Hospital at Home: Progress Made but More Work Needed

In a recent Annals article, Levine and colleagues reported a randomized controlled trial comparing the effect of home hospital care versus usual hospital care on patient outcomes (1). Home hospital interventions included physician and nurse home visits, video communication, remote monitoring, point-of-care tests, and in-home administration of intravenous medications. Compared with usual hospital care, home hospital care led to lower episodic spending, fewer readmissions, and less sedentary time. The researchers concluded that “substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care” (1).

These are important findings in the era of value-based health care. Although value-based payment or delivery reforms differ in specifics, many share a focus on improving care by reducing avoidable utilization, and in particular, hospitalization as a high-cost form of utilization. A notable example of policymaker and payer focus on this issue: In the first year of Primary Care First, a large, forthcoming Medicare value-based payment model, quality among participating practices will be evaluated solely on the basis of patients’ acute hospital utilization rates (with higher performance defined by lower hospitalization rates). In this policy context, findings like those described in the Annals article reflect interest in programs designed to improve quality and address costs by delivering hospital-level services in patients’ homes (collectively termed “hospital at home”).

However, although it is often discussed as a single intervention type, hospital at home in fact encompasses a heterogeneous group of initiatives that have yielded varying results. Moreover, although these programs are often framed as delivering hospital-level care at home, not all such care is equal. Home medication administration and care coordination may work well for certain conditions (for example, such as those chosen by Levine and colleagues) but not for others (for example, the many conditions and diagnoses that excluded patients from study eligibility). Variation in hospital-at-home intervention design and patient populations further complicates the ability to determine if, when, and to what extent hospital at home can in fact substitute for traditional hospital-level care.

In addition, policymakers and clinical leaders should carefully consider several issues as programs are designed, implemented, and evaluated:

1. Strong quality and safety regulations. Given the incentives inherently embedded in hospital at home (specifically, to shift care away from hospitals), strong safety and quality requirements are needed to protect against incentives to skimp on, or under-provide, care in home settings. Regulations are particularly critical given that hospital-at-home programs are not governed by accreditation and other standards that exist in traditional hospitals.
   
   
2. Vigilance about monitoring and interpreting unintended consequences. Every intervention is susceptible to potential unintended consequences. Of particular concern for hospital-at-home programs would be inappropriate shifts of care toward home, away from either hospital care (which might compromise outcomes and quality) or outpatient care (which might lead to overutilization or unnecessary spending). The issue of disparities may also loom large. (For example, in the Annals study, fewer women, black persons, and Medicare–Medicaid dual-eligible beneficiaries were in the intervention group than the control group.)
   
   Even as they monitor for these effects, policymakers and clinical leaders would also do well to carefully consider if and when unintended consequences are in fact undesired. For example, years of experience attempting to reduce hospital readmissions has yielded a critical lesson: Readmissions may be more inappropriate in some cases (for example, if they reflect poor care coordination or transitions from the original admission) but less so in others (for example, if they reflect care needs for higher risk or complexity patients or the natural history of chronic diseases). Similarly, shifts from usual hospital or outpatient settings toward home may be appropriate in some cases but not others.
   
   
3. Interaction with other payment and delivery reforms. It’s one thing to evaluate the benefits, drawbacks, and effects of individual programs; it’s another to do so in the context of other active reforms. This is a key issue for hospital-at-home programs, which have emerged on a landscape with other established and expanding payment (for example, bundled payments) and delivery (for example, telehealth) innovations. How does shifting hospital care to home settings affect these initiatives; or programs targeted at redesigning urgent care, emergency department care, and post–acute care; or the transitions between these settings? These are important considerations for policymakers and practitioners alike.

Given these issues, the final jury remains out on hospital-at-home programs. Policymakers and practice leaders must overcome these and other barriers to understand and quantify the ultimate benefit of these initiatives. Nonetheless, there is reason to be encouraged by the results described in the Annals article and other publications, which underscore hospital at home as a potential innovation that can return value to patients, clinicians, and policymakers.

References

1. Levine DM, Ouchi K, Blanchfield B, et al. Hospital-level care at home for acutely ill adults. A randomized controlled trial. Ann Intern Med. 2020;172:77-85. [PMID: 31842232] doi:10.7326/M19-0600