Outcomes Research in Review

Bundled Hospital-at-Home and Transitional Care Program Is Associated with Reduced Rate of Hospital Readmission

Federman AD, Soones T, DeCherrie LV, et al. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med. 2018;178:1033-1040.


 

References

Study Overview

Objective. To examine the effect of a hospital-at-home (HaH) and transitional care program on clinical outcomes and patient experiences when compared with inpatient hospitalization.

Design. Cohort study with matched controls.

Setting and participants. The study was conducted in a single center and aimed to evaluate a HaH program bundled with a 30-day postacute period of home-based transitional care. The program is funded by the Center for Medicare and Medicaid Innovation of the Centers for Medicare and Medicaid Services (CMS) with the goal of establishing a new HaH program that provides acute hospital-level care in a patient’s home as a substitute for transitional inpatient care.

Patients were eligible for the program if they were aged 18 years or older, lived in Manhattan, New York, had fee-for-service Medicare or private insurer that had contracted for HaH services, and required inpatient hospital admission for eligible conditions. Eligible conditions included acute exacerbations of asthma or chronic obstructive pulmonary disease, congestive heart failure (CHF), urinary tract infections (UTI), community-acquired pneumonia (CAP), cellulitis of lower extremities, deep venous thrombosis, pulmonary embolism, hypertensive urgency, hyperglycemia, and dehydration; this list was later expanded to 19 conditions representing 65 diagnosis-related groups. Patients were excluded if they were clinically unstable, required cardiac monitoring or intensive care, or lived in an unsafe home environment. Patients were identified in the emergency department (ED) and approached for enrollment in the program. Patients who were eligible for admission but refused HaH admission, or those who were identified as eligible for admission but for whom HaH clinicians were not available were enrolled as control patients.

Intervention. The HaH intervention included physician or nurse practitioner visits at home to provide acute care services including physical examination, illness and vital signs monitoring, intravenous infusions, wound care, and education regarding the illness. Nurses visited patients once or more a day to provide most of the care, and a physician or nurse practitioner saw patients at least daily in person or via video call facilitated by the nurse. A social worker also visited each patient at least once. Medical equipment, phlebotomy, and home radiography were also provided at home as needed. Patients were discharged from acute care when their acute illness resolved; subsequently, nurses and social workers provided self-management support and coordination of care with primary care.

Main outcome measures. Main study outcome measures include duration of the acute care period (length of stay [LOS]) and 30-day all-cause hospital readmissions or ED visits, transfer to a skilled nursing facility, and referral to a certified home health care agency. LOS was defined as being from the date the patient was listed for admission by an ED physician to the date that post-acute care was initiated (for HaH) or hospital discharge (for control patients). Other measures include patient’s rating of care measured using items in 6 of the 9 domains of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that were most salient to care at home, including communication with nurses, communication with physicians, pain management, communication about medicines, discharge information, and overall hospital rating.

Main results. The HaH clinical team approached 460 patients and enrolled 295 to the program. A total of 212 patients who were admitted to the hospital were enrolled as control patients. HaH patients were older than control patients, with an average age of 76.9 years (SD, 16.6) and 71.5 years (SD 13.8), respectively, and more likely to have at least 1 functional limitation (71.5% vs. 55.5%). The most frequent admission diagnoses to HaH were UTIs, CAP, cellulitis, and CHF. HaH patients had a shorter hospitalization LOS (3.2 days) compared with the control group (5.5 days; 95% confidence interval [CI], –1.8 to –2.7 days). HaH patients were less likely to have 30-day all-cause hospital readmissions (8.6% vs. 15.6%; 95% CI, –12.9% to –1.1%) and 30-day ED revisits (5.8% vs. 11.7%) compared to controls. Analysis adjusted for age, sex, race, ethnicity, education, insurance type, physical function, general health, and admitting diagnosis found that HaH patients had lower odds of hospital readmission (odds ratio [OR], 0.43; 95% CI, 0.36-0.52) and lower odds of ED revisits (OR, 0.39; 95% CI, 0.31-0.49). HaH patients reported higher ratings for communication with nurses and physicians and communication about medicines when compared with controls; they were also more likely to report the highest rating for overall hospital care (68.8% vs. 45.3%). Scores for pain management were lower for HaH patients when compared with controls.

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