Abstract
New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear. To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area. In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020. Enrollment in the T-HIH program. The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed. A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01). In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.
Highlights
Recent Centers for Medicare & Medicaid Services (CMS) waivers created during the COVID-19 public health emergency have created an opportunity for greatly expanding hospital at home (HaH) services by creating a defined payment mechanism for the program.[1]
Ten participants could not be matched, so analyses were performed for 395 veterans, 98 in the T-Hospital in Home (HIH) group and 297 in the control group
For patients in the transfer hospital in home (T-HIH) group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, −3.77 to 0.61 days), Veterans Affairs (VA) costs were 20% lower (−$5910; 95% CI, −$13 049 to $1229), combined VA and Medicare costs were 22% lower (−$7002; 95% CI, −$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, −6.5 days; 95% CI, −12.1 to −0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01)
Summary
Recent Centers for Medicare & Medicaid Services (CMS) waivers created during the COVID-19 public health emergency have created an opportunity for greatly expanding hospital at home (HaH) services by creating a defined payment mechanism for the program.[1]. HaH is a program that provides hospital-level care outside the hospital, usually at home.[4] In the US, rigorous observational[5] and randomized[6] studies of admission-avoidance HaH, in which patients are admitted directly to HaH, usually from a hospital emergency department, have demonstrated shorter lengths of stay, less delirium, improved function, and lower costs. Less is known about transfer HaH,[3,6,7,8] where the program facilitates the transfer of patients being treated in the hospital, who require ongoing hospital-level care, to complete their hospital care at home. A challenge for programs is whether the additional costs of hospital-level care at home (and their duration) could outweigh an additional period in the hospital, followed by less-expensive skilled home health care
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