Pandemic Leads to Shifting Care, Increasing Spotlight on At-Home Hospitalization

The COVID-19 pandemic brought about new flexibility and adaptations in "hospital-at-home" care for elderly patients, and the resulting model could be a meaningful way to optimize resources and curb health care costs.

Those are the topline findings of a new investigation out of Spain that looked at how the pandemic affected the use of home health care options among patients receiving geriatric care. The study compared hospitalization at home before the pandemic and in 2 periods after the start of the pandemic. The findings were published in Journal of the American Medical Directors Association.

The authors wrote that the growing aging population has created a need for more proactive care, rather than simply relying on reactive, hospital-based urgent care. In many cases, the authors said, at-home care is an appropriate way to treat patients, even those with serious conditions, such as those with cancer, those recovering from surgery, and those with chronic diseases.

The hospital-at-home model (HAH) is a version of at-home health care supported by family or informal caregivers. The investigators described 2 models of HAH: “step-up” and “step-down.”

“HAH may substitute an episode of inpatient care (step-up or inpatient avoidance pathway) or may enable an early supported discharge from the hospital (step-down) to continue medical treatments or rehabilitation,” they explained.

The specific model this study evaluated is based on a comprehensive geriatric assessment (CGA), in which an interdisciplinary team of health care providers identifies the most appropriate services and settings for patients.

When the COVID-19 pandemic began, such programs became even more urgent, the investigators said, as hospitals in many areas became overtaxed with COVID-19 cases and patients who were not infected sought to avoid the hospital for fear they might get sick.

In the new report, the authors sought to better understand how the HAH model worked in a real-world setting. To do so, they analyzed the experience of a Barcelona-based HAH system that is part of a broader network of health care providers.

The authors found that, over the course of the study period (2018-2021), the HAH capacity increased from 15 to 45 virtual beds. A total of 688 consecutive patients were treated in the study period, and their median age was 82.5 years; 59% were women.

Patients admitted to the HAH program during the pandemic were slightly older and had greater mobility impairment than in the prepandemic period, the investigators found. The study authors said step-up due to medical events, skin ulcers, and postacute stroke increased significantly over the course of the study period.

“Over time, there was a significant shift in the principal reasons for HAH: a decrease in ‘surgical profile’ (general and orthopedic), while medical events, care of pressure and vascular ulcers, and postacute stroke increased,” the authors said. “The team also attended a small number of acute COVID-19 patients.”

The length of stay of patients increased over the study period, but the rate of readmissions to an acute hospital did not shift significantly.

While step-up HAH services increased, step-down services decreased. The investigators said this was likely due to changes in the activity taking place in hospitals, as staff devoted more of their efforts to the pandemic.

The investigators concluded that the pandemic was an important catalyst for more firmly establishing at-home care in the health care system.

“CGA HAH represents a powerful evolution of traditional geriatric care and a valuable alternative to conventional hospitalization for health care systems,” they wrote.

Reference

Inzitari M, Arnal C, Ribera A, et al. Comprehensive geriatric hospital at home: adaptation to referral and case-mix changes during the COVID-19 pandemic. J Am Med Dir Assoc. Published online November 2022. doi:10.1016/j.jamda.2022.11.003

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