A randomized controlled trial of a novel home-based palliative care program: A report of a trial that could not be completed.

BACKGROUND: In response to a growing need for accessible, efficient, and effective palliative care services, we designed, implemented, and evaluated a novel palliative care at home (PC@H) model for people with serious illness that is centered around a community health worker, a registered nurse, and a social worker, with an advanced practice nurse and a physician for support. Our objectives were to measure the impact of receipt of PC@H on patient symptoms, quality of life, and healthcare utilization and costs. METHODS: We enrolled 136 patients with serious illness in this parallel, randomized controlled trial. Our primary outcome was change in symptom burden at 6 weeks. Secondary outcomes included change in symptom burden at 3 months, change in quality of life at 6 weeks and 3 months, estimated using a group t-test. In an exploratory aim, we examined the impact of PC@H on healthcare utilization and cost using a generalized linear model. RESULTS: PC@H resulted in a greater improvement in patient symptoms at 6 weeks (1.30 score improvement, n = 37) and 3 months (3.14 score improvement, n = 21) compared with controls. There were no differences in healthcare utilization and costs between the two groups. Unfortunately, due to the COVID-19 pandemic and a loss of funding, the trial was not able to be completed as originally intended. CONCLUSIONS: A palliative care at home model that leverages community health workers, registered nurses, and social workers as the primary deliverers of care may result in improved patient symptoms and quality of life compared with standard care. We did not demonstrate significant differences in healthcare utilization and cost associated with receipt of PC@H, likely due to inability to reach the intended sample size and insufficient statistical power, due to elements beyond the investigators' control such as the COVID-19 public health emergency and changes in grant funding.

Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis.

OBJECTIVES: To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes. DESIGN: Comparative effectiveness analysis. SETTING AND PARTICIPANTS: Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535). METHODS: We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community. RESULTS: The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different. CONCLUSIONS AND IMPLICATIONS: RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.

If You Give Them Away, It Still May Not Work: Challenges to Video Telehealth Device Use Among the Urban Homebound.

The growing homebound population may particularly benefit from video telehealth. However, some patients do not have the ability or resources to successfully use this modality. This report presents the experience of a large urban home-based primary care program disseminating cellular-enabled tablets with basic instruction to a subset of its patients who would not otherwise have had the ability to engage in video telehealth. Program goals included: increasing the number of patients able to engage in video encounters and leveraging technology to help achieve greater equity. While 123 homebound patients received devices for telehealth, only one-third successfully utilized them. We identified multiple barriers to telehealth utilization beyond physical access to a device, including a lack of skill. Efforts to increase video encounters among patient groups who are less experienced with technology cannot simply rely on device provision or basic instruction but must include reinforced learning strategies combined with ongoing technical assistance.

A Home Repair and Modification Program Embedded Within Mount Sinai Visiting Doctors.

The purpose of this study was to conduct an evaluation of a home modification and repair pilot program implemented within Mount Sinai Visiting Doctors. This program enrolled patients via referral from the home-based clinical team between August 15, 2019 and December 31, 2020. Patient functional status and home modification and repair needs were assessed by a social worker and subsequent interventions were tracked. This study includes two separate, concurrent analyses: (1) descriptive analyses based on data on program enrollees, repairs, and costs and (2) provider perspectives on the program. The program enrolled 33 patients. The average spending per patient was $528. The clinical team found this program feasible to implement and helped reduce burnout. Future program implementation and expansion will require more investment in staffing to ensure timely needs assessment and service delivery, and the addition of an occupational therapist to better assess and meet patient functional needs.

Development of telehealth principles and guidelines for older adults: A modified Delphi approach.

The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations.

Outcomes of home-based primary care for homebound older adults: A randomized clinical trial.

BACKGROUND: Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited. METHODS: We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients. RESULTS: The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p = 0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p = 0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p = 0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001). CONCLUSION: HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination.

A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.

Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period.

BACKGROUND: Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. METHODS: A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. RESULTS: Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower. CONCLUSIONS: HaH combined with 30-day post-acute transition care was less costly than inpatient care.

A research agenda for hospital at home.

