Last week marked the annual American Geriatrics Society (AGS) meeting which brings together geriatricians and other healthcare professionals (including a growing contingent of geriatric cardiologists) to highlight the latest in research related to caring for older adults. One of the highlights was the Henderson Lecture, given by Dr. Bruce Leff (Johns Hopkins) on the future of healthcare for older adults moving out of the hospital and into the home. The general concept is that the hospital can be a disorienting environment for older adults, and there are concomitant risks (including hospital-acquired infections, falls, delirium, deconditioning due to immobility) that may be reduced by providing acute care at home. Concomitantly, cost pressures are leading health systems and insurers to think of more “out of the box” solutions to avoid the high costs associated with traditional hospitalizations.
Data on hospital-at-home models have been encouraging. For example, a meta-analysis of over 60 clinical trials in 2012 demonstrated hospital-at-home led to reduced mortality, hospital readmission, and cost. The potential mechanisms are clear: a familiar environment reduces the risk of delirium, which has multiple adverse consequences. Opportunistic infections are much less likely. Family caregivers are more immediately available to provide comfort.
Conversely, it’s clear that many of today’s hospitalized patients are too ill (and at high risk for decompensation) for acute medical care to be safely delivered at home. Within cardiology, this includes conditions that are procedure-intensive (acute myocardial infarction) or require high-level monitoring (cardiogenic shock, unstable arrhythmia). But I think many other acute cardiovascular conditions common in older adults could be managed with reasonable ease at home (mild decompensated heart failure comes to mind), provided adequate resources. Barriers to more widespread adoption of home-base models include payment for these programs (currently a work in progress), as well as the logistics of providing equipment (Dr. Leff noted in his lecture how difficult it was to deliver something as simple as oxygen).
Nonetheless, the paradigm holds considerable promise, and I’d expect health systems to adopt more of these programs in the next 5-10 years. If nothing else, changing demographics (specifically the aging of the U.S. population) will demand more innovative solutions like this.
By: John Dodson, MD, MPH