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Goyal A, Taylor S. Health equity and Hospital at Home programs. J Hosp Med 2024; 19:435-439. [PMID: 38488219 DOI: 10.1002/jhm.13326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Anupama Goyal
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephanie Taylor
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Liu Y, Du S, Liu C, Xue T, Tang Y. Preference of primary care patients for home-based healthcare and support services: a discrete choice experiment in China. Front Public Health 2024; 12:1324776. [PMID: 38699415 PMCID: PMC11063295 DOI: 10.3389/fpubh.2024.1324776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Importance This research, utilizing discrete choice experiments, examines the preferences and willingness to pay for home-based healthcare and support services among residents in China, a country grappling with severe aging population, an area often underexplored in international scholarship. Objectives This study aims to solicit the preferences of primary care patients for home-based healthcare and support services in China. Design setting and participants A discrete choice experiment (DCE) was conducted on 312 primary care patients recruited from 13 community health centers in Wuhan and Kunming between January and May 2023. The experimental choice sets were generated using NGene, covering five attributes: Scope of services, health professionals, institutions, insurance reimbursements, and visiting fees. Main outcomes and measures The choice sets were further divided into three blocks, and each participant was asked to complete one block containing 12 choice tasks. Mixed logit models were established to estimate the relevant importance coefficients of and willingness to pay for different choices, while Latent Class Logit (LCL) modeling was conducted to capture possible preferences heterogeneity. Results The relevant importance of the scope of services reached 67.33%, compared with 19.84% for service institutions and 12.42% for health professionals. Overall, respondents preferred physician-led diagnostic and treatment services. LCL categorized the respondents into three groups: Group one (60.20%) was most concerned about the scope of services, prioritizing disease diagnosis and treatment over preventive care and mental health, while group two (16.60%) was most concerned about care providers (hospitals and medical doctors were preferred), and group three (23.20%) was most concerned about financial burdens. Conclusion Primary care patients prefer physical health and medical interventions for home-based healthcare and support services. However, heterogeneity in preferences is evident, indicating potential disparities in healthcare and support at home services in China.
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Affiliation(s)
- Yaqing Liu
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Sixian Du
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaojie Liu
- Department of Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Tianqin Xue
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuqing Tang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Wuhan, Hubei, China
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Hayden EM, Nentwich LM, Jung OS, Zheng H, White BA. Patient Perceptions of Emergency Department Observation Care at Home. Telemed J E Health 2024. [PMID: 38597956 DOI: 10.1089/tmj.2023.0705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Introduction: The Virtual Observation Unit (VOU) utilizes telehealth and community paramedicine to provide observation-level care in patients' homes. Patients' experience of this novel program has not been reported. Methods: A phone-based patient experience survey was administered to the patients who were admitted to the VOU at an urban, academic Emergency Department in the Northeast United States. The survey asked about patient's perception of the program's quality of care (0 = worst care possible, 10 = best care possible). t Tests with a Bonferroni adjustment assessed for differences between patient demographic groups. Results: The survey response rate was 40% (124/307). Overall mean scores for perceived quality of care were very high (9.51 ± 1.19). There were no significant differences in patient's perception of quality of care between demographic cohorts of age, gender, race, or ethnicity. Conclusions: Patient experience with a novel VOU program was very positive and did not differ significantly by demographic cohort. Further research is warranted.
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Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren M Nentwich
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Olivia S Jung
- Department of Health Policy and Management, University of California-Los Angeles, Los Angeles, California, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E, Disher G, Buchbinder R, O'Connor D. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev 2024; 3:CD014765. [PMID: 38438114 PMCID: PMC10911892 DOI: 10.1002/14651858.cd014765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale. OBJECTIVES (1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services. SEARCH METHODS We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders. DATA COLLECTION AND ANALYSIS Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home. MAIN RESULTS From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services. AUTHORS' CONCLUSIONS Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.
