Wealth Predicts Who Gets Hospital Care at Home, Barcelona Study Finds

Hospital at Home has become one of the most talked-about innovations in modern health care, promising to deliver acute-level treatment in the comfort of a patient’s own living room rather than in a hospital ward. For older adults with complex medical needs, the model offers obvious appeal: fewer falls and infections, less disorientation and delirium, and a recovery environment that is familiar and dignified. But a new study from Barcelona raises an uncomfortable question about who actually benefits from this model. According to research published in BMC Geriatrics by Maristella Belfiori of the University of Cagliari and colleagues at the Parc Sanitari Pere Virgili and the Vall d’Hebron Research Institute, access to hospital at home services among older adults in Barcelona is not determined by clinical need alone. Socioeconomic status, measured both at the individual level and across small neighborhood areas, shapes which patients are admitted to home-based hospital care — and which are routed instead into traditional bed-based units.

The research team set out to examine whether socioeconomic disparities influence admission to two distinct care models that both operate under the umbrella of Comprehensive Geriatric Assessment, a structured, multidisciplinary approach to evaluating the medical, functional, and psychosocial needs of older people. The first model was Hospital at Home, abbreviated HaH, which brings physician-led, nurse-supported acute care into the patient’s residence. The second was a bed-based intermediate care unit, or BBU, where patients receive comparable geriatric care but within a physical facility. Both services serve the same catchment population and are grounded in the same assessment philosophy, which makes them an ideal natural comparison: if admission decisions were driven purely by clinical criteria, the socioeconomic profiles of patients in the two pathways should look broadly similar. They did not.

To conduct the analysis, the researchers assembled a retrospective cohort of adults aged 65 and older who had been admitted to either the Hospital at Home service or the bed-based intermediate care unit at Parc Sanitari Pere Virgili between 2018 and 2023. Rather than relying solely on clinical records, the team linked these data to administrative health records that contained individual socioeconomic variables as well as small area-level indicators describing the neighborhoods in which patients lived. This dual-level design is technically important. Many studies of health inequality capture only individual characteristics such as income or education, but a person’s opportunity to receive care at home also depends on contextual factors — housing quality, caregiver availability, and the social fabric of the surrounding area — that individual variables cannot fully capture.

The statistical approach reflected this multi-layered structure. The researchers used mixed models, a class of regression techniques that can simultaneously estimate the effect of individual and area-level predictors while accounting for the clustering of patients within small geographic units. These models produced odds ratios quantifying how socioeconomic variables influenced the probability of being admitted to Hospital at Home rather than to the bed-based unit, adjusted for demographic and clinical characteristics. They also generated measures of clustering and heterogeneity, such as the intraclass correlation and interval-based odds ratio statistics, that reveal how much of the variation in admission decisions is attributable to where a patient lives rather than to who the patient is.

The headline finding was stark. After adjustment for demographic and clinical factors, patients with higher income had significantly greater odds of being admitted to Hospital at Home: the adjusted odds ratio was 1.68, with a 95 percent confidence interval of 1.45 to 1.96. In practical terms, this means that wealthier older adults were substantially more likely to receive their acute geriatric care at home, while economically disadvantaged patients with comparable clinical profiles were more often directed to the bed-based intermediate care unit. The unadjusted comparisons reinforced the pattern: Hospital at Home patients were, on average, younger, less burdened by multimorbidity, and more socioeconomically advantaged than their counterparts in the bed-based unit. Some of that difference reflects genuine clinical selection criteria, since home-based acute care requires a suitable home environment and a degree of stability, but the persistence of the income effect after adjustment indicates that clinical factors do not tell the whole story.

