Home-based Autologous Hematopoietic Stem Cell Transplantation to Improve Outcomes and Decrease Costs

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Physical, emotional, and financial burdens are especially demanding for older cancer patients undergoing autologous hematopoietic stem cell transplant (HCT), which requires prolonged hospitalizations or daily visits in outpatient clinics for 3-4 weeks and caregivers to be available 24/7. Home HCT is a novel strategy that provides intensive support, integrated care management, and individualized interventions focused on helping patients and caregivers manage care at home, with the potential to improve patient quality of life, reduce caregiver strain, and decrease healthcare utilization and costs. Building on our successful phase 1 home HCT pilot, we propose a randomized phase 2 trial of home vs. standard autologous HCT. In contrast to standard hospital-based care, providers of home HCT make daily house calls, working with patients and caregivers to form individualized treatment plans that facilitate management of HCT complications at home. Home-based care may have many advantages, particularly for older adults, and home HCT may result in better patient quality of life (remaining in their normal environment), better activity (easier to walk around the home or neighborhood than crowded hospital corridors), better nutrition (home vs. hospital food), better sleep (home vs. hospital bed), etc. Additionally, logistics are vastly simplified for caregivers who don’t need to drive back-and-forth daily, which could decrease caregiver strain, anxiety, and fatigue, thereby improving caregiver quality of life; in addition, this may free caregivers to provide more support for patients, further improving patient outcomes. In addition, increased confidence and ability to take care of patients at home may reduce emergency room visits and readmissions. Though upfront staffing costs may be higher, overall health system costs may be lowered by reducing complications and keeping patients out of the hospital. Our first aim is to determine the impact of home HCT on patient health, quality of life and function, including overall quality of life (FACT-BMT, primary endpoint), symptoms, physical function, cognitive function, fatigue, sleep, nutritional status, mental health, social support, self-efficacy, out-of-pocket costs, and return to work. Our second aim is to determine the impact of home HCT on caregiver well-being, including many of the above measures as well as caregiver strain (caregiver strain index, primary endpoint), burden, and satisfaction. Qualitative studies are part of both aims to better understand which aspects of home HCT are most impactful and may be applied to other diseases; this is especially important for planning future studies and implementation. The third aim is to determine the effect home HCT on healthcare utilization outcomes such as readmissions, length of stay, and overall costs. The long-term objectives are to improve outcomes for patients and caregivers by supporting their care at home; keeping patients at home and out of the hospital may in turn reduce costs. The success of this study may serve as a model for other strategies to reduce caregiver burden and keep patients out of the hospital by delivering quality care at home.