Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial
Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial
David M. Levine
Kei Ouchi 0 1
Charles T. Pu 1 3 4
Jeffrey L. Schnipper 1 2
0 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, MA , USA
1 Harvard Medical School , Boston, MA , USA
2 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital , Boston, MA , USA
3 Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital , Boston, MA , USA
4 Partners Healthcare System Center for Population Health , Boston, MA , USA
5 Partners HealthCare at Home , Waltham, MA , USA
BACKGROUND: Hospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient's home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking. OBJECTIVE: Determine if home hospital care reduces cost while maintaining quality, safety, and patient experience. DESIGN: Randomized controlled trial. PARTICIPANTS: Adults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma. INTERVENTION: Home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-ofcare testing. MAIN MEASURES: Primary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience. KEY RESULTS: Nine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups. CONCLUSIONS: The use of substitutive homehospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity.
home hospital; hospital at home; hospital alternative; homebased care
Hospitals are the standard of care for acute illness in the US,
but hospital care is expensive and often unsafe, particularly for
older individuals.1 While admitted, 20% suffer delirium,2 over
5% contract hospital-acquired infections,3 and many lose
functional status that is never regained.4 Timely access to
inpatient care is often poor: many hospital wards are typically
over 100% capacity, and emergency department (ED) waits
can be protracted. Moreover, hospital care is increasingly
costly, accounting for about one-third of total medical
expenditures, and is a leading cause of patient debt.5
A Bhome hospital^ is home-based provision of acute
services usually associated with the traditional inpatient hospital
setting.6 Prior work suggests home hospital care can reduce
cost, maintain quality and safety, and improve patient
experience for selected acutely ill adults who require traditional
hospital-level care.7–15 While home hospital care is familiar
in several developed countries,16 only two non-randomized
studies have been conducted in the US.
We sought to demonstrate the cost, safety, quality, and
patient experience of substitutive hospital-level care in the
home through a pilot randomized controlled trial.
This investigator-initiated study was approved by the Partners
HealthCare Human Research Committee as more than
minimal risk human subject research. It was registered at
clinicaltrials.gov, record NCT02864420. All participants
provided written informed consent. None of the study’s
commercial vendors participated in design, analysis, interpretation,
preparation, review, or approval.
We performed a randomized controlled trial at Brigham and
Women’s Hospital (BWH, an academic medical center) and
Brigham and Women’s Faulkner Hospital (a community
hospital) between September 12, 2016, and November 13, 2016.
Faulkner hospital was added in the last 3 weeks of the study to
increase sample size.
Participants were recruited in the ED. Participants were
initially pre-screened by a research assistant to ensure they were
adults, were not presenting for trauma or psychiatric
evaluation, and lived within our catchment area. After the decision
by the ED attending was made to admit a patient, s/he would
call the triage attending as per usual protocol to discuss
admission. If the patient at hand met inclusion and had no
exclusion criteria, and the ED attending was in agreement,
then the admission could be held so the home hospital team
could assess the patient for eligibility, interest, and consent
(Fig. 1). The goal of enrollment was minimal disruption to the
ED, for which we tracked various process measures (online
eTable 1), demonstrating minimal delays in the ED because of
the study protocol.
Inclusion and Exclusion Criteria
Participants were eligible for home hospital if they resided
within our catchment area, had capacity to consent, were
18 years old or older, and had a primary diagnosis of any
infection, heart failure exacerbation, COPD exacerbation, or
Participants were ineligible to enroll if they were
undomiciled, lacked utilities, were in police custody, screened
positive for domestic violence,17 or resided in a facility that
provided on-site medical care. Participants were also ineligible
if peripheral intravenous access could not be obtained in the
ED, they required routine administration of intravenous
narcotics, they had an acute concomitant condition (e.g.,
hemorrhage), they could not independently ambulate to a bedside
commode, or, as deemed by the home hospital attending, they
were likely to require a procedure not available in the home
hospital program (e.g., computed tomography, endoscopy,
surgery). Patients were also excluded if they were considered
at high risk for clinical deterioration based on already
validated general and disease-specific risk algorithms (online
eAppendix 1). No exclusion was made based on insurance
Age, years, median (IQR)
Female, n (%)
Race/ethnicity, n (%)
Partner status, n (%)
Primary language, n (%)
Insurance, n (%)
Education, n (%)
> 4-year college
< 4-year college
< High school
Employment, n (%)
Cigarette smoking, n (%)
PRISMA (0–7), median (IQR)
Ascertain dementia-8 (0–8),
Health literacy (
Medication count, median (IQR)
Comorbidity count, median
Code status: Full code, n (%)
Yes, surprised if died in 1 year, n
EuroQol VAS (
ADLs (0–6), median (IQR)
IADLs (0–8), median (IQR)
PHQ-2 (0–6), median (IQR)
PROMIS emotional support (
), median (IQR)
Hospital admission in last 6
months, n (%)
Emergency department visit in
last 6 months, n (%)
was stratified by condition with randomly selected block sizes
between 4 and 6 with allocation concealment via sealed
envelopes. Given the nature of the study, blinding of patients, study
staff, and physicians was not possible.
