New Program Tests SNF-Level Care at Home

Mass General Brigham is using a state grant to test an advanced care at home model for patients in need of skilled nursing facility services.

Mass General Brigham is testing a variation of the advanced care at home strategy on SNF care.

The health system is using a $4.6 million grant from the Massachusetts Executive Office of Health and Human Services to develop a short-term rehabilitation program that would be an alternative to traditional skilled nursing facilities, to which roughly 25% of Medicare patients are transferred after a hospital stay.

Health system officials say the program, which will follow the acute hospital care at home strategy, would help alleviate the lack of SNF and rehabilitation beds in Massachusetts, which is causing a logjam in hospitals. A recent report from the Massachusetts Health & Hospital Association indicates almost 2,000 hospital patients in the commonwealth are waiting—some for months--to be discharged into SNF care.

“If successful, this care model may lead to a complete transformation of how we deliver advanced rehab care to our patients,” David Levine, MD, MPH, MA, clinical director for research and development for Mass General Brigham’s Healthcare at Home program and principal investigator of the trial, said in a press release. “There are not enough rehab beds in Massachusetts, and if we can substitute facility-based care with home-based care, we will be able to help alleviate the capacity crisis that our healthcare systems have been experiencing across the state. This would have an immediate benefit for patients, family caregivers and clinicians.”

[Also read: Is There a Future for the Hospital at Home Strategy?]

Advanced care at home programs, sometimes called hospital at home, gained attention during the COVID-19 pandemic as a strategy to reduce hospital overcrowding and give selected patients the opportunity to receive care at home. The typical blueprint includes telehealth and remote patient monitoring services alongside in-home visits, often daily, by a care team.

More than 300 health systems and hospitals across the country are using some form of hospital at home service, many of them following a model developed by the Centers for Medicare & Medicaid Services (CMS), which includes a waiver to meet federal guidelines and be eligible for Medicare reimbursement. That waiver is scheduled to end this year, putting many programs that rely on the reimbursement in jeopardy.

Advocates say the program reduces hospital costs and patient length of stay, while improving clinical outcomes and patient and provider satisfaction. Critics say the program is complex and costly and adds to stress on caregivers and care teams.

The MGB program will enroll 300 patients from five Boston-area hospitals, half of which will receive care in a SNF and half of which will receive care at home. The home-based program will include 24-hour RPM and telehealth services through CNAs and physicians, on-demand care from home health aides and a paramedic-based mobile integrated health (MIH) team, and physical, occupational and speech therapy as needed.

Aside from the traditional metrics of cost of care, length of stay, patient and care provider satisfaction, and rehospitalization rates, this program will also evaluate the effect on family and caregivers.

MGB is one of the leaders in the acute care at home space, having launched an early prototype of the program in 2016. The health system has treated more than 3,000 patients in this program, including more than 1,000 in 2023, and received federal and state approval last year to expand the program to more hospitals.

“Being able to have that kind of vantage point, you can ensure greater health and safety of a patient as you’re tailoring their care plan to their personal environment,” Stephen Dorner, MD, MPH, MSc, chief clinical and innovation officer for Mass General Brigham Healthcare at Home, said in a September 2023 press release announcing the expansion.

This past January, a team of MGB researchers led by Levine published results of a nationwide survey of hospital at home programs. That study found a lower mortality rate among patients treated in acute care at home programs when compared to patients who were instead hospitalized, as well as spending less time in a SNF.

“For hundreds of years, since the inception of hospitals, we’ve told patients to go to a hospital to get acute medical care,” Levine said when the study was released. “But in the last 40 years, there’s been a global movement to bring care back to the home. We wanted to conduct this national analysis so there would be more data for policymakers and clinicians to make an informed decision about extending or even permanently approving the waiver to extend opportunities for patients to receive care in the comfort of home.”

“Home hospital care appears quite safe and of high quality from decades of research — you live longer, get readmitted less often, and have fewer adverse events.” He added. “If people had the opportunity to give this to their mom, their dad, their brother, their sister, they should.”

The SNF model isn’t without precedent. Nearby South Shore Health launched a SNF at home program in 2021, during the height of the pandemic, but pivoted to a more traditional acute care at home program because they couldn’t secure payer reimbursement.

"There's a difference between acute and critical care, and certain things we can't do at the home right now,” Kelly Lannutti, DO, the health system’s director of clinical transformation and co-medical director of MIH, told HealthLeaders in an April 2022 interview. “We eased back."

MGB tested its own SNF at home model in 2019, putting 10 patients through the program. Officials said the results “were promising and pointed toward lower cost and a better patient experience compared to traditional SNF care,” but the test was too small to draw more substantial conclusions.

“Now, thanks to this financial award …, we can test this innovative care delivery model that reimagines how we deliver post-acute care,” Levine said in the press release.