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Affiliation(s)
- Jason A Wallis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cabrini Health, Malvern, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Petra Makela
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jia Xi Han
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Evie M Tripp
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emma Gearon
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gary Disher
- New South Wales Ministry of Health, St Leonards, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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van Goor HMR, de Hond TAP, van Loon K, Breteler MJM, Kalkman CJ, Kaasjager KAH. Designing a Virtual Hospital-at-Home Intervention for Patients with Infectious Diseases: A Data-Driven Approach. J Clin Med 2024; 13:977. [PMID: 38398291 PMCID: PMC10889708 DOI: 10.3390/jcm13040977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/25/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Virtual hospital-at-home care might be an alternative to standard hospital care for patients with infectious diseases. In this study, we explore the potential for virtual hospital-at-home care and a potential design for this population. METHODS This was a retrospective cohort study of internal medicine patients suspected of infectious diseases, admitted between 1 January and 31 December 2019. We collected information on delivered care during emergency department visits, the first 24 h, between 24 and 72 h, and after 72 h of admission. Care components that could be delivered at home were combined into care packages, and the potential number of eligible patients per package was described. The most feasible package was described in detail. RESULTS 763 patients were included, mostly referred for general internal medicine (35%), and the most common diagnosis was lower respiratory tract infection (27%). The most frequently administered care components were laboratory tests, non-oral medication, and intercollegiate consultation. With a combination of telemonitoring, video consultation, non-oral medication administration, laboratory tests, oxygen therapy, and radiological diagnostics, 48% of patients were eligible for hospital-at-home care, with 35% already eligible directly after emergency department visits. CONCLUSION While the potential for virtual hospital-at-home care is high, it depends greatly on which care can be arranged.
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Affiliation(s)
- Harriët M. R. van Goor
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Titus A. P. de Hond
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Kim van Loon
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Martine J. M. Breteler
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Digital Health, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Cor J. Kalkman
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Karin A. H. Kaasjager
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
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Chen H, Ignatowicz A, Skrybant M, Lasserson D. An integrated understanding of the impact of hospital at home: a mixed-methods study to articulate and test a programme theory. BMC Health Serv Res 2024; 24:163. [PMID: 38308304 PMCID: PMC10835828 DOI: 10.1186/s12913-024-10619-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/18/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services. METHODS We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis. RESULTS The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7 days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden. CONCLUSIONS There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.
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Affiliation(s)
- Hong Chen
- Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK
| | - Agnieszka Ignatowicz
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TTT, UK
| | - Magdalena Skrybant
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TTT, UK
| | - Daniel Lasserson
- Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK.
- Department of Geriatric Medicine, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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Cox R, Kyle G, Suzuki A, Wishart L, McCusker M, McConnell A, Ward EC, Ross L, Webb C. Patient and multidisciplinary health professional perceptions of an Australian geriatric evaluation and management and rehabilitation hospital in the home service. J Health Serv Res Policy 2024; 29:31-41. [PMID: 37897739 DOI: 10.1177/13558196231193863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
OBJECTIVES Hospital in the Home models are rapidly expanding in response to increasing bed pressures. This study examined patient and multidisciplinary health professional perceptions of a new geriatric evaluation and management and rehabilitation hospital in the home service in Australia. The service was unique, as adults of all ages with a variety of rehabilitation or geriatric evaluation and management needs were within scope. METHODS A qualitative descriptive approach was used with a consumer co-researcher and a consumer advisor being integral to decision-making. Patient feedback was collected via a paper-based patient satisfaction survey between August 2020 and February 2022. Additionally, interviews with current and past staff were conducted from July to November 2021. Reflexive thematic analysis was conducted for qualitative data and descriptive statistics used for quantitative data. RESULTS Patient surveys were analysed (n = 199, 42.2% response rate) with 60.8% of participants aged 75 years or over and 26.6% speaking a language other than English. High satisfaction was expressed. Feelings of comfort, familiarity, convenience, and reassurance were voiced. A person-centred approach enhanced involvement in care. Challenges included carer burden and clear communication. Sixteen staff (33% response rate) were interviewed. In general, staff said the service was inclusive and responsive, and the home environment beneficial, particularly for patients from culturally diverse backgrounds. A strong hospital partnership and comprehensive multidisciplinary approach were vital. Challenges included fragmentation due to part-time roles and combining with a pre-existing acute hospital in the home service. CONCLUSIONS This qualitative exploration of staff and patients' perceptions of a geriatrician-led, multidisciplinary geriatric evaluation and management and rehabilitation hospital in the home service demonstrated that it was person-centred and optimised patients' control and ownership of care. The inclusive service parameters ensured responsiveness to diverse needs whilst allowing earlier return home from hospital, both of which are vital for quality patient care.