All patients received at a minimum one daily visit from an
attending general internist and two daily visits from a home
health registered nurse, with additional visits performed as
needed. Also tailored to patient need, participants could
receive medical meals and the services of a home health aide,
social worker, physical therapist, and/or occupational
Home hospital could provide oxygen therapy, respiratory
therapies (e.g., nebulizer), intravenous medications via
infusion pump (Smiths Medical, St. Paul, MN), in-home
radiology, and point-of-care blood diagnostics. All patients had
continuous monitoring of heart rate, respiratory rate, telemetry,
movement, falls, and sleep via a small skin patch (physIQ,
Chicago, IL; VitalConnect, San Jose, CA). Monitoring was
performed through machine-based algorithms, and clinical
staff reviewed any alarms produced by these algorithms as
part of their clinical care. Participants communicated with their
home hospital team via telephone, encrypted video, and
encrypted short message service (Everbridge, Burlington,
MA). The physician was available 24 hours a day for urgent
issues and visits. Criteria for discharge were by design left to
the discretion of the home hospital attending. We mandated no
treatment pathways or algorithms. Follow-up after discharge
was by design no different than usual care.
Participants randomized to the control group received usual
care in the hospital, also from an attending general internist,
with the addition of the aforementioned skin patch (placed
while in the ED). Hospital staff was unaware of the patch’s
Data Sources and Outcomes
For both groups, we interviewed patients on admission, at
discharge, and at 30-days post-discharge. On admission,
patients reported their sociodemographics (Table 1) and
completed assessments of frailty (PRISMA-7; > 2 indicates
frailty),18 cognitive impairment (Ascertain Dementia-8; > 1
indicates cognitive impairment),19 depression (Patient Health
Questionnaire-2; > 2 indicates depression),20 emotional
support (PROMIS Emotional Support 4a; > 17 indicates better
than average support),21 health literacy (BRIEF health literacy
screening tool; > 17 indicates adequate literacy),22 quality of
life (EuroQol Visual Analogue Scale),23 and functional status
scores [activities of daily living (ADLs) and instrumental
activities of daily living (IADLs)]. We supplemented
sociodemographic data with the hospitals’ electronic health
record (EHR) for items such as insurance status.
Our primary outcome was direct cost of the acute care
episode, calculated as the sum of non-physician labor,
supplies, monitoring equipment, medications, labs,
Table 3 Patient Safety
Home (n =
radiology, and transport directly attributed to the patient’s
care (online eAppendix 2). Both groups used an identical
cost calculation, except for transport (not applicable to the
hospital group) and non-physician labor. In the home
group, we multiplied non-physician labor hours by the
hourly direct rate to obtain cost; in the control group, we
multiplied non-physician labor hours by the hourly
unitbased direct rate (this is our institution’s best-practice in
estimating labor and derived directly from their internal
accounting system). Administrative costs are considered
indirect costs and were not included.
We did not include physician labor because this is
customarily separate from traditional hospital costs, and BWH does
not utilize a direct care model such as home hospital (e.g.,
physicians at BWH always work with residents or physician
assistants). The attending physician-to-patient ratios for home
hospital and BWH are capped at 1:4 and 1:16, respectively.
