The Provision of Acute Care Hospital Services in the Home During the COVID Public Health Emergency

The Pennsylvania Department of Health (DOH) recently released guidance permitting hospitals that have been approved by the Centers for Medicare & Medicaid Services (CMS) to participate in CMS’s Acute Hospital Care at Home program (CMS Program) to provide acute care inpatient services to patients in their home in accordance with the CMS Program and DOH requirements. The DOH Guidance can be viewed here.

The CMS Program is an expansion of the CMS Hospital Without Walls initiative that is intended to create additional flexibility for hospitals as they respond to the COVID-19 crisis. Patients can only receive acute care hospital services in the home if they are “transferred” to this at-home care from an emergency department or an inpatient hospital bed, after having an in-person physician evaluation and voluntarily agreeing to participate in the program.

Each hospital that wants to participate in the CMS Program must submit a waiver request by individual Medicare CCN number (i.e., a health system cannot submit a waiver request on behalf of multiple hospitals) seeking to waive Section 482.23(b) and (b)(1) of the Hospital Conditions of Participation, which require nursing services to be provided on premises 24 hours a day, 7 days a week and the immediate availability of a registered nurse for care of any patient. An expedited waiver process is available for hospitals that have previously provided at-home acute hospital services to at least 25 patients.

The CMS Program is limited to patients who meet the patient selection criteria and screening protocols approved by CMS. CMS stated that it “believes that treatment for more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols.” In order to participate in the CMS Program, hospitals must meet the following requirements:

• Have appropriate screening protocols in place before care at home begins to assess both medical and non-medical factors;
• Have a physician or advanced practice provider evaluate each patient daily either in-person or remotely;
• Have a registered nurse evaluate each patient once daily either in-person or remotely;
• Have two in-person visits daily by either registered nurses or mobile integrated health paramedics based on the patient’s nursing plan and hospital policies;
• Have the capability of immediate, on-demand remote audio connection with an Acute Hospital Care at Home team member who can immediately connect either an RN or MD to the patient;
• Have the ability to respond to a decompensating patient at the patient’s home within 30 minutes with an emergency personnel team (this can be provided by 911 or emergency paramedics);
• Track several patient safety metrics with weekly or monthly reporting, depending on the hospital’s prior experience level;
• Establish a local safety committee to review patient safety data;
• Use an accepted patient leveling process to ensure that only patients requiring an acute level of care are treated; and
• Provide or contract for other services required during an inpatient hospitalization, including the following minimum services:

• • Pharmacy
  • Infusion
  • Respiratory care including oxygen delivery
  • Diagnostics (labs, radiology)
  • Monitoring with at least 2 sets of patient vitals daily
  • Transportation
  • Food services including meal availability as needed by the patient
  • Durable medical equipment
  • Physical, occupation, and speech therapy
  • Social work and care coordination

In addition, Hospitals are required to submit monitoring data to CMS on a monthly basis. CMS has issued certain Frequently Asked Questions in connection with the CMS Program which can be viewed here.

As an extension of the hospital, the hospital must decide for each patient whether inpatient acute care services can be safely provided in that patient’s home. The hospital is responsible for adequate staffing, equipment, and services as required by the patient. The patient’s inpatient care in his/her home must be documented in a manner consistent with hospital policies and procedures.

A Pennsylvania-licensed hospital that has been approved by CMS to participate in the CMS Program can begin offering services to patients after it has submitted documentation to the DOH evidencing submission of its waiver request to CMS and CMS’s approval. The documentation must be submitted to the DOH via e-mail at RA-DAAC@pa.gov. The hospital’s DAAC Field Office Health Facility Quality Examiner must be copied on the e-mail communication. While a PSRS report does not need to be entered or amended prior to commencing these at-home services, hospitals must report through PSRS any incidents, serious events, or infrastructure failures relating to acute care services provided in the home.

The DOH recommends that an infection prevention and control (IPC) consultation be conducted by an infection preventionist or designated RN that would be well-positioned to educate on IPC measures, as resources allow. The DOH stated that this “best practice approach can be on-site or remote, and is intended to ensure that the patient-participant and their household contacts, as well as visiting clinical staff, can implement and maintain IPC practices consistent with guidance in PA-HAN-524, or its successor.”

Please contact Kirsten McAuliffe Raleigh at kirsten.raleigh@stevenslee.com or 610.205.6015 if you have any questions about this temporary program.