​Providing hospital-level care at a patient's home plus 30 days of postacute care as an alternative to hospitalization after an emergency department (ED) visit has the potential to improve patient outcomes, according to a study published in the August 2018 JAMA Internal Medicine. The study was funded as a demonstration project for the Medicare program, which does not currently pay for the so-called "hospital-at-home" benefit. The study enrolled 507 patients (mean age 74.6 years) treated at two New York City hospital EDs and eligible for hospital admission. Of the 507 patients who met eligibility for the hospital-at-home model, 295 agreed to participate in the program; the remaining 212 control patients who were eligible either refused participation or were treated in the ED at times when the clinicians who could initiate hospital-at-home coverage were unavailable. Some of the most frequently treated diagnoses that qualified patients for the program were urinary tract infections, community-acquired pneumonia, cellulitis, and congestive heart failure. Patients in the hospital-at-home program saw a nurse at least once per day and visited with a physician or nurse practitioner at least daily in person or via video call. Once the acute illness resolved, the 30-day postacute period started with additional services for hospital-at-home patients. Patients cared for at home had shorter acute-period stays than the control patients (3.2 versus 5.5 days) and were less likely than control patients to have 30-day all cause hospital readmissions (8.6% versus 15.6%) or to be transferred to a nursing home (1.7% versus 10.4%). "As health care evolves through a shift in focus to value and patient-centeredness, the [hospital-at-home] program may find increasing appeal among health care systems," the study authors conclude. An editorial accompanying the study says that "important clinical and policy issues" should be addressed before the hospital-at-home payment model is adopted more broadly. For example, minimum standards of care should be developed for care in the home setting as currently exist for care in the hospital setting.

HRC Recommends: Home care is a fast-growing segment of healthcare, but as many established home care providers can attest, home care faces unique risk exposures. The environment of care is largely uncontrolled by staff and is not uniform, and homes are not designed for the provision of healthcare. Healthcare providers should remain attuned to alternative payment models that have the potential to improve patient care and outcomes while evaluating their potential impact on healthcare quality and safety.