Hospital-level care at home found to be feasible for rural patients with acute conditions

One in five people in the United States live in a rural area. Patients in rural communities often struggle to access care because of travel difficulties, high costs and limited resources, leading to worse medical outcomes. With over 150 rural hospital closures since 2010, innovative approaches to care delivery in rural areas are needed. In a new study by investigators from Mass General Brigham and Ariadne Labs, in collaboration with colleagues at rural U.S. and Canadian health centers, researchers found that hospital-level care at home is feasible for patients living in rural areas with acute conditions who traditionally would have been cared for in a brick-and-mortar hospital, and substantially improved experiences of care and physical activity levels. Findings are published in JAMA Network Open.

Rural health care is in a crisis, and we need to think differently. Hospital-level care delivered in patients' homes has improved healthcare delivery in urban settings but may fill an even greater need in rural areas, where longer transit times, poor accessibility, and hospital closures challenge access to high quality care. We've shown that home hospital care not only works in rural settings, but that patients also prefer their care at home."

David Levine, MD, MPH, MA, Clinical Director of Research & Development at Mass General Brigham Healthcare at Home and Director of Ariadne Labs' Home Hospital Program

This randomized controlled trial included 161 adults who required inpatient care for acute conditions (primarily infections, heart failure, chronic obstructive pulmonary disease, or asthma). Participants were recruited after presenting for emergency care at Blessing Hospital (IL), Hazard Appalachian Regional Healthcare Regional Medical Center (KY), and Wetaskiwin Hospital and Care Centre (Canada). They were assigned to either traditional "brick-and-mortar" hospital care for the length of their treatment, or home hospital care, which was administered via twice daily in-home visits with nurses and paramedics and a daily remote visit with a physician or advanced practice provider.

Innovative technologies minimized the need for medical equipment to be brought into patients' homes. A wireless sticker on the patient's chest took the place of a typical hospital telemetry system for continuous monitoring. Intravenous infusions could be delivered from an ambulatory infusion pump small enough to fit in a fanny pack. A handheld meter could check a patient's labs right in the home.

Overall, there was no significant difference in cost for the two groups. Notably, when the researchers compared the control group to the home hospital patients who had been transferred home after less than 3 days of brick-and-mortar care, they found that the cost was 27% lower, emphasizing the importance of early transfers. Readmission rates were similar 30 days after treatment, and no major safety differences emerged between groups. Home patients were less sedentary, taking an average of 700 more steps per day than controls. They also reported substantially greater satisfaction-almost double that of their counterparts who received care at the hospital (a net promoter score of 88.4 vs. 45.5, with 100 indicating maximum satisfaction).

The researchers are continuing to analyze how home hospital impacts movement, qualitative experiences, and caregiver experiences. They are also working to develop a mobile clinic, housed in an electric vehicle, with the necessary technology to deliver hospital-level care to any rural area in the U.S.

"Hopefully this work can spur patients, clinicians, and healthcare leaders in rural areas to recommend, request, and build home hospital programs," Levine said. "Those particular areas that may have lost their hospital may be able to establish home hospital programs that are less expensive than brick-and-mortar care and employ clinicians that work locally. We hope others can use this research to take action in their communities because we have seen that when patients desire certain models of care, those models come to fruition. We feel this may be one innovation to help solve the rural healthcare crisis."