However, the BWH attending physician is assisted by 3
daytime and 2 night-time residents, in effect requiring more
physicians per patient than in home hospital. In addition, at nearby
academic medical centers that do have direct care models (i.e.,
no resident or mid-level provider assistance), attendings
typically see eight patients and still require overnight attending
We secondarily studied utilization, safety, quality, and
patient experience during the acute care episode. Utilization
measures included laboratory orders, radiology studies,
consultations, and length of stay, all derived from the EHR
(Table 2). Safety measures included adverse events (e.g.,
falls and standard hospital-acquired conditions), delirium
(captured by the Confusion Assessment Method,2 already
documented every 8 h at BWH as part of usual care), and the
unexpected return to hospital rate (intervention arm only;
*Wilcoxon rank-sum test for continuous variables and Fisher exact test
for categorical variables
Abbreviations: ED, emergency department; IV, intravenous; OT,
occupational therapy; PT, physical therapy
Table 3). Quality measures included pertinent Center for
Medicare and Medicaid Services (CMS) inpatient quality
measures (e.g., angiotensin-converting enzyme inhibitor in
a patient with heart failure of reduced ejection fraction), pain
scores, physical activity [exertion (any movement at least as
vigorous as slow walking, 0.02 g’s), steps, and upright
posture], and sleep. All measures were derived from the
EHR, except falls, physical activity, and sleep, which were
observed via the skin patch. We considered
hospitalacquired disability to be any reduction in a patient’s ADLs
or IADLs between admission and discharge.24 Patient
experience measures included the Care Transitions Measure
(CTM) 3, Picker patient experience questionnaire,25
recommending the hospital experience, and global
experience (Table 4). Experience measures were recorded during
the 30-day interview.
We additionally measured cost and utilization in the
30day post-discharge period using the same cost-accounting
method. We tracked readmissions, ED visits, primary care
visits, and specialist visits. As we only had access to records
from Partners HealthCare (the health system that includes
BWH), we asked participants whether they received any
health care outside of our health system and added those to
the cost estimates. This occurred in only two patients who
received a single primary care visit each outside of Partners.
Sample Size Considerations
From previous quasi-experimental data, home hospital
reduced the payer (not provider) cost of admission by 20–30%
with baseline payments of $7480 (SD $8112).7, 8 To achieve at
least 80% power with a type I error rate of 5%, we required 30
patients per arm to detect a 60% relative reduction in costs.
While this was an optimistic effect size based on the literature,
Abbreviations: ADLs, activities of daily living; ED, emergency department; IADLs, instrumental activities of daily living; IQR, interquartile range; IV,
intravenous; OT, occupational therapy; PT, physical therapy
*Wilcoxon rank-sum test for continuous variables and Fisher exact test for categorical variables
†Standard inpatient quality measures for pneumonia and heart failure (e.g., beta blocker for heart failure with reduced ejection fraction, smoking
cessation counseling) were achieved equally in both groups and are omitted because of space constraints
‡Two older patients in the home group shuffled while walking, resulting in a step count of almost zero being registered. These outliers drove the large
§Scale: 0 = the worst possible hospital; 10 = the best possible hospital
‖Scale: 0 = definitely would not recommend; 4 = definitely would recommend
we anticipated smaller variance based on our local data and
We had limited funding and could only continue our pilot
for at most 2.25 months. Thus, irrespective of enrollment, we a
priori planned to stop the pilot when funds were depleted.
Given our small sample size and, in the case of cost, skewed
data, we used non-parametric tests to compare home hospital
and usual care, presenting results as median and interquartile
range (IQR). We compared characteristics of participants in
both groups with the Wilcoxon rank-sum test for continuous
variables and the Fisher exact test for dichotomous and
categorical variables. We present cost data as percent change from
control given the sensitive nature of these data.
All tests for significance used a two-sided p value of 0.05.
We performed all analyses in SAS v9.4 (Cary, NC, USA).
A total of 57 patients were assessed for entry into the study; 21
were enrolled and randomized (Figure; details of those
declined/lost, online eTable 2). Twenty-seven patients declined
enrollment; six physicians declined to allow their patients to
enroll. All patients enrolled received their allocated treatment
and were followed until 30-days post discharge. One patient in
the home group was excluded from analysis. This patient was
a pre-specified Bn of one^ attempt at a separate model of early
transfer to home hospital after stabilization in the traditional
hospital. As a result, this patient had been in the hospital for 2
full days prior to enrollment. While we learned valuable
lessons about this model, this patient is not comparable to
the other home hospital patients.
