Skipping the hospital: acute hospital care at home for people living with dementia - PROJECT SUMMARY – Skipping the hospital: Acute hospital care at home for people living with dementia
In 2020, Alzheimer’s Disease and Related Dementias (ADRD) affected 5.8 million Americans and
represented the fastest growing segment of our population.1 It was the sixth leading cause of death in the US;
1 in 3 older adults died of ADRD; and cost of care was $305 billion. A constant for people living with dementia
(PLWD) is hospitalization: PLWD are hospitalized at twice the rate as older adults without ADRD.2,3 Well-
documented is the harm of hospitalization: 1 in 3 will lose functional status; 1 in 5 will become delirious.4,5 The
harm of hospitalization is magnified in PLWD: they have 5 times the odds of an adverse event.6,7
Acute hospital care at home (AHCaH) was specifically developed as a substitutive delivery model to
help avoid these common harms for older adults while receiving the care that they need at home. The
current model provides hospital-level care in the home after presenting to the emergency department (ED) with
an acute illness such as infection or heart failure. AHCaH includes twice daily in-home nurse visits, daily
physician visits, physical and occupational therapy, intravenous medications, biometric monitoring, in-home
diagnostics, home health aide care, and 24/7 response. Serious illness conversations (SICs) at home for
applicable patients are essential for setting goals of care and ideal given the home environment. Prior studies
including several randomized controlled trials demonstrated significant improvements in 30-day readmission,
safety, and cost.8–15 The impact on family caregivers and clinicians caring for PLWD is understudied. The
mechanism of action for home hospital is patients are more physically active, sleep better, have more days at
home in a familiar environment with improved locus of control and experience, and have less hospital-acquired
disability.”16 Home hospital care is now approved at over 296 hospitals in 37 states.
There exists a critical need to better serve PLWD and their family caregivers when they become acutely ill.
Despite its focus on older adults, few home hospital efforts specifically target PLWD and may decline such
patients due to insufficient family caregiver support in the home, perceived risk of caring for PLWD in the
home, and lack of clear goals of care. We propose a 3-part PLWD-specific year-long pre-enrolled AHCaH
pathway: 1) in-home SIC and caregiver resourcing; 2) video and in-home acute illness evaluation on demand
including mobile integrated health paramedic and home health aide; and 3) as needed and as appropriate
AHCaH with additional ADRD resources including home health aide care and delirium prevention measures.
Our overarching aim is to implement and evaluate (NIH Stage III) an AHCaH pathway specifically for
PLWD that will serve as a national model. We will evaluate in a randomized controlled trial the effect of a pre-
enrollment AHCaH pathway on quality of life over 12 months for persons with moderate to severe dementia
(Aim 1). We will evaluate the experiences of family caregivers using a mixed-methods approach (quantitative
and qualitative) in both pre-enrolled home hospital and usual care (Aim 2).
