Hospital at Home for Children—an Emerging Model of Acute Care Free

Hospital at Home (HaH) is a model of care that allows hospitals to treat patients with inpatient level care inside the home.¹  With HaH, hospitals typically evaluate a patient in-person at an emergency department (ED) or inpatient ward and then can admit to HaH if the patient meets predetermined eligibility criteria. Once admitted to HaH, services include twice daily in-home nurse visits, daily physician visits, and ability to have appropriate emergency personnel at the patient’s home within 30 minutes.¹  There is often confusion and incorrect categorization of clinical programs as HaH when they should be defined as outpatient parenteral antibiotic therapy (OPAT),²  remote patient monitoring,³  or skilled home nursing.⁴ 

Acute hospital care in the home has been implemented worldwide in adult medicine since the 1960s and became significantly more prevalent during the coronavirus disease 2019 pandemic. Decades of research including dozens of randomized controlled trials have shown improved patient outcomes.^5,6  Specifically, HaH in adults in the United States is associated with lower cost of care and similar or lower readmission and ED presentation.^7,8  The Acute Hospital Care at Home waiver established in 2020 created the regulatory and payment framework that is now used by almost 300 hospitals.¹  The waiver pays hospitals at parity to bricks and mortar hospitals for acute care delivered at home for fee-for-service Medicare and Medicaid beneficiaries and includes mandatory safety reporting. Unfortunately, this waiver does not apply to free-standing children’s hospitals, and thus, there is no published literature on pediatric HaH programs in the United States.

However, numerous pediatric HaH programs are in place internationally for common pediatric diseases such as bronchiolitis,⁹  neonatal hyperbilirubinemia,¹⁰  acute infections,¹¹  vomiting and diarrhea,¹¹  and respiratory diseases.^11–13  Studies have demonstrated equivalent clinical effectiveness to in hospital care for common acute pediatric illnesses⁹  and financial savings to both the hospital and the family.^12,14,15  Another study also demonstrated patient and caregiver preference for HaH over conventional hospitalization.¹⁶  It is uncertain whether these benefits will translate similarly to pediatric acute hospital care at home in the United States.

In this month’s Hospital Pediatrics, Agundez-Regiosa et al describe and evaluate a home program in Spain for children with bone and joint infections.¹⁷  Eligible patients were clinically stable with adequate oral intake and were evaluated by orthopedics before transition to what the authors refer to as HaH. Most patients were referred from the inpatient pediatric ward and others from orthopedics, the emergency department, and maxillofacial surgery. Other notable inclusion criteria included reliable caregivers with the ability to administer intravenous (IV) medications, “suitable home environment,” and no language barriers. The study included 88 children over 4 years, primarily with osteomyelitis and septic arthritis, who required IV antibiotics that were administered at home by caregivers after training with nursing staff. Physicians performed daily clinical monitoring of children admitted to the service and at a minimum, patients received 2 phone calls a day from the medical team. Patients had the opportunity for home physician visits (in-person and telemedicine) and home nurse visits. The median conventional hospital length of stay was 3 days followed by a subsequent home stay of 7 days. This was significantly fewer in-hospital days than the average hospital stay of 8.5 days for osteoarticular infections before implementation, though a longer overall length of stay. There were rare antibiotic-related adverse events and 2 patients required readmission for conventional hospitalization. One additional patient had a readmission within 30 days of discharge. The authors calculated a daily savings of 68% per patient per hospital day when comparing conventional hospitalization to their service.

Although we appreciate that this study described care provided at a higher level than typical OPAT models, we think it is important to clarify and highlight that the program described is not consistent with the world congress definition of HaH.¹⁸  Critical distinguishing features of HaH include the necessity of daily provider and nurse visits without reliance on caregivers for medication administration. Table 1 outlines some of the key differentiators of several home-based care delivery programs. Thus, the model of care described by Agundez-Regiosa et al better fits an enhanced OPAT program, and pushes the boundaries of patient-centered, home-based care in an important direction. As pediatric institutions think about developing HaH in the United States, it is critical to understand the definition and program requirements to deliver truly substitutive hospital-level care.

This program decreased the number of days in the hospital, but it resulted in an overall longer length of stay (10 days) compared with the conventional hospitalization group (8.5 days) and was also longer than what has been reported in the literature (6–7 days) for pediatric osteoarticular infections.^19,20  It is unclear if the patients in this study had longer duration of IV antibiotics that led to longer lengths of stay or if they were monitored for a longer period of time after transitioning to enteral antibiotics. This ease and convenience of monitoring at home is a potential threat to unnecessarily lowering the threshold for hospitalization, which not only applies to length of stay but also to hospital admission in the first place. In fact, the relatively low readmission rate (approximately 1%) in this study (compared with literature reports of 5%–6%^19,20 ) might also be evidence of lower acuity patients being selected for the intervention. For HaH to truly replace in-hospital care, it should share the same admission and discharge criteria as a bricks and mortar admission. For example, the Acute Hospital Care at Home waiver requires all patients to require the appropriate level of care using criteria such as Milliman or InterQual. A similar approach should be taken for pediatric HaH.

Health equity, as it relates to access to and quality of healthcare, is an imperative dimension to consider in both the design and evaluation of new models of care. In many ways, moving care into the patient’s home may help to decrease barriers to care, such as transportation, food insecurity, and childcare of other children in the home. There is a dearth of research on the impact of HaH on health equity, but there is promise of a positive impact. A recent study found that 30-day ED revisits were significantly reduced in patients insured by Medicaid admitted to HaH when compared with conventional hospitalization. There was no difference in ED revisit rates for those with private insurance, indicating that perhaps HaH is more beneficial for those with more socioeconomic deprivation. The study team hypothesized that having providers in the home may have allowed the team to better address social determinants of health, such as food insecurity, access to medical equipment, and caregiver dynamics.²¹  Moving hospital care into the home will likely allow providers to identify and intervene on social influencers of health at a higher frequency than conventional hospitalizations when providers are often blind to how a patient’s home environment has impacted their health.

Advances in technology facilitate high quality and high acuity care to be provided in a patient’s home; however, without thoughtful design and planning, they risk worsening already existing gaps in access to care because of reliance on a suitable home environment, present and competent caregivers, internet connectivity, digital literacy, and easy communication. Some of these risks can be mitigated by programs providing their own technology and internet connectivity, designing their technology to be passive and user-friendly, and making it accessible in languages other than English. As programs arise, it is critical to measure uptake and outcomes stratified by key measures of equity. Addressing this in the design-phase of new programs will be critical to ensure that HaH is a facilitator to equity rather than a threat. Measuring inequities that persist despite thoughtful program design will inform potential mitigation strategies, such as expanding payer coverage of resources (eg, digital navigators, interpreters, internet hotspots) that could make care in the home more feasible for disadvantaged households.²²