Admission-Avoidance Hospital-at-Home for Medically Complex Patients: Evidence from an Israeli Pilot to Inform National Policy

Background : Hospital-at-Home programs have shown favorable outcomes in selected diagnostic groups, but evidence remains limited for medically complex internal medicine patients requiring inpatient-level care. This evidence gap is particularly relevant as Hospital-at-Home expands from local initiatives to nationally supported care models, including recent regulatory and financing reforms in Israel. The aim of this study was to evaluate the safety and clinical outcomes of a hybrid admission-avoidance Hospital-at-Home program for medically complex internal medicine patients and consider its implications for the implementation of Israel’s emerging national Hospital-at-Home framework. Methods : We conducted a retrospective matched cohort study of 28 medically complex internal medicine patients enrolled in the Hadassah-Meuhedet Hospital-at-Home (HMHH) program between September and November 2022 and 84 hospitalized controls matched by age (±4 years), sex, medication burden, and hospitalization date. The HMHH intervention provided admission-avoidance hospital-level care at home, including 24/7 physiologic monitoring, daily physician and nurse visits, telemedicine support, and coordinated hospital - health plan oversight. Primary safety outcomes included newly acquired infections, pressure injuries, incident delirium, falls, and 6-month mortality; secondary outcomes included 30-day readmission, length of stay, and medication changes. Results : Baseline comorbidity burden was comparable between groups (mean Charlson Comorbidity Index 6.18). No HMHH patients developed new delirium, compared with 26% of controls (p=0.006). Multiple adverse events (≥2) occurred only among controls. The cumulative adverse outcome index favored the home group (p=0.044). No significant differences were observed in 30-day readmissions, length of stay, or medication changes. Functional impairment was the strongest predictor of adverse events. Conclusion : This early pilot provides preliminary evidence that admission-avoidance Hospital-at-Home can be safely extended to carefully selected medically complex internal medicine patients. As Israel transitions toward a nationally regulated and funded Hospital-at-Home model, these findings highlight the importance of patient-selection criteria, quality and safety measurement, and appropriate clinical infrastructure. Larger multicenter studies are needed to confirm these findings and evaluate resource use, cost-effectiveness, and scalability.