The nine patients randomized home had a median age of
65 years (IQR, 28), 22% were female, 44% White, and 56%
partnered (Table 1). Most (67%) spoke English as their
primary language, 67% had private insurance, 56% were
employed, and 33% had less than a high school education.
The 11 patients randomized to control were not statistically
different, although they trended toward younger (median age
60 years [IQR 29]), more often female (73%), more
Englishspeaking (82%), less privately insured (27%), more educated
(55% with college degree), and more unemployed (27%).
Patients’ clinical characteristics were similar between
groups (Table 1). In the home group, patients had mild frailty
(2/7 [IQR, 2]), unlikely dementia and depression (AD-8 0/8
[IQR, 0], PHQ2 0/6 [IQR, 0]), excellent functional status
(ADLs 6/6 [IQR, 0] and IADLs 8/8 [IQR, 2]), high health
literacy (19.5 [IQR, 7]), and excellent social support (20/20
[IQR, 2]). Patients reported moderately high quality of life (75/
100 [IQR, 10]. Patients in the control group had significantly
Despite reassuring self-reported characteristics, patients in
both groups were chronically ill and frequently used care. In
the last 6 months, 44% of home group patients had been
admitted; 56% had visited the ED. Home group patients had
seven (IQR, 7) chronic comorbidities and took eight (IQR, 13)
Cost and Utilization
Median direct cost of the acute care episode for home patients
was 52% (IQR, 28%; p = 0.05) lower than for control patients.
Median length of stay was 3.0 days in both groups (p = 0.8;
Table 2). During the care episode, home patients had fewer
laboratory orders (6 vs. 19; p < 0.01) and received consultations
less often (0% vs. 27%; p = 0.04), with a trend toward less
imaging. Each day, home patients received a median of one
physician visit (range: 1 to 3) and two nurse visits (range: 2 to 4).
Median direct costs for the acute care plus 30-day
postdischarge period for home patients was 67% (IQR, 77%; p <
0.01) lower, with non-significant trends toward less use of
home health services, fewer readmissions, and improved
follow-up with their primary care clinicians within 14 days
of discharge (Table 2).
Safety, Quality, and Activity
No adverse safety events and no transfers back to hospital
occurred in home patients (Table 3). One control patient had
nosocomial acute kidney injury. Neither group used
indwelling urinary catheters or restraints.
Pain scores were similar in both groups (Table 3). Both
groups were similarly provided pneumococcal vaccination,
influenza vaccination, smoking cessation counseling, and the
CMS heart failure measures (e.g., beta blocker for heart failure
with reduced ejection fraction) when applicable.
Home patients had more minutes of physical activity per
day (median minutes, 209 [IQR, 90] vs. 78 [IQR, 44];
p < 0.01), spent more time upright (median hours per day,
4.8 [IQR, 1.4] vs. 2.7 [IQR, 1.8]; p < 0.01), and had a trend
toward more sleep (Table 4).
There was a trend toward more hospital acquired disability
in the control group: ADLs and IADLs were respectively
worse at discharge in 9% and 18% of the control group vs.
0% and 0% of the home group.
Patients in the home and control group reported high global
satisfaction and would always recommend their experience to
others (Table 4). Home patients had a trend toward better
Picker experience scores.
In this small two-site pilot study, providing care to acutely ill
adults at home compared to the traditional hospital reduced
cost, decreased utilization, and improved physical activity,
without appreciably changing quality, safety, or patient
experience. We also observed trends toward reduced
hospitalacquired disability, readmission, and disposition to home
health services among home hospital patients.
The goal of the home hospital model is to get the Bright care
to the right patient at the right time.^ Home hospital reduces
cost, for example, because it reduces nursing labor (similar
patient:nurse ratio, but 2 visits at home versus 24 h care in the
hospital), reduces utilization (fewer laboratory draws and
consultations), likely improves follow-up with primary care,
and possibly reduces readmission (online eAppendix 2 for
cost details). It delivers care in a more patient-centered
manner: patients can be surrounded by their family and friends, eat
their own food, move around in their own home, and sleep in
their own bed, with the supports of the home hospital team.
