Jeffrey Burl

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

ADVANCING GERIATRIC NURSING PRACTICE: Geriatric Nurse Practitioners in Long-Term Care: Demonstration of Effectiveness in Managed Care

OBJECTIVE: This study was undertaken to review the impact of utilizing geriatric nurse practitioner/physician (GNP/MD) teams on cost and utilization for a cohort of Medicare HMO enrollees residing in long‐term care facilities. The results would be used by the organization for further development of the GNP Program.

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.

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.

Hip protector compliance: a 13-month study on factors and cost in a long-term care facility

OBJECTIVE To determine if a high compliance rate for wearing external hip protectors could be achieved and sustained in a long-term care population. STUDY DESIGN A 13-month prospective study of daytime use of external hip protectors in an at-risk long-term care population. SETTING One hundred-bed not-for-profit long-term care facility. PARTICIPANTS Thirty-eight ambulatory residents having at least 1 of 4 risk factors (osteoporosis, recent fall, positive fall screen, previous fracture). INTERVENTION The rehabilitation department coordinated an implementation program. Members of the rehabilitation team met with eligible participants, primary caregivers, families, and other support staff for educational instruction and a description of the program. The rehabilitation team assumed overall responsibility for measuring and ordering hip protectors and monitoring compliance. RESULTS By the end of the third month, hip protector compliance averaged greater than 90% daily wear. The average number of falls per month in the hip protector group was 3.9 versus 1.3 in nonparticipants. Estimated total indirect staff time was 7.75 hours. The total cost of the study (hip protectors and indirect staff time) was 6,300 US dollars. CONCLUSIONS High hip protector compliance is both feasible and sustainable in an at-risk long-term care population. Achieving high compliance requires an interdisciplinary approach with one department acting as a champion. The cost of protectors could be a barrier to widespread use. Facilities might be unable to cover the cost until the product is paid for by third-party payers.

Comparison of Stress Experienced by Family Members of Patients Treated in Hospital at Home with That of Those Receiving Traditional Acute Hospital Care

OBJECTIVES: To compare differences in the stress experienced by family members of patients cared for in a physician‐led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations.

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

Health Care Provider Evaluation of a Substitutive Model of Hospital at Home

Objective:To evaluate Hospital at Home (HaH), a substitute for inpatient care, from the perspectives of participating providers. Research Design:Multivariate general estimating equations regression analyses of a patient-specific survey of providers delivering HaH care in a prospective, nonrandomized clinical trial. Subjects:Eleven physicians and 26 nurses employed in 3 Medicare-Advantage plans and 1 Veterans Administration medical center. Measures:Problems with care; benefits; problem-free index. Results:Case response rates were 95% and 82% for physicians and nurses, respectively. The overall problem-free index was high (mean 4.4, median 5, scale 1–5). “Major” problems were cited for 14 of 84 patients (17%), most relating to logistic issues without adverse patient outcomes. Positive effects included quicker patient functional recovery, greater opportunities for patient teaching, and increased communication with family caregivers. In multivariate analysis, the problem-free index was lower for nurses compared with physicians in one site; for patients with cellulitis; and for patients with a higher acuity (APACHE II) score. HaH physicians and nurses differed in their judgments of hours of continuous nursing required by patients. Conclusions:The health care provider evaluation of substitutive HaH care was positive, providing support for the viability of this innovative model of care. Without provider support, no new model of care will survive. These findings also provide insight into areas to attend to in implementation. Organizations considering adoption of the HaH should monitor provider views to promote quality improvement in HaH.