Home Time as a Patient-Centered Outcome

As health care systems shift toward value-based care, traditional endpoint quality measures such as mortality and disease incidences are insufficient to answer the true value of care, which consists of health outcomes and the cost of outcome delivery. At the same time, few traditional endpoint quality measures look at the experience of care. The concept of home time first appeared in stroke literature as a measure for independence at home and patient satisfaction given patients' desire to return home after stroke.1 Subsequently, other stroke studies demonstrated home time as a complementary patient-centered outcome measure to other stroke outcomes.2,3 This novel measure also correlated with the traditional time-to-event mortality and hospital outcomes in patients hospitalized with heart failure.4 Home time has the potential to be a quality measure for person-centered care, in which the individuals collaborate and share decision making with healthcare providers to create comprehensive and holistic plans that align with individual's goals and preferences.

Lee et al. demonstrated an inverse relationship between home time and several patient-centered outcomes, including poorer self-rated health, mobility impairment, depression, limited social activities, difficulty in self-care, and functional limitation in a community dwelling Medicare population.5 Given the association between home time and these other patient-centered outcomes, there are several advantages of using home time as a patient-centered outcome.

First, home time can be easily calculated using administrative claims data by subtracting the number of days spent outside of home, such as acute care in the hospitals and acute or subacute rehabilitation in skilled nursing facilities (SNFs), from the number of days in the year.

Second, the concept of home time is easy to understand by patients, families, and clinicians.

Third, home time has clear correlation to the patients' experience and quality of life than traditional endpoint quality measures, such as mortality and adverse events.6,7

Finally, just as home time can reflect on patients' experiences, it can also shed light on health care utilization and cost by those who are generally older and frailer and by those who may experience the downward spiral of hospitalizations and rehabilitation in SNFs.

Limitations of Home Time

First, it is important to remember that home time does not translate to the absence of disability and need for help. Many patients have support at home that allow them to return home sooner, but they still require assistance from informal and formal caregivers. Conversely, patients who have limited support at home may have longer stay in the hospital and rehabilitation centers, and correspondingly shorter home time. Therefore, when using home time as a patient-centered outcome, it is important to measure other patient-centered outcomes concurrently to paint a more comprehensive picture of the patient population.

Second, certain medical conditions, such as joint replacement for severe osteoarthritis and stroke, may require intensive treatment and rehabilitation which cannot be achieved at home to regain function, and therefore will reduce home time.

Third, insurance plans and their coverage can have an impact on home time. For example, some patients who have Medicare and medical conditions that require longer rehabilitation in SNFs may not be able to stay in SNFs beyond day 20 since Medicare only covers a portion of the care from day 21 to 100 and patients are responsible for a coinsurance cost during this time and all cost beyond day 100. This means that these patients may have longer home time than their actual medical needs.

Finally, there may be geographical variation of home time depending on the resources available in the region. For example, in an area where there are few hospitals and rehabilitation centers, patients may have longer home time when compared to similar cohorts in an area that is resource rich.8 With these limitations, home time should not be used as a stand-alone patient-centered outcome but rather an integral part of the evaluation when examining the intervention and patient-centered care.

As health systems move to tackle the triple aim of health care by improving health outcomes, reducing the per capita cost of health care and enhancing patients' experience of care, it is important to find novel quality measures to provide insight to all three prongs. As a patient-centered outcome, home time provides direct correlation to patients' experiences and perspectives on health and cost of care. While there are still many limitations about home time that need to be further explored and addressed, home time can be used in combination with other important outcomes to provide comprehensive insight to the studied interventions.

References

  1. Quinn TJ, Dawson J, Lees JS, et al. Time spent at home poststroke: "home-time" a meaningful and robust outcome measure for stroke trials. Stroke 2008;39:231-3.
  2. Mishra NK, Shuaib A, LLyden P, et al. Home time is extended in patients with ischemic stroke who receive thrombolytic therapy: a validation study of home time as an outcome measure. Stroke 2011;42:1046-50.
  3. Fonarow GC, Liang L, Thomas L, et al. Assessment of home-time after acute ischemic stroke in Medicare beneficiaries. Stroke 2016;47:836-42.
  4. Greene SJ, O'Brien EC, Mentz RJ, et al. Home-time after discharge among patients hospitalized with heart failure. J Am Coll Cardiol 2018;71:2643-52.
  5. Lee H, Shi SM, Kim DH. Home time as a patient-centered outcome in administrative claims data. J Am Geriatr Soc 2019;67:347-51.
  6. Rasmussen RS, Ostergaard A, Kjaer P, et al. Stroke rehabilitation at home before and after discharge reduced disability and improved quality of life: a randomised controlled trial. Clin Rehabil 2016;30:225-36.
  7. Dewilde S, Annemans L, Peeters A, et al. The relationship between home-time, quality of life and costs after ischemic stroke: the impact of the need for mobility aids, home and car modifications on home-time. Disabil Rehabil 2018:1-7.
  8. O'Brien EC, Xian Y, Xu H, et al. Hospital variation in home-time after acute ischemic stroke: insights from the PROSPER study (Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research). Stroke 2016;47:2627-33.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Geriatrics, Skilled Nursing Facilities, Patient Satisfaction, Caregivers, Independent Living, Self Care, Deductibles and Coinsurance, Quality of Life, Health Care Costs, Medicare, Patient-Centered Care, Stroke, Rehabilitation Centers, Outcome Assessment (Health Care), Hospitalization, Heart Failure, Osteoarthritis, Arthroplasty, Replacement


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