The home is also an ideal place to empower patients and
caregivers around self-management during and after the
episode. Performing medication reconciliation with the medicine
cabinet in sight and dietary education in a patient’s kitchen are
powerful touch points. Discharge without home health or in a
timely manner was also likely facilitated, as the home hospital
team had greater confidence in a patient’s ability to function at
home because they were already in the home setting.
To our knowledge, this is the first randomized controlled
trial of home hospital performed in the US. Importantly, what
constitutes a Bhome hospital^ is highly variable both
nationally and internationally.26, 27 Our model involves a physician
in the home, delivers twice-daily nurse visits and 24-h
physician coverage, provides acute care similar to that received in a
traditional hospital to acutely ill patients who otherwise would
have been admitted, and offers cutting edge connectivity
(continuous monitoring, video, and texting). This differs from most
home-based models in its ability to handle high patient acuity
and enmesh physician medical decision-making with a
patient-tailored care team. Careful patient selection also
Previous work corroborates our findings. Others providing
substitutive care to acutely ill patients have shown reduced
cost (20–30%) and decreased utilization, all while maintaining
or improving on quality, safety, and patient experience.7, 8
Two randomized controlled trials in Italy for patients
presenting with COPD and heart failure exacerbations echo these
findings and demonstrated reductions in readmission.9, 28 An
older randomized controlled trial in Australia found a 51%
reduction in cost.13, 29 Our findings regarding physical activity
build on other work.15, 24 Our study included patients of a
somewhat younger median age than others.
Our study has limitations. First, our small sample size
resulted in unequal groups and insufficient ability to adjust
for some clinically important differences between them. In a
larger trial, we would expect these differences to be decreased.
Second, the small sample size left us underpowered to detect
significant differences for many of our secondary outcomes.
However, this study was designed as a pilot, and it is notable
that even with our small sample size we were able to detect
statistically significant differences in our primary outcome and
several secondary outcomes because of the large effect sizes.
Third, we only recruited from two, albeit distinct sites, limiting
generalizability. For example, our cost calculations may be
less valid at an institution with different staffing structures and
patient to clinician ratios. Fourth, 63% of patients declined to
participate, approximately the inverse of prior work (online
eTable 2).7 This was likely due to our robust randomization
scheme, which only allowed us to approach patients just
before Brolling upstairs,^ a time when most patients had
already mentally prepared for traditional admission. It may
also be reflective of a patient culture that is not yet comfortable
with home hospitalization. On the other hand, this approach
greatly minimized selection bias between the enrolled patients
in the two arms of the study.
Despite important incremental improvements in traditional
hospitals, the structure and care delivered are still very
reminiscent of hospitals 50 years ago. Some hospital structures
have persisted for over 100 years. Reimagining the best place
to care for select acutely ill adults holds enormous potential.
This randomized controlled pilot of substitutive home
hospital care demonstrates improvements in cost,
utilization, and physical activity while likely maintaining quality,
safety, and experience, with more definitive results awaiting
a larger trial.
Acknowledgements: The authors would like to acknowledge the
home hospital clinicians who cared for the home hospital patients.
The authors also graciously acknowledge the various departments at
Brigham Health who were instrumental to the success of the home
hospital program: Cardiology, Emergency Medicine, General Internal
Medicine and Primary Care, Hospital Medicine, Pharmacy,
Laboratory, and Population Health.
Corresponding Author: David M. Levine, MD MPH MA; Division of
General Internal Medicine and Primary Care Brigham and Women’s
Hospital, Boston, MA, USA (e-mail: ).
Compliance with Ethical Standards:
Prior Presentations: Society of General Internal Medicine—national
conference; Washington, DC, 2017. Awarded Lipkin Award.
Conflicts of Interest: The authors declare that they do not have a
conflict of interest.
Financial Support: Partners HealthCare Population Health
Management provided funding support for the home hospital clinical program.
Dr. Levine received funding support from an Institutional National
Research Service Award from (T32HP10251) and the Ryoichi Sasakawa
The NIH had no role in the design and conduct of the study; the
collection, management, analysis, and interpretation of the data; or
the preparation, review, or approval of the manuscript.
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