Equally revealing was the geography of the disparity. The researchers found that area-level socioeconomic context explained roughly 20 percent of the variability in Hospital at Home admission, and that the strength of socioeconomic effects varied widely across small areas within the city. In some neighborhoods, socioeconomic position appeared to exert a powerful influence on whether a patient reached the home-based pathway; in others, the effect was muted. This heterogeneity, quantified through the mixed-model framework using measures such as the median odds ratio and the proportion of opposed odds ratios, suggests that access to hospital care at home is not uniformly patterned across Barcelona but is locally mediated — by differences in housing stock, social support networks, and possibly by the way services are organized and delivered in different primary care service areas.

The implications reach far beyond one Catalan health district. Hospital at Home models are expanding rapidly across Europe, North America, and beyond, propelled by aging populations, hospital capacity pressures, and evidence that many older patients fare better at home. Governments and health systems have embraced the model as a cornerstone of future acute care. Yet the Barcelona findings highlight a structural risk: if eligibility and referral processes implicitly favor patients with higher incomes, better housing, or stronger family support networks, the model could widen rather than narrow existing health inequalities. Patients who stand to benefit most from avoiding a hospital admission — those living in deprived neighborhoods, with fewer resources and more fragmented support — may be the very ones least likely to be offered home-based care, defaulting instead to institutional settings that carry higher risks of functional decline for frail older people.

The authors frame their conclusions as a call to action for health systems designing and scaling home hospital services. Ensuring equitable delivery, they argue, requires explicitly addressing the social barriers that shape access: identifying health-related social needs during the Comprehensive Geriatric Assessment, adapting services to patients whose homes or support networks are less favorable, and monitoring socioeconomic equity in referral patterns as rigorously as clinical outcomes are monitored. The study’s granularity matters here. By using small area-level indicators rather than crude citywide measures, the researchers demonstrated that disadvantage operates at a neighborhood scale, meaning that equity interventions may need to be locally targeted rather than uniformly applied.

Methodologically, the study has the strengths and limitations typical of retrospective administrative data research. Its cohort design captures real-world admission patterns over six years, and the linkage of individual records to area-level socioeconomic data provides a nuanced picture that single-level analyses would miss. Ethics approval was granted by the Vall d’Hebron Research Institute Ethics Committee under protocol PR(AG)107/2020, with informed consent waived because the analysis used anonymized retrospective datasets and was conducted in accordance with the Declaration of Helsinki. The work was funded by the Instituto de Salud Carlos III through project PI22/00845, co-funded by the European Union, and the authors declare no competing interests. Because the data reflect a single provider in Barcelona, the exact magnitudes of the disparities may differ elsewhere, but the analytical strategy — and the warning it carries — is readily transferable to any health system rolling out home-based acute care.

The article, published open access in BMC Geriatrics on 23 September 2026, arrives at a moment when the future shape of hospital care is being actively negotiated in legislatures, insurers’ boardrooms, and clinical guidelines. As Hospital at Home shifts from pilot projects to mainstream infrastructure, the Barcelona study offers a clear technical lesson: admission algorithms and referral pathways are not socially neutral. Without deliberate design, the comfort and clinical advantages of being treated at home will flow preferentially to those who already hold the most resources, while older adults with the greatest socioeconomic vulnerability remain on the ward. The research suggests that the measure of a successful hospital at home program should therefore be twofold — not only whether patients recover well at home, but also whether the patients admitted to those beds at home are there because of their clinical need, and not because of their income or their postcode.

Subject of Research: Socioeconomic inequalities in access to hospital at home care for older adults

Article Title: Beyond clinical need: socioeconomic inequalities in access to hospital at home among older adults

Article References: Belfiori, M., Pérez, L. M., Villa-García, L., Planesas-Pérez, O., Salucci, C., Inzitari, M., & Ribera, A. (2026). Beyond clinical need: socioeconomic inequalities in access to hospital at home among older adults. BMC Geriatrics. https://doi.org/10.1186/s12877-026-08310-z

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08310-z

Keywords: Hospital at Home, socioeconomic inequality, older adults, geriatrics, Comprehensive Geriatric Assessment, health equity, Barcelona, intermediate care, income disparities, health services research, mixed models, BMC Geriatrics