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Affiliation(s)
- Ruth Cox
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Greg Kyle
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Anya Suzuki
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Laurelie Wishart
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Melissa McCusker
- Community and Oral Health, Metro South Health, Brisbane, QLD, Australia
| | - Alexander McConnell
- Consumer Partner, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Elizabeth C Ward
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
- School of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Leo Ross
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Clare Webb
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
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Haywood HB, Fonarow GC, Khan MS, Van Spall HGC, Morris AA, Nassif ME, Kittleson MM, Butler J, Greene SJ. Hospital at Home as a Treatment Strategy for Worsening Heart Failure. Circ Heart Fail 2023; 16:e010456. [PMID: 37646170 DOI: 10.1161/circheartfailure.122.010456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.
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Affiliation(s)
- Hubert B Haywood
- Department of Medicine, Duke University Medical Center, Durham, NC (H.B.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center (G.C.F.)
| | | | - Harriette G C Van Spall
- Department of Medicine (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
- Population Health Research Institute (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
| | | | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.E.N.)
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.S.K., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (S.J.G.)
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Acute home-based care for patients with cancer to avoid, substitute, and follow emergency department visits: a conceptual framework using Porter’s Five Forces. EMERGENCY CANCER CARE 2022; 1:8. [PMID: 35844665 PMCID: PMC9247981 DOI: 10.1186/s44201-022-00008-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/08/2022] [Indexed: 12/04/2022]
Abstract
Background Patients with cancer constitute a large and increasing segment of patients who receive unscheduled hospital-based care due to treatment-related symptoms and disease progression. The initial hospital-based touchpoint for these unscheduled hospitalizations is often the emergency department. Traditional models of emergency department and inpatient hospital-based care are saturated and incapable of scaling to accommodate the future, increased needs projected for this population. New models of care are necessary to address this gap. Acute home-based care is a promising tool potentially providing patient-centric, efficient care to eligible patients. Methods We applied Porter’s Five Forces framework that addresses the bargaining power of buyers and suppliers, threat of substitutes and new entrants, and industry rivalries plus the sixth force of regulation to clarify the factors that will promote or challenge the adoption of a home-based cancer care referral model before or following emergency department visits. Exploring this framework provides insights into the complexities of scaling an acute home-based cancer care model and highlights ways for health systems including hospitals, emergency departments, physician groups, and individual emergency physicians and oncologists to optimize their roles in this emerging model of care. Results We found that current workforce shortages, as well as workflow, infrastructure, and regulatory complexities, pose major challenges that unless carefully addressed may restrict the growth of acute home-based cancer care. Additional uncertainties persist around appropriate payment models and the competitive landscape. Key promoting factors include the recognized need in the cancer community and among payers for new models to decrease unscheduled hospitalizations and emergency department visits as well as the uptake of home-based and technology-enabled solutions during the COVID-19 pandemic. A better understanding of these forces helps to clarify the risks and opportunities as new entrants build their programs. Conclusions Acute home-based cancer care is a promising tool to complement traditional outpatient clinics, emergency departments, and inpatient hospital-based models of cancer care. New technologies and policies increasingly enable a broader scope of cancer care in the home setting.
