More than 200 hospitals are taking advantage of federal waivers to develop and manage Acute Hospital at Home programs. But those waivers won't last forever, and supporters need to prove that the concept should continue beyond the pandemic.
An innovative program that gives healthcare organizations an opportunity to provide ICU-level care for patients at home is facing an uncertain future, even though 202 hospitals and 92 health systems across the country are using it.
The Acute Hospital Care at Home program was developed by the Centers for Medicare & Medicaid Services to reduce expensive hospitalizations and give patients the opportunity to receive care at home. Healthcare organizations were encouraged to launch these programs by CMS waivers enacted during the COVID-19 public health emergency that boost reimbursements and reduce barriers on the use of telehealth and other services.
But with the PHE coming to an end, many participating health systems are scrambling to determine how to keep those programs going without the waivers – and how to redesign them to help populations other than those infected by the virus.
“It would significantly curtail the ability for these programs to either continue or expand,” says Stephen Parodi, MD, executive vice president of external affairs, communications, and brand at The Permanente Federation and associate executive director of The Permanente Medical Group.
Parodi has been guiding the hospital at home strategy at Kaiser Permanente since the health system launched its program in 2014-15. He was a participant in one of two panels devoted to the topic at the recent American Telemedicine Association conference in Boston, and he’s also part of the Advanced Care at Home Coalition (AHCAH), a group of some 20 health systems and connected care advocates lobbying the federal government to continue supporting the program beyond the end of the PHE.
Putting the Concept Into Action
Kaiser Permanente is one of several high-profile health systems that see the hospital at home strategy becoming intrinsic to value-based healthcare. The program is designed to take patients who would otherwise occupy a hospital bed and put them at home, in their own beds, while the health system designs a care plan around them that includes in-person and virtual services. Each program is different, with some health systems incorporating home health services, community paramedicine, pharmacy services, even social services.
"The whole idea of remote patient monitoring has really been taken to the next level with this type of program," Parodi says, .
Supporters say the program reduces expensive hospital stays and costs, saves hospital beds for those who need inpatient care, cuts down on adverse health events and rehospitalizations and improves clinical outcomes.
Carolyn Yang, MD, an internist with Brigham and Women's Hospital and part of their Acute Hospital at Home program and a panelist at the ATA conference, noted that their latest study saw a cost reduction of 38% in the hospital at home program when compared to inpatient costs.
"It is exciting to see this space grow fast," she said.
“We all know the best place in this world is home,” added Swetha Gudibanda, MD, a hospitalist at Wisconsin's Marshfield Clinic who appeared on the same ATA panel as Parodi. “So why not [provide that care] at home?”
Home-based care is far different from inpatient care, and these programs have to be designed and managed carefully to take into account changing workflows, on-demand access to care providers, reliable power sources, even safety and security.
Parodi noted that these programs have to build in redundancies that aren't needed in a hospital setting.
"You've got to think through all these different layers to make sure the program is safe," he said during his panel.
But the home setting also offers care providers a lot more insight into the patient, including diet and exercise habits, family interactions and other issues that might affect one's health.
"We've had instances where there's hoarding, or there [are] 40 cats, or there's a giant snake as a pet," said Margaret Paulson, DO, medical director of the Mayo Clinic's Advanced Care at Home & Home Health programs, which are serving patients in Minnesota, Wisconsin and Florida via a telemedicine hub in Jacksonville, Florida.
Parodi says the Hospital at Home program, in whatever form it's being used, "really is opening doors at a number of levels." It allows the health system to engage with patients at a new level, promoting overall and continued health and well-being instead of episodic care, and it enables providers to identify and address other concerns, including social determinants of health. And it's all built into the patient's daily routines.
"We can literally schedule around the patient's day," he says
"What we're seeing is a level of interaction that's quite different than what we've had before," Parodi adds. "And we'll continue to learn" how to improve that interaction with newer and better services, including medical management, social services and preventive care.
Looking Beyond the CMS Waivers
But that growth will need some help. With the CMS waivers due to end with the PHE, health systems are looking to augment coverage from other payers and redesign aspects of the program that won't be allowed after the PHE, such as the use of telehealth and digital health and certain home health care services. They're also looking at new business cases for the program, such as identifying other patient populations who would benefit from this type of care.
"Hospital at Home is really this shiny bright object right now, which is great, but what is the 'Why?'" asked David Houghton, MD, medical director of digital medicine at New Orleans' Ochsner Health system and an ATA panelist. And Yang, of Brigham & Women's, who was on the same panel, noted that the program "has aligned opportunities" within the payer market, "which is exciting," but more work needs to be done to establish long-term sustainability.
To help the transition from pandemic to post-pandemic healthcare, the AHCAH has thrown its support behind the Hospital Inpatient Services Modernization Act, a bill introduced in both the House and Senate that would extend the CMS waivers for the Acute Hospital at Home program two years after the end of the PHE and require CMS to issue regulations on health and safety requirements for the program, which some see as a step towards making the program more permanent.
“The benefits of advanced care at home will serve patients well beyond the pandemic,” Parodi said in a March 2022 press release by the AHCAH supporting the bills. “By extending these flexibilities, Congress will create a predictable pathway for medical professionals to fully realize advances in the care delivery system that enable patients to be treated with safe, equitable, person-centered care in the comfort of their own homes.”
At the ATA event and in a separate interview, Parodi said those with Hospital at Home programs "need to have outcomes data" to prove the program's long-term value to both Congress and CMS. He said supporters are also asking that the Center for Medicare & Medicaid Innovation (CMMI) study the program.
He said the concept offers more opportunities for health systems to partner with local and community health resources to shape healthcare delivery and push health and wellness resources. And it will help healthcare executives rethink how care is delivered within the hospital itself.
"There's a lot of innovation going on in this space … that will have an impact on healthcare," he says. "And we still have a lot to learn about how to do this."
“We all know the best place in the world is home. So why not [provide that care] at home?”
— Swetha Gudibanda, MD, a hospitalist at the Marshfield Clinic.
Eric Wicklund is the Innovation and Technology Editor for HealthLeaders.
More than 200 hospitals and 90 health systems have launched Acute Hospital at Home programs, which combine digital health and telehealth with in-person services to take patients who would otherwise be in a hospital bed and treat tham at home.
Many of these programs were launched during the pandemic with help from waivers created by the Centers for Medicare & Medicaid Services to expand telehealth services and coverage during the public health emergency.
Those waivers will end when the PHE ends, putting some of these programs at peril. Supporters are now looking to chart a long-term strategy to keep them going and expand their value.