Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences

Abstract

This case-control study compares the patient outcomes and ratings of care between patients who received hospital-at-home care bundled with a 30-day postacute transitional care period vs traditional inpatient care.

Key Points

Question

What is the association of providing hospital-at-home care bundled with a 30-day postacute period of home-based transitional care with clinical outcomes and patients’ experiences compared with traditional inpatient care?

Findings

This case-control study with 507 participants found that compared with patients receiving inpatient care, patients receiving hospital-at-home care had shorter length of stay; lower rates of 30-day hospital readmission, emergency department visits, and skilled nursing facility admissions; and better ratings of care. There were no differences in the rates of adverse events.

Meaning

Hospital-at-home care bundled with a 30-day episode of postacute transitional care may be a safe and effective alternative to inpatient care for some patients.

Abstract

Importance

Hospital-at-home (HaH) care provides acute hospital-level care in a patient’s home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care.

Objective

To report outcomes of this new payment model for HaH care.

Design, Setting, and Participants

Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated.

Exposures

HaH care or inpatient care.

Main Outcomes and Measures

Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting.

Results

Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, −2.3 days; 95% CI, −1.8 to −2.7 days; weighted P < .001); lower rates of readmissions (8.6% [25] vs 15.6% [32]; difference, −7.0%; 95% CI, −12.9% to −1.1%; weighted P < .001), ED revisits (5.8% [17] vs 11.7% [24]; difference, −5.9%; 95% CI, −11.0% to −0.7%; weighted P < .001), and SNF admissions (1.7% [5] vs 10.4% [22]; difference, −8.7%; 95% CI, −13.0% to −4.3%; weighted P < .001); and were also more likely to rate their hospital care highly (68.8% [119] vs 45.3% [67]; difference, 23.5%; 95% CI, 12.9% to 34.1%; weighted P < .001). There were no differences in referrals to certified home health agencies.

Conclusions and Relevance

HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare’s current portfolio of shared savings programs.