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KADAKIA KUSHALT, BALATBAT CELYNNEA, SIU ALBERTL, COHEN IGLENN, WILKINS CONSUELOH, DZAU VICTORJ, OFFODILE 2nd ANAEZEC. Hospital-at-Home: Multistakeholder Considerations for Program Dissemination and Scale. Milbank Q 2022; 100:673-701. [PMID: 36148893 PMCID: PMC9576240 DOI: 10.1111/1468-0009.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Policy Points Hospital-at-Home (HaH) is a home-based alternative for acute care that has expanded significantly under COVID-19 regulatory flexibilities. The post-pandemic policy agenda for HaH will require consideration of multistakeholder perspectives, including patient, caregiver, provider, clinical operations, technology, equity, legal, quality, and payer. Key policy challenges include reaching a consensus on program standards, clarifying caregivers' issues, creating sustainable reimbursement mechanisms, and mitigating potential equity concerns. Key policy prescriptions include creating a national surveillance system for quality and safety, clarifying legal standards for care in the home, and deploying payment reforms through value-based models.
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Levine DM, Paz M, Burke K, Beaumont R, Boxer RB, Morris CA, Britton KA, Orav EJ, Schnipper JL. Remote vs In-home Physician Visits for Hospital-Level Care at Home: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2229067. [PMID: 36040741 PMCID: PMC9428739 DOI: 10.1001/jamanetworkopen.2022.29067] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown. OBJECTIVE To compare remote and in-home physician care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020. INTERVENTIONS All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary. MAIN OUTCOMES AND MEASURES The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates. RESULTS A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit. CONCLUSIONS AND RELEVANCE In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04080570.
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Affiliation(s)
- David M. Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mary Paz
- MGH Institute of Health Professions, Boston, Massachusetts
| | | | - Ryan Beaumont
- Northeastern University Bouvé College of Health Sciences, Boston, Massachusetts
| | - Robert B. Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Charles A. Morris
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kathryn A. Britton
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Leff B, DeCherrie LV, Montalto M, Levine DM. A research agenda for hospital at home. J Am Geriatr Soc 2022; 70:1060-1069. [PMID: 35211969 PMCID: PMC9303641 DOI: 10.1111/jgs.17715] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hospital at home (HaH) provides hospital-level care at home as a substitute for traditional hospital care. Interest in HaH is increasing markedly. While multiple studies of HaH have demonstrated that HaH provides safe, high-quality, cost-effective care, there remain many unanswered research questions. The objective of this study is to develop a research agenda to guide future HaH-related research. METHODS Survey of attendees of first World HaH Congress 2019 for input on research for the future HaH development. Selection and ranking of important topic areas for future HaH-related research. Development of research domains and research questions and issues using grounded theory approach, supplemented by focused literature reviews. RESULTS 240 conference attendees responded to the survey (response rate, 55.3%). The majority were from Europe (64%) and North America (11%) and were HaH program leaders (29%), HaH physicians (27%), and researchers (13%). Nine research domains for future HaH research were identified: 1) definition of the HaH model of care; 2) the HaH clinical model; 3) measurement and outcomes of HaH; 4) patient and caregiver experience with HaH; 5) education and training of HaH clinicians; 6) technology and telehealth for HaH; 7) regulatory and payment issues in HaH; 8) implementation and scaling of HaH; and 9) ethical issues in HaH. Key research issues and questions were identified for each domain. CONCLUSIONS While highly evidence-based, unanswered research questions regarding HaH remain, focusing research efforts on the domains identified in this study will serve to improve HaH for all key HaH stakeholders.
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Affiliation(s)
- Bruce Leff
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Linda V DeCherrie
- Department of Geriatric and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael Montalto
- Hospital in the Home Unit, Epworth Hospital, Melbourne, Victoria, Australia
| | - David M Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
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Ouchi K, Liu S, Tonellato D, Keschner YG, Kennedy M, Levine DM. Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities. J Am Coll Emerg Physicians Open 2021; 2:e12517. [PMID: 34322684 PMCID: PMC8295243 DOI: 10.1002/emp2.12517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/27/2021] [Accepted: 07/01/2021] [Indexed: 12/03/2022] Open
Abstract
The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Shan Liu
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Daniel Tonellato
- Department of Emergency MedicineMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
- Department of Emergency MedicineGeorgetown University School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Yonatan G. Keschner
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Maura Kennedy
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - David M. Levine
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal Medicine and Primary CareBrigham and Women's HospitalBostonMassachusettsUSA
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