical record reviews. At baseline, interrater reliability was verified among the staff. Quality checks of medical record reviews were done midway through the study. Interrater reliability for ratings on the components of the daily patient interview was confirmed in 13 paired observations ( = 0.91). Interrater reliability among study sites was similar. Medical Record Reviews Medical records were abstracted by using a standardized instrument that captured illness acuity, health status, medication use, results of laboratory tests, treatments, the hospital course and complications, health outcomes, and whether treatment standards were met. Illness acuity was determined by using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (17). Health status was measured by using clinical indicators appropriate to the diagnoses, a checklist of chronic medical conditions, and the Charlson comorbidity index (18). Medication use was defined as the number of prescribed medications taken on a daily basis at the time of admission. Diagnostic and therapeutic interventions were categorized as potentially difficult or not difficult to do in the home. The patients clinical course was characterized according to whether emergency situations (those that required physician evaluation within 30 minutes, such as the development of acute shortness of breath) or critical complications (death, transfer to intensive care setting, intubation, or myocardial infarction) occurred. Clinical care was examined with regard to completion of illness-specific standards of care (19-21). Eligible patients who consented to participate completed a baseline interview that included demographic information, self-reported health status, assessment of sleep, Katz activities (22), Lawton instrumental activities of daily living (23), continence, mobility, the Geriatric Depression Scale (24), Jaeger vision test, the Mini-Mental State Examination (MMSE) (25), the Digit Span Test (26), and evaluation by the Confusion Assessment Method (CAM) (27). Subsequently, patients were evaluated daily until discharge by using a structured interview consisting of the MMSE, Digit Span Test, and CAM rating. A family member, caregiver, or person who knew the patient well was interviewed at the time of admission to complete the modified Blessed Dementia Rating Scale (28). At 2 weeks after admission, patients and family members were interviewed by telephone to obtain the patients current functional status and to assess his or her satisfaction with care. Intervention: The Hospital-at-Home Model of Care The hospital-at-home model of care has been described previously (15). Briefly, a patient requiring admission to the acute care hospital for a target illness was identified in an emergency department or ambulatory site and his or her eligibility status was determined. Nonstudy medical personnel, usually emergency department physicians, made the decision to hospitalize the patient. All patients who were offered but who declined hospital-at-home care were admitted to the acute care hospital. After informed consent was obtained, the patient was transported home by an ambulance. Patients were evaluated by the hospital-at-home physician either in the emergency department or shortly after arriving at home. Patients who required oxygen therapy were sent home with a portable oxygen apparatus pending delivery of home oxygen therapy. The hospital-at-home nurse met the ambulance at the patients home. The patient had subsequent direct one-on-one nursing supervision for an initial period of at least 8 hours at site 3 and for a period of 24 hours at sites 1 and 2. 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 emergent visits. Nursing and other care components, such as durable medical equipme

Satisfaction with Hospital at Home Care

OBJECTIVES: To examine differences in satisfaction with acute care between patients who received treatment in a physician‐led substitutive Hospital at Home program and those who received usual acute hospital care.

The Ironic Business Case For Chronic Care In The Acute Care Setting

The U.S. health care system provides acute care tools to deal with the problems of chronic disease, and strategies are needed to engage hospitals in chronic care innovations. Acute care-based models that improve chronic care have been developed, but their diffusion is limited by the absence of a business case for adoption. Yet a financial case for improving chronic care is possible by aggregating previously tested models into a service line that can be customized to local circumstances. Beyond benefits to hospitals, patients and payers could benefit from improved patient outcomes and costs; society could benefit from more appropriate deployment of resources.

Informing clinical practice guideline development and implementation: Prevalence of coexisting conditions among adults with coronary heart disease

OBJECTIVES: To describe the prevalence of coexisting conditions that affect clinical decision‐making in adults with coronary heart disease (CHD).

Physician Satisfaction with Chronic Care Processes: A Cluster-Randomized Trial of Guided Care

PURPOSE Chronically ill older patients with multiple conditions are challenging to care for, and new models of care for this population are needed. This study evaluates the effect of the Guided Care model on primary care physicians’ impressions of processes of care for chronically ill older patients. METHODS In Guided Care a specially educated registered nurse works at the practice with 2 to 5 primary care physicians, performing 8 clinical activities for 50 to 60 chronically ill older patients. The care model was tested in a cluster-randomized controlled trial between 2006 and 2009. All eligible primary care physicians in 14 pods (teams of physicians and their chronically ill older patients) agreed to participate (n = 49). Pods were randomly assigned to provide either Guided Care or usual care. Physicians were surveyed at baseline and 1 year later. We assessed the effects of Guided Care using responses from 38 physicians who completed both survey questionnaires. We measured physicians’ satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff. RESULTS Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher (ρ<0.05 in linear regression models). Other differences did not reach statistical significance. CONCLUSIONS Based on physician report, Guided Care provides important benefits to physicians by improving communication with chronically ill older patients and their families and in physicians’ knowledge of their patients’ clinical conditions.

Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care

OBJECTIVES: To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care.

American geriatrics society identifies another five things that healthcare providers and patients should question

Since 2012, the American Geriatrics Society (AGS) has also been collaborating with the American Board of Internal Medicine (ABIM) Foundation, joining its “Choosing Wisely” campaign on two separate lists of Five Things Healthcare Providers and Patients Should Question. The campaign is designed to engage healthcare organizations and professionals, individuals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Participating healthcare providers are asked to identify five things—tests, medications, or procedures—that appear to harm rather than help. Providers then share this information in a published article about these things on the ABIM campaigns website (www.choosingwisely.org). The first AGS list was published in February 2013.

