Home hospitalization is one of the solutions for dealing with the growing demand for hospital beds, and reducing the duration of hospitalization and its costs. Home-based hospitalization has several definitions. These include: “hospitalisation or active treatment of a patient at home for a predefined period in order to shorten an existing hospital stay or to prevent it in defined facilitating conditions” [
17], and “a service that provides in-home hospital care to patients with complex clinical conditions who would be hospitalized in conventional facilities due to an acute episode, and require 24/7 monitoring and follow-up that is only available in the hospital” [
8,
23]. Community-based home hospitalisation services are gradually becoming part of the standard care in many healthcare systems in the form of different service models and for an extensive range of diagnoses.
Notably, home care that does not replace hospital care is not included under the definition of home hospitalisation. Home hospitalisation is intended for suitable patients of all ages, but in practice more than 90% of patients are elderly, mainly aged 75 and older, who are hospitalised often and normally for lengthier periods than average. Therefore, home hospitalisation has entered medical consciousness and practice as a therapeutic tool in the world of geriatric medicine [
9].
Furthermore, hospitalisation is costly for health systems and is a health risk for many patients, including medical complications related to the hospital stay, such as infections that might be contracted during a hospital stay, falls, unnecessary tests, and mistaken medications, as well as potential cognitive and functional harm to patients, particularly the elderly, due to being in a strange place where they have no control over their fate [
5,
33,
37]. In addition, high occupancy rate contributes to the development of antibiotic resistant infections in hospitals, which are estimated to cause the death of 4000–6000 patients every year The State Comptroller and Ombudsman of Israel [
36]. This has led to a change in the location in which treatment is provided. Home hospitalization has also grown due to the development of home care equipment and technologies, the wish to let patients choose where they want to be treated, to cut costs and hospital days, and to improve patients' health outcomes [
3,
5,
18]. The diversion of medical treatments from hospitals to the community and into patients’ homes, and the development of home hospitalization as an alternative to inpatient care, have been gradually developing in the Western world in the last two decades as part of the global healthcare trend aimed at coping with the shortage of resources, overload of the health system, reducing complications of hospital stays and improving the quality of care and patient wellbeing [
28]. In the US, the “Hospital at Home Program” was developed by researchers at the Johns Hopkins Schools of Medicine and Public Health in Baltimore, Maryland, and it was first implemented in 1995. The main purpose was to create an alternative treatment option for elderly patients who either refused to go the hospital or were at higher risk of hospital-acquired infections and other adverse events. According to early trials of this program, the costs of at home care was 32% less than traditional hospital care and consequently [
20,
22].
Since then, many countries have adopted and exploited the principles of the program and have developed similar services. For example, in Canada, the multifaceted evidence-based INSPIRED COPD Outreach Program (Implementing a Novel and Supportive Program of Individualized Care for Patients and Families Living with REspiratory Disease) was first implemented in Halifax, Nova Scotia in 2010. Multidisciplinary healthcare teams provide a holistic home care services to the patients and their families [
27]. In the recent decades, several countries have begun to expand home hospitalization services with great success. For example,
Australia (in the state of Victoria) Spain and France. Other countries such as Canada and England have local initiatives. In the United States, home hospitalization was recognized for Medicare funding at the end of 2020 as part of the Corona emergency provisions and the service has been in an accelerated support process since then.[
13‐
15,
17,
24,
35]. The implementation of home-based hospitalization optimized the use of resources by providing health services for specific groups who do not require conventional hospitalization [
8]. In Israel, the average hospital stay is 5.2 days compared to an OECD average of 6.4. This is compatible with the low rate of beds and high occupancy of hospital beds in Israel (93.8%), which is second highest of all OECD countries–preceded only by Ireland [
6], and indicative of maximal utilization of the bed infrastructure. The low bed ratio per capita is a result of a long-standing government policy aiming to transfer as many treatments as possible to the community, and to control hospitalisation costs [
32]. In 2016, the bed occupancy rate in general hospital wards in Israel was 94%, versus an average of only 75% in European Union countries and in similar countries [
10]. The resulting situation is a significant overload in the inpatient and emergency rooms in Israel.
