The role of social dynamics in the health outcomes of a Hospital at Home

Context: Catalyzed by the strain of the COVID19 pandemic, US Centers for Medicare & Medicaid Services introduced the Acute Care at Home Waiver in 2020 to facilitate implementation of hospital at home (H@H) programs. Research has demonstrated the quality, safe, equitable, and effective care associated with H@H. However, little is known about the patient context that affects health outcomes in H@H programs.

Objective: To describe the role of social dynamics that influence enrollment in a H@H program and the characteristics of social structure and support that improve patient health outcomes.

Study Design and Analysis: Phenomenological inquiry with patients who were included in a matched cohort-control retrospective chart review. For the present study, we applied constant comparative analysis.

Setting: Academic medical center in the American South

Population studied: Patients admitted with COVID19 and, subsequently enrolled into the H@H program from February 1, 2021, to January 31, 2022

Results: Of 100 patients who met inclusion criteria, we completed interviews with 33 patients in Sept-Oct 2022. Statistical comparison of responders and non-responders showed no significant differences by sex, race, age, or severity of disease.

Even before discharge to H@H, social dynamics influenced patient decision making in the enrollment process. Four social dynamics factors prompted patients to enroll in H@H: perception of low attention from hospital staff during their admission; loneliness and isolation linked to visitor limitations during the COVID19 pandemic; family encouragement to enroll; and patient perceptions that they were needed at home.

Once home, social structure and support system were critical to patient success. Patients with adults available for full-time instrumental support (including cooking, cleaning, home health support) described the full benefits of the program. Conversely, patients who were themselves caregivers (patients with children in the home or who were fulltime caregivers for another household member) described interrupted space and time that interfered with recovery.

Conclusion: Building on evidence for the effectiveness of H@H programs, this study identifies the social dynamics that clinicians should consider as they identify and enroll patients into a H@H. Clinicians should conduct an in-depth social history, asking candidates about social and familial roles and household responsibilities to tailor the H@H to patient needs.