How to integrate multiple comorbidities in guideline development: Article 10 in integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report

BACKGROUND Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 10th of a series of 14 articles that were prepared to advise guideline developers in respiratory and other diseases. This article deals with how multiple comorbidities (co-existing chronic conditions) may be more effectively integrated into guidelines. METHODS In this review we addressed the following topics and questions using chronic obstructive pulmonary disease (COPD) as an example. (1) How important are multiple comorbidities for guidelines? (2) How have other organizations involved in the development of guidelines for single chronic disease approached the problem of multiple comorbidities? (3) What are the implications of multiple comorbidities for pharmacological treatment? (4) What are the potential changes induced by multiple comorbidities in guidelines? (5) What are the implications of considering a population of older patients with multiple comorbidities in designing clinical trials? Our conclusions are based on available evidence from the published literature, experience from guideline developers, and workshop discussions. We did not attempt to examine all Clinical Practice Guidelines (CPGs) and relevant literature. Instead, we selected CPGs generated by prominent professional organizations and relevant literature published in widely read journals, which are likely to have a high impact on clinical practice. RESULTS AND CONCLUSIONS A widening gap exists between the reality of the care of patients with multiple chronic conditions and the practical clinical recommendations driven by CPGs focused on a single disease, such as COPD. Guideline development panels should aim for multidisciplinary representation, especially when contemplating recommendations for individuals aged 65 years or older (who often have multiple comorbidities), and should evaluate the quality of evidence and the strength of recommendations targeted at this population. A priority area for research should be to assess the effect of multiple concomitant medications and assess how their combined effects are altered by genetic, physiological, disease-related, and other factors. One step that should be implemented immediately would be for existing COPD guidelines to add new sections to address the impact of multiple comorbidities on screening, diagnosis, prevention, and management recommendations. Research should focus on the possible interaction of multiple medications. Furthermore, genetic, physiological, disease-related, and other factors that may influence the directness (applicability) of the evidence for the target population in clinical practice guidelines should be examined.

Multiple chronic conditions and life expectancy: a life table analysis

Background:The number of people living with multiple chronic conditions is increasing, but we know little about the impact of multimorbidity on life expectancy. Objective:We analyze life expectancy in Medicare beneficiaries by number of chronic conditions. Research Design:A retrospective cohort study using single-decrement period life tables. Subjects:Medicare fee-for-service beneficiaries (N=1,372,272) aged 67 and older as of January 1, 2008. Measures:Our primary outcome measure is life expectancy. We categorize study subjects by sex, race, selected chronic conditions (heart disease, cancer, chronic obstructive pulmonary disease, stroke, and Alzheimer disease), and number of comorbid conditions. Comorbidity was measured as a count of conditions collected by Chronic Conditions Warehouse and the Charlson Comorbidity Index. Results:Life expectancy decreases with each additional chronic condition. A 67-year-old individual with no chronic conditions will live on average 22.6 additional years. A 67-year-old individual with 5 chronic conditions and ≥10 chronic conditions will live 7.7 fewer years and 17.6 fewer years, respectively. The average marginal decline in life expectancy is 1.8 years with each additional chronic condition—ranging from 0.4 fewer years with the first condition to 2.6 fewer years with the sixth condition. These results are consistent by sex and race. We observe differences in life expectancy by selected conditions at 67, but these differences diminish with age and increasing numbers of comorbid conditions. Conclusions:Social Security and Medicare actuaries should account for the growing number of beneficiaries with multiple chronic conditions when determining population projections and trust fund solvency.

Healthcare task difficulty among older adults with multimorbidity.

Background:Applying disease-specific guidelines to people with multimorbidity may result in complex regimens that impose treatment burden. Objectives:To describe and validate a measure of healthcare task difficulty (HCTD) in a sample of older adults with multimorbidity. Research Design:Cross-sectional and longitudinal secondary data analysis. Subjects:Multimorbid adults aged 65 years or older from primary care clinics. Measures:We generated a scale (0–16) of self-reported difficulty with 8 HCTD and conducted factor analysis to assess its dimensionality and internal consistency. To assess predictive ability, cross-sectional associations of HCTD and number of chronic diseases, and conditions that add to health status complexity (falls, visual, and hearing impairment), patient activation, patient-reported quality of chronic illness care (Patient Assessment of Chronic Illness Care), mental and physical health (SF-36) were tested using statistical tests for trend (n=904). Longitudinal analyses of the effects of change in HCTD on changes in the outcomes were conducted among a subset (n=370) with ≥1 follow-up at 6 and/or 18 months. All models were adjusted for age, education, sex, race, and time. Results:Greater HCTD was associated with worse mental and physical health [Cuzick test for trend (P<0.05)], and patient-reported quality of chronic illness care (P<0.05). In longitudinal analysis, increasing patient activation was associated with declining HCTD over time (P<0.01). Increasing HCTD over time was associated with declining mental (P<0.001) and physical health (P=0.001) and patient-reported quality of chronic illness care (P<0.05). Conclusions:The findings of this study establish the construct validity of the HCTD scale.