BACKGROUND: Hospital at home (HaH) provides hospital-level care at home as a substitute for traditional hospital care. Interest in HaH is increasing markedly. While multiple studies of HaH have demonstrated that HaH provides safe, high-quality, cost-effective care, there remain many unanswered research questions. The objective of this study is to develop a research agenda to guide future HaH-related research. METHODS: Survey of attendees of first World HaH Congress 2019 for input on research for the future HaH development. Selection and ranking of important topic areas for future HaH-related research. Development of research domains and research questions and issues using grounded theory approach, supplemented by focused literature reviews. RESULTS: 240 conference attendees responded to the survey (response rate, 55.3%). The majority were from Europe (64%) and North America (11%) and were HaH program leaders (29%), HaH physicians (27%), and researchers (13%). Nine research domains for future HaH research were identified: 1) definition of the HaH model of care; 2) the HaH clinical model; 3) measurement and outcomes of HaH; 4) patient and caregiver experience with HaH; 5) education and training of HaH clinicians; 6) technology and telehealth for HaH; 7) regulatory and payment issues in HaH; 8) implementation and scaling of HaH; and 9) ethical issues in HaH. Key research issues and questions were identified for each domain. CONCLUSIONS: While highly evidence-based, unanswered research questions regarding HaH remain, focusing research efforts on the domains identified in this study will serve to improve HaH for all key HaH stakeholders.

Outcomes of Hospital at Home for Older Adults with and without High Levels of Social Support.

The evaluation of social support within hospital at home (HaH) programs has been limited. We performed a secondary analysis of a prospective cohort evaluation of 295 participants receiving HaH care and 212 patients undergoing traditional hospitalization from November of 2014 to August of 2017. We examined the confounding and moderating effects of instrumental and informational social support upon length of stay and 30-day rehospitalization, emergency department (ED) visit, and skilled nursing facility admission. Instrumental social support attenuated the effects of HaH upon any ED visit (base model: OR 0.61, p = 0.037; controlling for social support: OR 0.71, p = 0.15). The association of HaH with other outcomes remained unchanged. Interactions between HaH and informational or instrumental social support for all outcomes were not significant. Lack of high levels of social support had little effect on the positive outcomes of HaH care, suggesting similar benefits of HaH services for patients with lower levels of social support.

Hospital at Home services: An inventory of fee-for-service payments to inform Medicare reimbursement.

BACKGROUND: Hospital at Home (HaH) is a growing model of care with proven patient benefits. However, for the types of services required to provide an episode of HaH, full Medicare reimbursement is traditionally paid only if care is provided in inpatient facilities. DESIGN: This project identifies HaH services that could be reimbursable under Medicare to inform episodic care within fee-for-service (FFS) Medicare. SETTING: All data are derived from acute services provided from the Mount Sinai HaH program between 2014 and 2017 as part of a Center for Medicare and Medicaid Innovation (CMMI) demonstration program. PARTICIPANTS: The sample was limited to patients with one of the following five admitting diagnoses: urinary tract infection (n = 70), pneumonia (n = 60), cellulitis (n = 45), heart failure (n = 37), and chronic lung disease (n = 24) for a total of 236 acute episodes. MEASUREMENTS: HaH services were inventoried from three sources: electronic medical records, Medicare billing and itemized vendor billing. For each admitting diagnosis, four reimbursement scenarios were evaluated: (1) FFS Medicare without a home health episode, (2) FFS Medicare with a home health episode, (3) two-sided risk ACO with a home health episode, and (4) two-sided risk ACO without a home health episode. RESULTS: Across diagnoses, there were 1.5-1.9 MD visits and 1.5-2.7 nursing visits per episode. The Medicare FFS model without home health care had the lowest reimbursement potential ($964-$1604) per episode. The Medicare fee-for-service within ACO models with home health care had the greatest potential for reimbursement $4519-$4718. There was limited variation in costs by diagnosis. CONCLUSION AND RELEVANCE: Though existing payment models might be used to pay for many HaH acute services, significant gaps in reimbursement remain. Extending the benefits of HaH to the Medicare beneficiaries that are likely to derive the greatest benefit will require new payment models for FFS Medicare.

