Elsevier

Health Policy

Volume 55, Issue 1, January 2001, Pages 71-79
Health Policy

Hospital at home: what is its place in the health system?

https://doi.org/10.1016/S0168-8510(00)00114-7Get rights and content

Abstract

Given the expansion of hospital at home in Western countries, policymakers, providers and financial managers are exploring the causes for this and examining whether hospital at home is an alternative to hospitalization for reasons of cost containment and quality of care. The purpose of this paper is to describe hospital at home, discuss its development and examine its role in the health system. A variety of models of hospital at home exist, serving a varied patient case-mix. This article claims that the reasons for the expansion of medical home care are not solely economic. Although a number of studies have examined the cost effectiveness of this service, no consensus has been reached. In fact, the growth of this service seems to be related to a number of other factors: the increase in the number of elderly and chronically ill people, the lack of availability and accessibility of acute and sub-acute inpatient services, technological innovation, improvements in the standard of living and the preference of some patients to be treated at home. Therefore, hospital at home must be examined, not as an independent service, but as part of a continuum of services, with the hospital system at one end and community services at the other end. Further research will help determine its optimal place along this continuum.

Introduction

During the past two decades, the Western world has seen a significant increase in the number of patients receiving medical care at home, in the extent and type of medical services provided in the home, in the number of agencies providing these services and in the public expenditures for them [1], [2], [3], [4], [5], [6], [7], [8], [9]. Among the reasons for this are: the increase in the number of older and chronically ill people who use health services with great frequency; the lack of availability and accessibility of acute and sub-acute in-patient services in certain locations; technological innovations which make it possible to provide medical care in the home [8], [9], [10]; improved living conditions; intensified consumer involvement in setting priorities in health services; and the preference of some patients for medical and nursing home care over (sometimes protracted) hospitalization [11], [12], [13], [14].

Clearly, different health care systems have different objectives related to the expansion of hospital at home care. These include providing services to small populations dispersed over large geographical areas, improving access, easing the burden of hospitals and responding to patient preferences. One of the main objectives, shared by virtually all systems, is to adopt measures to contain costs of services provided by the health system, without lowering the quality of care [1], [4], [10]. However, it is not clear whether the provision of medical care in the home is ‘economical’ and ‘efficient’, relative to other types of medical care.

The main concern of health policymakers, providers and financial managers is whether hospital at home is an inexpensive alternative to hospitalization — that is, whether it reduces the length of hospital stays (if patients can be transferred from hospital to home care) or prevents them altogether, or whether it is a separate service that requires additional resources, thereby increasing, rather than reducing, expenditures for health. Although this question has been examined in many studies, no consensus has been reached regarding the answer [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. Not only are researchers divided in their opinions of the financial efficiency of this service, but they also vary greatly in their definition of what constitutes hospital at home, the target population, the treatments that should be included and the medical professionals who should be involved. Moreover, there is no agreement regarding the desired outcome of hospital at home, or the appropriate measures for their assessment [27], [28]. The goals of this article are to describe hospital at home and to examine the reasons for its development and its role in the health system.

Section snippets

Characteristics of hospital at home

Hospital at home, also known as ‘home hospitalization’, ‘medical home care’ or ‘hospital without walls’ [29], is medical service provided in a patient's home. A variety of services may fit this definition — from traditional home care (including personal care and 24-h supervision) to the use of medical technology that provides antibiotics, intravenous feeding, dialysis and other treatments in the home [2], [3], [8], [9], [10]. Provision of medical treatments in the home gathered momentum with

The development of hospital at home

During the past decade, home hospital services in Western countries have developed more rapidly than any other medical service. Between 1987 and 1997, public expenditure for this service in the US increased nearly 7-fold — from $2 billion to $13.6 billion — while public expenditure for long-term care ‘only’ doubled. In 1987, expenditure for home hospital care was only 10% of all Medicare expenses for long-term care, while 10 years later it represented 24% of this expenditure [40]. Between 1989

Conclusion: the role of hospital at home in the health system

The above discussion suggests that hospital at home must be examined within the context of other health services and not as an independent service. Given the current consensus that it is advantageous to have a variety of services which can be adapted to meet the discrete needs of each patient, hospital at home surely has a role to play. It is therefore necessary to see this service as part of a comprehensive continuum of services, at one end of which lies the hospital system and at the other

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