The Home Hospital: An Alternative for Older Patients?

Dr. Leff is Associate Professor of Medicine, ohns Hopkins University School of Medicine and School of Hygiene and Public Health. Baltimore. His studies are supported by a grant from the john A. Hartford Foundation of New York. T he acute-care hospital-the current paradigm and gold standard of care for acutely and seriously ill patients-may not always be an ideal environment for older patients, who are significantly at risk for adverse events in this setting. For example, they often experience functional decline, delirium, and incontinence in the acute-care hospital, increasing the risk of dependency and subsequent nursing-home care. In addition, iatrogenic complications are common and their incidence increases with patient age. Given such potential hazards, alternatives to traditional hospital care of the elderly have been developed. Hospital-based models such as Acute Care for the Elderly (ACE) units apply principles of clinical geriatrics to create a more friendly hospital experience that promotes functional recovery. Another model-the home hospital-allows patients to avoid the inpatient acutecare environment completely. Several types of home-hospital models have been developed. In some, all of the critical elements of acute-hospital care (e.g., physician and nursing care, medicines, appropriate diagnostic and therapeutic technologies) are brought to patients' homes. Other models facilitate early hospital discharge by providing in-home services that many in the United States would consider to be standard postacute-discharge care. Some home-hospital programs have focused solely on patients who have undergone surgery (e.g., hernia repair, total knee or hip replacement), others have targeted older patients with certain medical conditions, and still others have combined surgical and medical patients into a single program. Most home-hospital programs have been developed and studied in the United Kingdom and Australia, countries with national health insurance schemes. Before discussing the potential for the home hospital in the U.S. health-care system, I will review recent studies of home-hospital models that have substituted for inpatient hospital admissions and provided substantial physician input.