Background Although more than seven million older adults struggle or are unable to leave their homes independently, only a small minority access home‐based primary care (HBPC). Despite substantial growth of HBPC, fueled by growing evidence supporting positive patient outcomes and cost savings, the population remains dramatically underserved and many evidence gaps still exist around scope of practice and key issues in care delivery and quality. Understanding the current state of the field is critical to the delivery of high‐quality home‐based care. Methods We conducted a systematic search of the peer‐reviewed literature on HBPC, published between January 2010 and January 2020, using Medline, CINAHL, Embase, Web of Science, and Scopus online libraries. All studies were evaluated by two members of the research team, and key findings were extracted. Results The initial search yielded 1730 unique studies for screening. Of these initial results, 1322 were deemed not relevant to this review. Of the 408 studies deemed potentially relevant, 79 were included in the study. Researchers identified five overarching themes: the provision of HBPC, the composition of care teams, HBPC outcomes, the role of telehealth, and emergency preparedness efforts. Conclusion The need and desire for growth of HBPC has been highlighted by the recent COVID‐19 pandemic. Current research on HBPC finds a diverse scope of practice, successful use of interdisciplinary teams, positive outcomes, and increasing interest in telehealth with many areas ripe for further research.

BACKGROUND/OBJECTIVES: To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries. DESIGN: A systematic review of the peer-reviewed and gray literature of home-based primary care and palliative care programs among Medicaid beneficiaries including dual eligibles. SETTING: HBMC including home-based primary care and palliative care programs. PARTICIPANTS: Studies describing Medicaid beneficiaries receiving HBMC. MEASUREMENTS: Three groups of studies were included: those focused on HBMC specifically for Medicaid beneficiaries, studies that described the proportion of Medicaid patients receiving HBMC, and those that used Medicaid status as a dependent variable in studying HBMC. RESULTS: The peer-reviewed and gray literature searches revealed 574 unique studies of which only 16 met inclusion criteria. Few publications described HBMC as an integral care delivery model for Medicaid programs. Data from the programs described suggest the use of HBMC for Medicaid beneficiaries can reduce healthcare costs. The addition of social supports to HBMC appears to convey additional savings and benefits.CONCLUSION: This systematic literature review highlights the relative dearth of literature regarding the use and impact of HBMC in the Medicaid population. HBMC has great potential to reduce Medicaid costs, and innovative programs combining HBMC with social support systems need to be tested.

Background Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from “voltage drop” (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or “program drift.” (decreased benefit arising from deviations from study protocols). Methods Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. Results Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11–44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (− 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). Conclusions We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential ‘program drift’ or ‘voltage drop.’ Trial registration Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study “in which the assignment of the medical intervention is not at the discretion of the investigator.” Electronic supplementary material The online version of this article (10.1186/s12913-019-4063-8) contains supplementary material, which is available to aut...

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