Health systems and hospitals have implemented “hospital at home” programs for several years, but the trend increased in popularity during the COVID-19 pandemic due to a Centers for Medicare & Medicaid Services (“CMS”) waiver. Hospitals view these programs as an efficient way to treat patients, and CMS encouraged the program out of a desire to prevent the spread of COVID-19 via contact among hospital patients and to lessen the risk of overcrowding hospitals during the height of the pandemic. This innovative way of treating patients has also encouraged partnerships and affiliations between health care entities, payors and information technology related companies to facilitate the transfer of treatment from the hospital to the patient’s home.
In response to the COVID-19 public health emergency, CMS implemented a waiver application program (the “Waiver”) whereby acute care hospitals can treat patients with certain diagnoses at home, rather than in the hospital, so long as the patient meets applicable requirements and the hospital provides a specified level of care. Hospitals that qualify for the Waiver are reimbursed by CMS as if the patient was treated in the hospital. This Waiver was recently extended until December 2024. As of December 14, 2023, 129 systems and 308 hospitals in 37 states have been approved for the Waiver.
Specifically, CMS is allowing waiver of the requirement found at §482.23(b) and (b)(1) of the Hospital Conditions of Participation for CMS certified hospitals, which requires full-time nursing services for admitted patients. Instead, CMS is allowing patients, who meet certain requirements, to be treated at home and visited at least twice daily in person by a paramedic, and once daily, either in person or virtually, by both a registered nurse (“RN”) and a physician or advanced practice practitioner. Health care providers monitor patients virtually and must be available to respond to a patient’s needs quickly.
To qualify for the Waiver, patients must be admitted to the hospital at home program from the hospital’s emergency department or inpatient department after being assessed by a physician or advanced practice practitioner. The patient is then transported home and health care providers must set up remote monitoring equipment that allows the patient to be visited virtually by the required health care providers. CMS allows monitoring to occur via audio connection, if there is an immediate connection to the patient’s health care team and the participating hospital is prepared to provide an in-home response within 30 minutes if necessary.
Further, hospitals must fill out a Waiver application that attests to their ability to coordinate certain services remotely, such as pharmacy, infusion, respiratory care and oxygen delivery, diagnostics, transportation, food services, provision of durable medical equipment, and social work coordination, among others. Hospitals must also report certain metrics to CMS, which are: (1) unanticipated mortality during the acute episode of care; (2) escalation rate (transfer back to the traditional hospital setting during the acute episode); and (3) volume of patients treated in the program.
Many hospitals may see the Waiver as an opportunity to save on costs. The price of admitting a patient into the hospital can be significant when considering laundry, cleaning costs, electricity, and other overhead expenses.
Patients also appear to prefer the hospital at home program. Based on surveys conducted by Moving Health Home, a coalition discussed in more detail below, a majority of hospital at home patients surveyed are comfortable receiving care in their homes, are confident in the quality of care they are receiving, would prefer and recommend care in the home, and support expanded care in the home. Brigham Health studied the efficacy of its hospital at home program and found that for in-home patients, post-acute care utilization and readmission rates were lower, and the in-home patients were less likely to visit the emergency department within 30 days of discharge.
There are some things to consider when contemplating starting a hospital at home program. First, upfront costs can be considerable, including transporting the patient from the hospital back to the patient’s home, providing the necessary personnel to provide daily in-person check-ins, and setting up equipment in the patient’s home. These high costs can be offset by the volume of patients if the qualifying patients are amenable to being treated at home. Some may be fearful that they are not receiving the same quality of care as in a hospital, since an RN or physician is not required to see the patient in person unless the patient’s condition warrants such a visit.
Adequate staffing can be a challenge, particularly when facing a health care professional shortage, as are many hospitals currently. Ensuring that a hospital has enough paramedics working to provide two at-home visits daily, plus enough RNs that can provide one in-home visit daily, if needed, is a major hurdle to implementing this program.
Coordinating the day of admittance can be complicated, too. The patient must first qualify for the program, and then the patient must be transported back home. Thereafter, an assessment must be completed in order to determine if the patient’s house is suitable for the program. Does the home have adequate heat and air conditioning? Is there enough space for the remote monitoring equipment? Does the patient’s home have adequate internet and/or phone connectivity? Is the patient able to meet daily needs living there? Is there any concern regarding domestic violence? Is the home located within 30 minutes of the hospital, so that the hospital can meet the requirement to be in the patient’s home within 30 minutes of a call if necessary? Some patients’ homes may not meet all requirements, especially those living in rural areas without high-speed internet or in a location close enough to the hospital. Consequently, rural hospitals may be disproportionately burdened by the Waiver requirements, as they may not be able to partake in the program at all if the majority of their patients’ homes cannot satisfy all CMS requirements.
After determining that the home is suitable, the hospital must install the necessary equipment, and ensure that it is working properly and will transmit all required information to the patient’s health care team successfully. This may require the hospital to provide an IT professional to the patient on the day of admission to explain the equipment and how to use it, if necessary.
The level of patient care is another consideration. In a hospital, a patient can receive immediate in-person care, whereas if they are treated at home, they only have a guarantee of being seen within 30 minutes of a call, if determined necessary, by the on-call RN. Then, after being seen by the RN, the patient may need to be transported to the hospital, causing further delay in any necessary emergency care. Also, patients in hospitals are routinely seen by RNs, not by paramedics, but in the hospital at home program, paramedics, and not RNs, are to visit twice a day in order to determine the patient’s overall health and wellbeing. Finally, the Waiver does require hospitals to provide many of the same services in the patient’s home as in the hospital, such as pharmacy, diagnostics, oxygen delivery, and others, and there is more likely to be a delay in transporting these services to a patient’s home than there is in providing these services to a patient in the hospital where they are readily available.
Hospitals may implement at-home programs outside of the Waiver, but they may run into challenges with payors. Most private payors will not reimburse for these types of services and treatment. However, if a hospital can find an amenable payor, then its hospital at home program does not need to comply with the Waiver’s requirements.
Hospital at Home Partnerships and Collaborations
Hospital at home programs have inspired many innovative partnerships and affiliations, many of which operate outside of the Waiver. For example, Amazon, Ascension, DaVita and others teamed up to create Moving Health Home, a coalition focused on encouraging policy change at both the state and federal levels to allow the home to be the primary site of clinical care.
Atrium Health and Best Buy have partnered up, as well. For three years, Best Buy will go to Atrium Health patients’ homes on behalf of Atrium Health and set up remote monitoring equipment and train the patient or caregivers on how to use the devices. In return, Atrium will purchase the equipment from Best Buy and use Best Buy’s Geek Squad services for installation and retrieval when the patient is discharged.
Mayo Clinic, Kaiser Permanente, Cleveland Clinic, Covenant Health, and others affiliated to create Medically Home, an organization that aims to provide health care in patients’ homes rather than a hospital or other medical treatment setting. Medically Home has developed software and a technology kit geared to provide in home services to patients, and a reimbursement model that connects health systems seeking reimbursement for in home services with third party payors.
Contessa brings hospital care to patients’ homes and has partnered with multiple health systems around the country, such as Baylor Scott & White Health, Mount Sinai Health System, Penn State Health, Highmark Health, and others.
Hospital at home programs appear to help patients recover more efficiently in a comfortable setting. It also allows hospitals to utilize valuable bedspace for patients who are in need of a high level of care, and spurs innovation between hospitals and other health care related companies who provide resources to both the hospital and the patient at home. Given the popularity of this program and the extension of the Waiver, it appears that this method of delivering health care will be sticking around.