The (Continuing) Evolution of the Hospital at Home Strategy

The CMS model may be gone, but healthcare leaders are seeing value in other care programs that involve less heavy lifting and offer better reimbursement.

The CMS Hospital at Home program may be dead – or at least furloughed for the time being – but that doesn’t mean the strategy is a lost cause.

Hundreds of healthcare organizations across the country were experimenting with the idea of providing care in the home long before CMS came along with its Acute Hospital Care at Home (AHCaH) program and pandemic-era waiver, which enabled some 400 participating organizations to qualify for Medicare reimbursement. And while the waiver has expired and those participating organizations have for the most part phased out their programs, others are still going strong with less-intensive programs primarily based on ambulatory care.

[Also read: Defining the Benefits of the Hospital at Home Strategy.]

“This is really the future in terms of how we can safely provide quality care,” Ron Li, Medical Director of Digital Health and the Health Care at Home program at Stanford Health Care, said during a recent webinar held by the Hospital at Home Users Group.

The CMS concept had more than its share of skeptics. Some criticized the complexity of the model, and the many rules tied to qualifying for Medicare reimbursement. Others questioned the disruption to patients and their families, amid the idea that providers were looking to recreate the hospital room in the home rather than develop a home-based hospital care program. Still more questioned whether hospital-level care should even be delivered in the home.

There was also a cost problem. According to a recent survey of C-Suite executives by Sage Growth Partners, only 13% reported “significant ROI” in their Hospital at Home programs, while 20% saw negative ROI. Another 47% reported some ROI in their programs, and 20% said they broke even.

But that same survey also noted the benefits. Some 67% said the program improved access to care, while 73% saw improved patient satisfaction, 67% said it reduced length of stay, another 67% said it helped reduce avoidable readmissions, and 53 % said it reduced hospital-acquired infections.

When asked what virtual care services helped improve patient safety, Hospital at Home didn’t crack the top 5.

Moving Away From the CMS Model

So how are health systems and hospitals moving forward with the Hospital at Home concept?

Roberts Schwartz, EVP and Chief Innovation Officer at Houston Methodist, says her health system never bought into the CMS model because it was too complex and costly. Houston Methodist is looking more toward what she calls a “Hospital at Home Lite” model, focused around a care traffic control that helps the health system plan where patients are best suited to receive care.

“I can get them out [of the hospital] three days earlier and get them to the home three days earlier because they're tethered and I can keep an eye on them and adjust the meds up or down,” she says, describing a platform that includes some remote patient monitoring and virtual care.

“A lot of people who leave the hospital and are not really that stable, but they don't have nursing home benefits and they don't have long term care benefits and they really have to go home with family and the family needs support,” she added. “And the question is how can we in a light way [and] offer that support?”

Different Models, Different Structures

Several health systems are approaching that question with different ideas. Some were highlighted in the HaH User’s Group webinar.

The webinar, moderated by Stephen Dorner, MD, MPH, MSc, Chief of Clinical Operations & Medical Affairs for Mass General Brigham’s Healthcare at Home program, featured speakers from five health systems taking a different tack from the CMS model. It underscored the reality that many healthcare organizations were put off by the complexity and costs in the AHCaH model, and are looking for a simpler program.

The webinar offered an intriguing look into a few such programs:

• Stanford’s Health Care at Home model is a virtual-only program aimed at replacing the last day of a hospital stay and easing the transition from hospital to home. Its goal is to reduce inpatient length of stay, opening up beds for patients in the hospital, and provide connected care for patients at home, improving recovery and rehabilitation, boosting clinical outcomes and reducing the risk of a rehospitalization.
• Sentara Health’s Sentara To Home (S2H) program, launched in 2020, focuses on reducing length of stay by transitioning patients home early. Patients are seen by a doctor or nurse within 24 hours of discharge, after which the care team decides on a plan for follow-up visits. The program has seen improvements in cost avoidance and reduced LOS, while averaging four visits over about two weeks.
• Penn State Health’s Home Recovery Care and Home Recovery Care Plus programs are designed to catch patients before they show up at the hospital. Patients are screened and admitted to the programs through clinics or their own homes, and the programs are supported by value-based contracts and risk-sharing with payers, rather than a fee-for-service setup, with the focus on cost-savings and outcomes.
• UnityPoint Health, meanwhile, offers a Care at Home Clinic, an ambulatory care service launched in 2018 that offers a suite of home care options – what Peter Read, DO, Medical Director of Unity Point Clinic Care at Home, called “a clinic that makes house calls.” The non-virtual program offers 30-day bundled services ranging from wellness visits all the way up to hospital-level care and is billed primarily through E&M codes.

The upshot of the webinar is that health systems and hospitals are trying many different strategies, with the common denominator being an effort to reduce length of stay – either by discharging patients earlier and continuing care in the home or getting to them before they go to the hospital.

Entering ‘Uncharted Territory’

Dorner, whose Mass General Brigham Healthcare at Home program has reported some of the biggest successes with the Hospital at Home strategy, noted that health systems and hospitals are feeling their way in a new landscape. Some are finding that if they can reach patients early, those patients can spend a few days at home receiving some care before going into the hospital for more advanced care, rather than entering the hospital two or three days early.

“We’re in a bit of uncharted territory,” he said.

Others are wondering if the metrics used to measure a program’s success may be flawed. With some rehospitalizations that aren’t unavoidable, Li said, a care at home program could “shepherd them back” to the hospital, improving long-term outcomes and reducing the length of stay at the other end.

“What we’re seeing is the emergence is a new set of care,” he said, adding that quality of care during and after readmissions might be different than in other cases.

When asked what they wished they had known when they started a Hospital at Home program, the webinar participants offered some interesting insights. Katie Westman, Director of Clinical Programming for Senior Health Services in Allina Health’s Continuing Care program, said she would have spent more time developing the value proposition with home health programs rather than hospital admissions teams.

Both Li and Sophia Loo, also a part of the Stanford Health Care program, said they would have spent more time developing co-management standards for patients transitioning to the home, particularly with specialists. Kamia Thakur, MD, Medical Director of the Hospital at Home program at Penn State Health, said she would have surrounded the program with more physician champions. Read, meanwhile, said he would have focused more time on developing a string value proposition. Too many programs, he hinted, floundered because they started with one idea in mind and had to pivot when that didn’t pan out.

“If we had 10 times the team we would have 10 times the enrollment,” he said.

Colin Findlay, MD, Associate CMO at Sentara Norfolk General Hospital, said he would have asked for more resources.

“If we had 10 times the team we would have 10 times the enrollment,” he said.