Choosing Inpatient vs Home Treatment: Why Patients Accept or Decline Hospital at Home.

BACKGROUND/OBJECTIVES: Hospital at home (HaH) provides interdisciplinary acute care in the home as a substitute for inpatient hospitalization. Studies have demonstrated that HaH care is associated with better quality care, fewer complications, and better patient and caregiver experience. Still, some patients decline HaH. The objective of the study was to characterize patients who accept vs decline HaH care and describe reasons for their decisions in the context of a Center for Medicare and Medicaid Innovation demonstration of HaH. DESIGN/SETTING/PARTICIPANTS: A total of 442 patients with Medicare or other eligible insurance, 18 years or older, who met study eligibility criteria were offered HaH at Mount Sinai Hospitals in New York, NY, between September 1, 2014, and August 31, 2017. MEASUREMENTS: Reasons for accepting or declining HaH were recorded. Age, sex, insurance type, and admission diagnoses of HaH acceptors and refusers were compared in univariate analyses. RESULTS: Of the 442 patients offered HaH, 66.7% accepted. Main reasons for enrolling in HaH included being more comfortable at home (78.2%) and being near family (40.7%). Specific reasons given for refusing HaH included preferring in-hospital care (15.0%) and concern that HaH would not meet care needs (12.9%). CONCLUSION: Two-thirds of patients offered HaH care opted to receive it. The reasons for declining HaH provided by those who chose not to participate should be considered for quality improvement, and reasons for acceptance may be helpful in marketing and other efforts to promote HaH participation. J Am Geriatr Soc 68:1579-1583, 2020.

Implementation of Post-Acute Rehabilitation at Home: A Skilled Nursing Facility-Substitutive Model.

OBJECTIVES: For patients who require frequent and intensive therapy services after hospitalization, rehabilitation is predominantly provided in skilled nursing facilities (SNFs). Delivering post-acute rehabilitation in patients' homes offers a potential alternative. Our aim was to describe and evaluate services and functional outcomes and then identify factors associated with the provision of a 30-day post-acute care (PAC) bundle of rehabilitation, medical, and social services provided via the Rehabilitation at Home (RaH) program. DESIGN: Single-arm retrospective review of patients participating in the RaH program. SETTING: Multidisciplinary home-based delivery of PAC in Manhattan. PARTICIPANTS: Individuals 18 years or older residing in a specified catchment area and qualifying for SNF-based rehabilitation services from October 2015 to September 2017. RESULTS: A total of 237 patients participated in RaH over 264 episodes of care. Participants were predominantly older than 85 years (57%; mean = 84.2; standard deviation [SD] = 10.0 years) and of non-Hispanic white (70%) race and ethnicity. Most were admitted after hospitalization (88.2%) for 117 different diagnostic related groups. Average length of stay in RaH was 14.2 (SD = 6.5) days with patients receiving 1.83 (SD = 2.22) medical provider, 1.67 (SD = 1.58) nursing, and 5.24 (SD = 1.05) physical therapist visits weekly. Most of the patients fully or almost fully met their goals for bed mobility (65%), bed transfer (69%), chair transfer (67%), and ambulation (64%) with the majority achieving moderate or considerable (61%) global functional improvement. Achieving moderate or considerable global improvement was negatively associated with dementia diagnosis (odds ratio [OR] = .23; 95% confidence interval [CI] = .08-.71) and positively associated with higher baseline ambulation (OR = 5.51; 95% CI = 2.22-13.66). At 30 days, 87.3% of participants were living in the community. CONCLUSION: Delivering SNF-level post-acute rehabilitation care in patients' homes for a broad range of diagnoses is feasible and associated with functional improvement. This approach may help older adults maintain living status in the community. J Am Geriatr Soc 68:1584-1593, 2020.

The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop.

BACKGROUND: Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from "voltage drop" (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or "program drift." (decreased benefit arising from deviations from study protocols). METHODS: Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. RESULTS: Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11-44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (- 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). CONCLUSIONS: We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential 'program drift' or 'voltage drop.' TRIAL REGISTRATION: Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study "in which the assignment of the medical intervention is not at the discretion of the investigator."