Asthma Clinical Trial
Official title:
Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial
The investigators propose a home hospital model of care that substitutes for treatment in an acute care hospital. Limited studies of the home hospital model have demonstrated that a sizeable proportion of acute care can be delivered in the home with equal quality and safety, reduced cost, and improved patient experience.
Hospitals are the standard of care for acute illness in the United States, but hospital care
is expensive and often unsafe, especially for older individuals. While admitted, 20% suffer
delirium, over 5% contract hospital-acquired infections, and most lose functional status that
is never regained. Timely access to inpatient care is poor: many hospital wards are typically
over 100% capacity, and emergency department waits can be protracted. Moreover, hospital care
is increasingly costly: many internal medicine admissions have a negative margin (i.e.,
expenditures exceed hospital revenues) and incur patient debt.
The investigators propose a home hospital model of care that substitutes for treatment in an
acute care hospital. Studies of the home hospital model have demonstrated that a sizeable
proportion of acute care can be delivered in the home with equal quality and safety, 20%
reduced cost, and 20% improved patient experience. While this is the standard of care in
several developed countries, only 2 non-randomized demonstration projects have been conducted
in the United States, each with highly local needs. Taken together, home hospital evidence is
promising but falls short due to non-robust experimental design, failure to implement modern
medical technology, and poor enlistment of community support.
The home hospital module offers most of the same medical components that are standard of care
in an acute care hospital. The typical staff (medical doctor [MD], registered nurse [RN],
case manager), diagnostics (blood tests, vital signs, telemetry, x-ray, and ultrasound),
intravenous therapy, and oxygen/nebulizer therapy will all be available for home hospital.
Optional deployment of food services, home health aide, physical therapist, occupational
therapist, and social worker will be tailored to patient need. Home hospital improves upon
the components of a typical ward's standard of care in several ways:
Point of care blood diagnostics (results at the bedside in <5 minutes); Minimally invasive
continuous vital signs, telemetry, activity tracking, and sleep tracking; Automated alerting
of MDs by mobile phone for any worrisome vital sign patterns; On-demand 24/7 clinician video
visits; 4 to 1 patient to attending MD ratio, compared to typical 16 to 1;
Ambulatory/portable infusion pumps that can be worn on the hip; Optional access to a personal
home health aide.
Should a matter be emergent (that is, requiring in-person assistance in less than 20
minutes), then 9-1-1 will be called and the patient will be returned to the hospital
immediately. In previous iterations of home hospital this happens in about 2% of patients.
Clinical parameters measured will be at the discretion of the physician and nurse, who treat
the participant following evidence-based practice guidelines, just as in the usual care
setting. In addition, the investigators will be tracking a wide variety of measures of
quality and safety, including some measures tailored to each primary diagnosis.
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