Hospital At Home grew out of the experiences of homebound older patients and the geriatricians who provided ongoing care to them by making housecalls. These physicians observed that many of their patients experienced adverse events in the hospital while others refused hospitalization because their experiences in the hospital were so difficult. In the latter case, the physicians found themselves forced to patch together a care plan to deliver the best care possible under a difficult set of circumstances.
To remedy this situation, Dr. John Burton, at the time the Chief of Geriatrics at Johns Hopkins School of Medicine, and Dr. Donna Regenstreif, Program Officer at The John A Hartford Foundation, conceived of a Hospital At Home that would provide safe and effective hospital- level care in the home. A study team was put together that included other geriatricians: Dr. Bruce Leff, M.D., who was the Project Director, and Dr. William Greenough, a geriatrician co-investigator with broad experience in providing care in the home and Ms. Susan Guido, R.N. a nurse with broad experience in caring for older persons. Faculty from the Johns Hopkins University Bloomberg School of Public Health, Dr. Donald Steinwachs, Ph.D., Chair of the Department of Health Policy and Management, and Dr. Lynda Burton, Sc.D., a health services researcher, designed the study and measurement methodology. The team developed medical eligibility criteria1 for patients for treatment in Hospital at Home, and developed the basic clinical model of Hospital at Home care.
Seventeen patients were treated in a pilot trial of the program at the Johns Hopkins Bayview Medical Center, that showed that Hospital at Home was feasible, safe and cost effective.2 In this pilot study, strong support from the Johns Hopkins Bayview Medical Center was essential. The hospital administrator had the vision to see Hospital at Home as a logical extension of hospital services, and he understood the need to expand service to older persons and to address future bed shortages.
To evaluate the efficacy of Hospital at Home, a National Demonstration and Evaluation Study was conducted3 to test the feasibility of Hospital At Home care in three cities: two in Medicare managed care organizations and one in a Veterans Administration health center. At each of the study sites there was a geriatrician who led the program. Dr. Bruce Naughton, M.D., a leader in geriatrics at Kaleida Health Care, was the principal investigator for the study at the State University of New York at Buffalo. Dr. Naughton has continued the Hospital at Home model focusing on patients with congestive heart failure. Dr. Scott Mader, M. D. led at the Portland, Oregon VA Medical Center. Under Dr. Mader’s leadership the Hospital at Home program continues to provide care at the Portland VA. Dr. Jeffrey Burl, a geriatrician at Fallon Medical Center in Worcester, MA., was the principal investigator at that site. The methodology for ascertainment of delirium was developed by Sharon Inouye, M. D., who was a consultant with the Hospital at Home project.
The study coordinating team at Hopkins was expanded to include an economist, Kevin Frick, Ph.D. who carried out the cost analysis. More recently, as work has focused on dissemination to other sites, Jill Marsteller, Ph.D., whose expertise is in management and organizational behavior, has joined the team.
2 Leff B, Burton L, Guido S, Greenough WB, Steinwachs D, Burton JR. Home Hospital program: A pilot study, Journal of the American Geriatrics Society, 1999; 47:697-702.
3Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, Greenough WB, Guido S, Langston C, Frick KD, Steinwachs D, Burton JR. Hospital At Home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients, Annals of Internal Medicine, 2005, in press.
