Association of Costs and Days at Home With Transfer Hospital in Home

IMPORTANCE: New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home—that is, completing hospitalization at home—is unclear. OBJECTIVE: To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program’s service area. DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020. INTERVENTION: Enrollment in the T-HIH program. MAIN OUTCOMES AND MEASURES: The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed. RESULTS: A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, −3.77 to 0.61 days), VA costs were 20% lower (−$5910; 95% CI, −$13 049 to $1229), combined VA and Medicare costs were 22% lower (−$7002; 95% CI, −$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, −6.5 days; 95% CI, −12.1 to −0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01). CONCLUSIONS AND RELEVANCE: In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.