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The ‘Hospital at home’ (HaH) model avoids hospital admission by transferring healthcare and treatment to the patient's home. We aimed to compare the effectiveness and direct healthcare costs of treating elderly patients with decompensated heart failure (HF) using HaH care vs. inpatient hospital care (IHC) in a cardiology unit.Eighty patients aged over 65 years who presented at the emergency department with decompensated HF were randomly assigned to IHC or HaH. All patients were studied for 1 year. Seventy-one patients completed the study, of these 34 were admitted to cardiology and 37 received HaH care. No significant differences were found in baseline characteristics, including comorbidity, functional status, and health-related quality of life. Clinical outcomes were similar after initial admission and also after the 12 months of follow-up. Death or re-admission due to HF or another cardiovascular event occurred in 19 patients in IHC and 20 in HaH (P=0.88). Changes in functional status and health-related quality of life over the follow-up period were not significantly different. The average cost of the initial admission was 4502 ± 2153€ in IHC and 2541 ± 1334€ in HaH (P < 0.001). During 12 months of follow-up, the average expenditure was 4619 ± 7679€ and 3425 ± 4948€ (P=0.83) respectively.Hospital at home care allows an important reduction in the costs during the index episode compared with hospital care, whilst maintaining similar outcomes with respect to cardiovascular mortality and morbidity and quality of life at 1 year follow-up.