Hospital at home plus transition care reduced readmissions, improved patient satisfaction in a case-control study

A trial that bundled hospital-at-home (HaH) care with 30 days of postacute transitional care found shorter lengths of stay, fewer readmissions, and higher patient satisfaction compared to usual hospital care.

Hah programs enable patients to receive hospital-level care in their homes rather than typical home care; although the details of different HaH models may differ slightly, all provide services usually available only in the hospital.

The case-control study included 295 patients treated under this HaH-Plus model from Nov. 18, 2014, to Aug. 31, 2017, in New York City. All had fee-for-service Medicare and acute medical illness requiring inpatient-level care. The control group consisted of 212 patients who met HaH eligibility but declined participation or were seen in the ED when an HaH admission could not be initiated. The mean age of the study patients was 74.6 years, and 68.6% were women. Results were published by JAMA Internal Medicine on June 25.

Compared to the controls, HaH patients had shorter acute length of stay (3.2 days vs. 5.5 days; difference, −2.3 days [95% CI, −1.8 to −2.7]; P<0.001) and lower rates of readmission (8.6% vs. 15.6%; difference, −7.0% [95% CI, −12.9% to −1.1%]; P<0.001), ED revisits (5.8% vs. 11.7%; difference, −5.9% [95% CI, −11.0% to −0.7%]; P<0.001), and skilled nursing facility admission (1.7% vs. 10.4%; difference, −8.7% [95% CI, −13.0% to −4.3%]; P<0.001). They were also more likely to rate their hospital care highly (68.8% vs. 45.3%; difference, 23.5% [95% CI, 12.9% to 34.1%]; P<0.001).

This HaH intervention differed from previous ones by including more diagnoses (19, representing 65 diagnosis-related groups) and bundling HaH with 30 days of postacute care to improve care coordination, facilitate access, and enhance postacute illness self-management. “Although a randomized trial design might have provided a more precise figure for the efficacy of postacute care coupled with HaH care, our findings suggest that this extension of HaH care enhances its effect,” the authors said.

The authors also highlighted some noteworthy differences between the groups—the HaH patients had lower urinary catheter insertion rates but also lower ratings of their pain management. The study was limited by its observational design and was subject to selection bias, although HaH patients were older and had more functional impairment than controls, which would be expected to bias outcomes in favor of controls. The results of this study led the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to recommend full implementation of this model as a Medicare alternative payment model, the authors reported.

An accompanying commentary was more cautious about the model's potential, saying that “a rigorous test of the HaH-Plus payment model in select conditions seems more appropriate than the wide-scale implementation recommended by the PTAC.” Challenges include maintaining quality and safety, avoiding unintended consequences, and designing a bundled payment, the editorialists said.