Alternatives to Hospital/Nursing Home Care

One of the issues seniors face when they experience an illness or become frail is related to their next step. Would a hospital stay prove helpful? Short term rehabilitation residence? Adult living facility with step down nursing care? Or stay at home care? These have become hot topics with government agencies looking at the bottom line for each of these steps, costs. The National Academies of Science, Engineering, and Medicine (NASEM) has launched a major project on the quality of nursing home care. In a 2021 report, the authors concluded "primary care in the United states is fragile and weakening" implying that medical practice shas to be in line with the services patients need.t


We recently came across a challenging study related to this issue. It appeared in Annual of Internal Medicine, July 2021, Vol 174:no. 7, with the long title "Is Comprehensive Geriatric Assessment Admission Avoidance Hospital at Home an Alternative to Hospital Admission for Older Persons?" The authors describe the objective of the study: "To assess the clinical effectiveness of admission avoidance hospital at home (HAH) with comprehensive geriatric assessment (CGA) for older people."


Back in 2000, Fried et al in an article in Arch Intern Med concluded that people preferred home care to hospital care in the treatment of acute illness. Recent newspaper reports following epidemiological statistics related to deaths in nursing homes and hospitals only seemed to increase the desire to be treated at home. This was reinforced by the challenge hospitals experienced for general health care during the COVID-19 pandemic. To quote  Stuart M. Butler, PhD in an article in JAMA (April 13, 2021) "Hundreds of thousands of people who are older and disabled live in nursing homes not because they need specialized care, but because Medicare payment rules make that the only housing with daily living care they can afford".


Having visited a number of nursing homes in New York City, Boston and Denver, it came apparent to this author that these homes serve, in general, two two different cohort groups of residents. One requires short term post acute care services. (My co-editor is an example of this type of resident who needed the care following an extended stay in a hospital for treatment of his almost fatal bout with sepsis). The other group consists of long term care residents who need basic daily living care and when asked would like to return to their community and friends.


Hospital at Home is designed for older persons who are in declining health, aimed to reduce the risk of loss of independence and subsequent admission to institutional care. Simply put, if you can get similar care at home to what is achieved in a hospital setting, why choose hospital care. While this type of program is person centered, it also involves potential cost savings for Medicare. This would be measured by comparing two types of programs and determining health outcomes of older persons in the two settings. (Note the Conley et al study in JAMA Intern Med 2016;176:1693-1702 that looked at alternative strategies to inpatient hospitalization)


One government agency that is quite interested in hospital admissions vs hospital at home is The National Institute For Health Research Health Services and Delivery Programs. They were the primary funding source for a research study comparing the two admission steps. The principal investigator was Sasha Sheppard, MSc., DPhil. of the University of Oxford, Nuffield Department of Population Health Sciences, Richard Doll Building, Old Road Campus, Oxford OX37LF, United Kingdom (email, The study involved 1055 older patients (mean age 83.3) who were medically unwell, were physiologically stable and were referred for hospital admission. Those interested in extended details of the study are referred to Annals of Internal Medicine,  2021;174:889-898. The purpose of the study was to see if avoiding hospital/nursing home care would reduce the risk for a loss of independence, "align with an older person's preference to receive hospital-level care in their homes if similar outcomes can be achieved". The Home an Alternative to Hospital Admission had the same results as hospital admission but showed a decrease in admission to long term residential care at 6 months. The authors conclude "This type (home as hospital) service can provide an alternative to hospitalization for selected older persons". One should note that there were similar mortality rates in both populations at 6 months, possibly because of the mean age of the population studied. One also has to be careful in generalizing this study to the USA.  Another shortcoming in this study is the patient population studied."The results are more strongly related to patients who were referred after a special assessment process in a hospital".  There could have been an element of bias in the referral process. With all these caveats, this type of program may prove to be one of a buffet of programs that may help meet the needs of patients and provide quality of service from the entire health staff.


There is no question that some measure of change has to be instituted in the level of care for the older population in this country. This has to be done sooner than later  so that as the population ages we will not have another medical crisis.   


By Harold Rubin
updated October 22, 2021

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