Home hospital care.

Abstract

To the Editor: All proponents of intensive medical care in the home will find gratification and encouragement in the innovative Home Hospitalization (HH) program of Leff and colleagues.1 Their model brings technical and medical expertise to the patient's home at a new and exciting level. Moreover, their programmatic, meticulous development of this enterprise, so fully documented,2, 3 provides the opportunity to evaluate both the extensive planning and support this endeavor required and its impact on patients and patient care. The report of the 17 patients who inaugurated this program emphasizes further the diversity found in the management of home hospital care. Home hospitalization can focus on specific clinical needs or can serve heterogeneous populations; it can build on a preexisting homecare network, including physician home visits, or it can stand independently. However, HH must always be distinguished by the constant availability of a physician, the coordinated, multi-disciplinary staff, and the provision of acute care of limited duration. Leff and his colleagues acknowledge the multiplicity of HH models in their discussion, and it is appropriate, on the occasion of their report, to take stock of the HH phenomenon worldwide. The largest HH program described in the English, medical literature is that founded in Jerusalem in November 1991.4, 5 By the end of 1998, 5141 patients had received care in this setting. The hub of its team approach is indeed the physician, with other medical professionals, such as nurses and physiotherapists, participating regularly at the physician's discretion. In the Jerusalem experience, the diseases most suitable for HH care have been those selected a priori by Leff and colleagues: 40% of patients have heart disease, 19% nonrespiratory infections, and 14% respiratory diseases. On the other hand, in Jerusalem only 15% of HH patients live alone compared with 53% of the patients whom Leff and colleagues recruited. This suggests that HH patients in Jerusalem are more likely to be functionally dependent even before their acute illness. The Jerusalem HH program does not provide chronic care. Median duration of HH is 4 weeks, and more than two-thirds of patients are discharged within 2 months. Patients requiring longer care frequently have special needs, for example, chronic ventilation, or are patients with advanced malignancies. The economic feasibility of HH in Jerusalem was established when a population without access to HH was available for comparison.4 Now that other prepaid medical providers have also opted to provide brief, intensified physician home-care to facilitate hospital discharge, such comparisons are no longer possible. However, it is noteworthy that in the absence of sweeping changes in financing hospital care in Israel, such as a diagnosis-related groups (DRG) scheme, the HH target population continues to experience falling per capita hospitalization rates, which had declined by 8.5% by the end of 1997. The estimated savings derived from decreased hospital utilization by 1997 exceeded program costs by a factor of 2.9. The Jerusalem HH program curtails costs by discharging patients rapidly to their homes or by preventing anticipated hospital care. The model developed by Leff et al., on the other hand, enters the scene immediately after the decision to hospitalize has been made and then provides a direct home-based alternative to in-patient care. Interestingly, in this paradigm, the savings reaped by HH care in comparison with hospitalizations of similar length increase with the duration of care. No firm conclusions can be drawn from the small numbers of this premiere report, but the trend that Leff and colleagues present shows little increase in overall cost when HH increases from 4 to 8 days. This most likely stems from the unavoidable cost of extensive testing in the initial patient evaluation. The cost efficiency of home care grows over time as the patient's course becomes more predictable and the treatment better focused. The medical economic environment in the United States, in which the length of a hospital stay is strictly proscribed, dictates early HH intervention. However, the first hospital day may not always be the optimal time to initiate HH, and the discharge from the acute department may not be the last opportunity to provide HH economically. Intensive homecare can also replace rehabilitation department or subacute institutional care that sometimes follows acute medical care in the DRG era. The home hospital venture promises to be an exciting mode of care for geriatricians in the future and, it is hoped, will entice medical economists and managers as well. New strides must be scrupulously monitored and rigorously judged, as Leff and colleagues have done in exemplary fashion, but they must also set out in several directions in order to discover the most fertile terrain.