Days spent at home in the last 6 months of life has in recent years been proposed as a highly patient-centered quality measure: It focuses on what patients want. The focus on days at home arises from the recognition that reductions in hospital length of stay have come at the cost of more frequent discharges to and more days spent in subacute nursing and rehabilitation facilities, sometimes in a vicious cycle, leading to longer times spent away from home. This defect in the health care system is structural: Inter-facility transfer is seen by many as a feature, not a defect, of the system.
Hospital at Home (HaH), a model of care that provides hospital-level care in a patient’s home in lieu of traditional hospital care for patients who are not enrolled in hospice, provides an opportunity to resolve this defect and improve patient experience and quality of care. In 2015, The Mount Sinai Health System implemented HaH-Plus through a Center for Medicare and Medicaid Innovation (CMMI) Health Care Innovation Award. HaH-Plus supplements acute HaH services with 30 days of post-acute transition services. Similar to previous studies, compared with control patients who received traditional hospital care, those who received HaH-Plus care had decreased readmissions, delirium, falls, and hospital-acquired infections, as well as better patient experience.
HaH-Plus is neither hospice care nor care designed specifically for persons at the end of life, but we found that HaH-Plus care was associated with more days at home in the last 180 days of life. We examined the medical records and Medicare claims data for all HaH-Plus and control patients who died within 180 days of receiving HaH-Plus or traditional hospital care. Control patients were eligible for HaH-Plus care but admitted to the hospital because they either arrived during non-admitting hours for HaH-Plus or refused HaH-Plus care.
During our 3-year CMMI award period, 361 Medicare patients received HaH-Plus, 236 of whom were Medicare fee-for-service with available claims data. Of 212 control patients, 109 were Medicare fee-for-service with available claims. Among the 236 HaH-Plus patients, there were 25 deaths, and among 109 controls, there were 12 deaths within 180 days of treatment.
HaH-Plus Program Reduces Patient Days Spent in Health Care Facilities in Final 180 Days of Life
HaH-Plus patients spent an average of almost 20 days more outside of health care facilities in their last 6 months of life compared to control patients (170.3 days vs. 150.5 days, respectively). Much of the difference was due to a sharp reduction in days spent in the inpatient hospital setting, 23.8 days for the control cohort versus only 5.7 for HaH-Plus patients.
Fewer days spent in facilities for HaH-Plus patients likely occurred through various mechanisms. HaH-Plus patients avoided hospital days for treatment of their initial acute medical illness. Receiving care for their initial acute illness at home helped them avoid the hard-wired default discharge pathway from the hospital into additional facility-based care such as inpatient rehabilitation or skilled nursing facility care. The HaH-Plus patients experienced fewer complications (delirium, falls, and hospital-acquired infections) that would have added hospital or skilled nursing days. Care at home provided in the post-acute phase of HaH-Plus resulted in lower readmission rates to the hospital. Also, because HaH-Plus patients were already at home, they may have been more likely to have their preference to receive care at home honored.
As we describe above, Hospital at Home is distinctly not hospice care. The vast majority of HaH patients studied to date across multiple trials are neither identified to be hospice eligible nor in their last 6 months of life upon enrollment. Yet they do share at least one feature: They both increase days at home at the end of life. However, hospice requires recognition and acknowledgement that death is near and a change in Medicare benefits for patients who elect it. By disrupting the usual pathways of where acute care is provided, HaH-Plus care creates the opportunity for more days at home at the end of life for a larger number of patients — not as a substitute, but rather as another option for those who do not wish to or have not elected such services. Finally, this review of our HaH-Plus experience provides an additional example of how health systems can effect meaningful improvement in an outcome of great importance to patients.