Hospital Care at Home Cuts Healthcare Costs in Half at MA Hospital

March 28, 2018 - Healthcare costs for an acute care episode were 52 percent lower when acutely ill patients received hospital care at home, rather than being placed in a hospital bed, according to a recent study in the Journal of General Internal Medicine.

The results from the small case study at Brigham and Women’s Hospital (BWH) and affiliated Faulkner Hospital indicated that patients who are admitted to the emergency department can safely receive hospital-level care in the comforts of their own home and save hospitals money.

“We haven’t dramatically changed the way we’ve taken care of acutely ill patients in this country for almost a century,” wrote lead author David Levine, MD, MPH, MA, a physician and researcher in the Division of General Internal Medicine and Primary Care at BWH. “There are a lot of unintended consequences of hospitalization. Being able to shift the site of care is a powerful way to change how we care for acutely ill patients and it hasn’t been studied in the US with intense rigor.”

Hospital care is a major cost driver. The Healthcare Cost and Utilization Project reported that there was over 35.7 million inpatient stays in 2015, with actual costs per stay averaging $11,259.

Allowing patients to recover or receive care in the home represents an opportunity to reduce the occurrence of expensive hospital stays and free up beds in the hospital for severely ill patients. But providers have expressed concerns that at-home care may not decrease costs or that the cost-reduction will jeopardize patient safety and care quality.

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The recent case study at BWH involving 57 patients countered those concerns. The analysis showed that hospitals may be able to reduce healthcare costs with hospital-level care at home without decreasing care quality.

The Boston-based hospital selected eligible patients to participate in the at home care model who were admitted to the emergency department with an infection or exacerbations of heart failure, chronic obstructive pulmonary disease, or asthma.

These patients received a daily visit from an attending general internist and twice-daily visits from a home health registered nurse. The at-home care model also included 24-hour physician coverage, acute care similar to that offered in a traditional hospital setting to acutely ill patients, and the use of “cutting-edge connectivity” (e.g., continuous monitoring, video, and texting).

“This differs from most home-based models in its ability to handle high patient acuity and enmesh physician medical decision-making with a patient-tailored care team,” researchers added.

Compared to a control group of patients treated in the hospital, patients who were treated at home experienced fewer laboratory tests (6 tests versus 19 tests) and received provider consultations less often (0 percent versus 27 percent).

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Patients receiving hospital care in their own homes also used fewer healthcare services. At-home patients received a median of one physician visit and two nurse visits, while patients admitted to the hospital had a median of three physician visits and four nurse visits.

Lower utilization of services and staff time resulted in acute care episodes for at-home patients to be about half the cost of similar episodes in the hospital. And those savings extended into the post-discharge period.

The median direct healthcare costs for the acute care episode and 30 days after discharge were 67 percent lower for at home patients, with trends toward less use of home health services, fewer hospital readmissions, and better primary care follow-up within 14 days of discharge.

While healthcare costs dropped under the new care model, care quality was not significantly different compared to the quality of the control group in the hospital.

Researchers observed no adverse safety events and no transfers back to the hospital among at-home patients. Pain scores were similar for both groups and providers similarly delivered influenza vaccination, smoking cessation counseling, pneumococcal vaccination, and the CMS heart failure measures (e.g., beta blocker for heart failure with reduced ejection fraction).

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Care quality may have been slightly better for at home patients, the study added. Acutely ill patients treated at home experienced more physical activity time per day (209 minutes versus 78 minutes) and spent more time in the upright position (4.8 hours a day versus 2.7 hours a day).

Patients in the control group also experienced more hospital-acquired disabilities compared to at home patients. Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) were 9 percent and 18 percent worse at discharge, respectively, for patients treated at the hospital.

The small number of patients offered hospital-level care at their homes did not experience a decrease in ADLs and IADLs.

Researchers pointed out that the case study at BWH only involved a small number of patients. But the model has potential to significantly reduce the costs of hospital care for a larger number of qualifying patients while ensuring they are treated safely and comfortably.

“The home hospital model delivers care in a more patient-centered manner: patients can be surrounded by their family and friends, eat their own food, move around in their own home, and sleep in their own bed, with the supports of the home hospital team,” said Levine.

Levine and his team plan to conduct a larger scale trial in the near future to prove hospital care in the home is possible for more patients, Brigham and Women’s Hospital reported.