In recent decades, Israeli health maintenance organizations (HMOs), established various services to care for the population in the community and at home, but a home hospital service–where a patient receives services at home instead of being admitted to a hospital–did not exist. The HMOs are, not-for-profit health maintenance organizations which provide universal coverage to all citizens and permanent residents of Israel with access to a statutory benefits package. Specifically, to home care in Israel–inpatient hospitalization and home care are both paid in full and have a budgetary coverage by the HMO (Each individual freely chooses from among four competing). Generally, Israel has a national health insurance system that provides. The healthcare system is financed by general taxes and an earmarked payroll tax (health tax). These funds are allocated to the health plans according to a capitation formula, with risk adjustment intended to sufficiently compensate the plans for the cost of members.
In 2018, Maccabi Healthcare Services (MHS), the second largest HMO in Israel, was the first to establish a community-based home hospitalization (CBHH) program, because it understood that the patient’s place was in the community, and following the wish to improve patient's well-being and their responsiveness to care. This CBHH program constitutes a breakthrough and a first-of-its-kind model in Israel, and it is expected to result in reducing hospital overload and costs, while providing best personal care to patients requiring hospitalisation. CBHH represents a dramatic change to the traditional concept of acute hospitalization, as well as an organizational change that must be managed within the Israeli health system.
Maintaining financial resource management and reducing health costs is a significant challenge and a necessary need for the continued existence of any health organization. According to Perroca and Ek [
30], who reviewed home hospitalisation programs in Sweden, such programs have clinical and economic efficacy due to the need to reduce costs in the public sector, which are increasing with the rise in life expectancy and in the number of people over 80 in the country. Aimonino Ricauda et al. [
1], conducted a comparative study in Torino, Italy with 104 patients with chronic obstructive pulmonary disease (52 in home hospitalisation and 52 in a control group). The results indicated a reduction in repeat hospitalisations among the group of patients in home hospitalisation during the 6 months after discharge, lower direct costs in home hospitalisation versus hospital stay, and higher satisfaction among patients in home hospitalisation [
2].
A three-year comparative study between patients in home hospitalisation and a control group of patients in hospital care, conducted among 507 adult patients in New York showed that patients in home hospitalisation had shorter acute hospitalisation, less complications, less repeat hospitalisations, and lower costs than the control group [
13,
14]. reported less hospital days and a considerable cut in costs among 1276 adult patients in home hospitalisation, especially among those aged 75 and older. Hernandez et al. [
17] conducted a 10 year prospective evaluation to investigate the clinical outcomes, costs and barriers to embracing a home hospitalisation/early discharge program among 4165 patients with respiratory tract illnesses, as well as patients after surgery, cardiac, oncological, and others with acute illnesses The results showed high acceptance of the service (82%), very high satisfaction with the service by patients and carers (98.5% satisfied) and shortening the hospital stay by one day. Despite the rise in patient complexity over the years, the mortality rate remained identical (2%), the rate of repeat hospitalisations within 30 days diminished by 2% and the rate of visits to the emergency room diminished by 1%. With regard to costs, at first the results showed that home hospitalisation was cheaper, but at present, there is no difference in the payment schemes for both types of services [
17]. Levine et al. [
26] suggested, based on trials conducted using an at-home care delivery model, that the cost associated with acute care episode was 52% lower than those of traditional inpatient care [
26].
While, in the long run, the introduction of new medical services and technologies has the power to reduce future health costs as shown in several studies that have examined the economic effects of chronic illness [
12,
25], in the short term, the question of the economic viability of home hospitalization to the Israeli HMOs must be examined. This is because in health economy, often when health services that replace existing health services are added, even if the new service is cheaper, in fact we create a supply of health services/new technologies that cause patients to consume more health services. Therefore, in the short-term overall health expenditures are increased. The cost savings of the new service or technology are often seen in the long run because they reduce complications and improve the overall health of patients [
7,
29].
There are many studies on home hospitalization in the Western world; however, there are limited studies about the cost compared to inpatient hospitalization. Specifically, in the State of Israel where CBHH is a new phenomenon, the subject has hardly been studied.
Thus, the objective of this study was to examine costs of CBHH in comparison to costs of inpatient hospital care in the Israeli public health system. The provision of an empirical assessment of costs enables understanding the economic feasibility of the service.