Care for older people at home can be as good, or better, than hospital care

A new study led by NDPH researchers shows that caring for a select group of vulnerable, older people at home can improve patient outcomes, while reducing pressures on hospitals. The results were published on 19 April 2021 in Annals of Internal Medicine. 

The past year has highlighted the chronic shortage of hospital beds in the UK and other countries.  Even in pre-pandemic times, one of the greatest challenges the NHS faces is the growing older population, who are being admitted to hospital in increasing numbers, for instance due to a fall or sudden illness.

Besides putting pressure on hospital resources and budgets, there are concerns that this may not be the best place to care for older people. There is evidence that, for older people, hospital admission may cause acute confusion (delirium), reduce mobility and accelerate the transition to residential care.

An alternative to hospital admission is a ‘Hospital at Home’ arrangement, where hospital-standard care is provided to patients in their homes. As in a hospital ward, patients have access to a geriatrician and multi-disciplinary team, medicines, oxygen and intravenous treatment; and they can be transferred to hospital if required. Hospital at Home models are already operating in a few areas of the UK, and surveys have consistently found that most older people prefer to receive care at home. Until now, however, there was no clear evidence on whether Hospital at Home care affects patient outcomes.

NDPH researchers have published the results of the largest study to date on Hospital at Home care. This involved over 1000 older participants (average age 83 years) recruited between March 2015 and June 2018 across the UK. Participants had been referred for hospital admission for many different reasons that included acute functional decline or infection (but not more severe health issues, such as a heart attack). Those who agreed to take part in the trial were randomly assigned to either hospital admission or Hospital at Home treatment.

After six months, the results of the study found:

• There was little difference in the proportion of participants living at home: 78.6% participants in the Hospital at Home group were living at home, compared with 75.3% participants in the hospitalised group.
• There was little difference in the proportion of patients who had died: 16.9% of participants in the Hospital at Home group had died, compared with 17.7% in the hospital group.
• Participants in the Hospital at Home model were slightly less likely to be in long-term residential care (5.7% vs 8.7%).
• There was no difference in cognitive impairment, impact on daily living activities or new chronic conditions.
• After one month participants in the Hospital at Home model were slightly less likely to develop acute confusion (delirium) (1.7% vs 4.4%).

The study, which was funded by the National Institute of Health Research (NIHR), also reported higher levels of patient satisfaction with Hospital at Home care. In particular, Hospital at Home scored more highly regarding the length of time waiting for care to start, contacting staff, being involved in decisions and discussing further health or social care services.

It is not yet known whether Hospital at Home care is cheaper than hospital-based care, but the research team are investigating this in an economic analysis.

Study lead Professor Sasha Shepperd said: ‘Our study has produced valuable information to guide policy and healthcare providers. Up until now, nobody has known whether to fully invest in Hospital at Home nationwide, or to focus on hospital care. Whether it is more expensive or not, if it means the same or better health outcomes and less disruption for certain patients then we should consider doing it.’