geriatrics
Hospital Care and Older Adults
Alternatives to Hospitalization
In the past few years, several new models of health care delivery have been developed in which the patient is managed in the home (see also Home Health Care ). The overall goal of these models is to provide a higher quality of care and management that keeps older adults out of both hospitals and skilled nursing homes and promotes aging in place. Overall, these are known as home- and community-based services that include traditional home health services but have been expanded to include other models, some of which have been initiated as demonstration projects. Independence at Home(IAH) is a demonstration project that is sponsored by the Centers for Medicare and Medicaid Services (CMS). This model started in 2012 and has been renewed multiple times. In this model, homebound, frail older adults receive physician or advanced practice provider (eg, nurse practitioners, physician assistants) services in their home. The goal of this model is to keep the patient in their home and out of the hospital. To be included in this model of care, patients must be homebound and have 2 or more chronic conditions. Patients have benefited from the IAH model with fewer hospitalizations and greater satisfaction. The Hospital at Home (HAH) model enables organizations to provide hospital-level care in the patient's home. Most of the participating patients are acutely ill older adults. The goal of this model is to decrease the number of days a patient spends in the hospital, reduce hospital costs, improve patient satisfaction, and improve outcomes. In most cases, these patients are generally stable but require extended hospital-level skilled care such as daily visits from a physician or advanced practice provider and daily monitoring of their medical condition. The benefits of this model include lower morbidity, less delirium caused by sedating drugs, less use of restraints, and high caregiver satisfaction. TheEmergency Triage, Treat, and Transport (ET3)model developed by CMS allows ambulance care teams to have greater flexibility in deciding where a patient should receive care. Instead of transporting a patient to a hospital emergency department, the ambulance care team, often in consultation with an advanced practice provider (APP), can divert the patient to an urgent care center or physician office or can facilitate care in the patient's home with the help of an APP who may be in the ambulance or accessible via telehealth. 