Hospital Care Comes Home

This is the first post in a four-part ACCCBuzz blog series on the hospital-at-home model.

Before the COVID-19 pandemic, patients with cancer received care in three settings: hospital inpatient, hospital emergency room, and the outpatient clinic—whether hospital- or practice-based. But just as the pandemic overturned deep-rooted barriers to telehealth uptake, it also brought renewed attention to the hospital-at-home model. 

For more than 30 years, the hospital-at-home care delivery model has been under study. A first iteration of the model—as described in the 2014 National Academies’ The Future of Home Health Care Workshop—envisioned home-based care for older adults with chronic health conditions along a continuum. At one end are low-acuity individuals who need informal at-home services, and at the other end are acutely ill individuals who need hospital-level care at home. 

Bruce A. Leff, MD, professor of Medicine and director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine, is a leading proponent of the hospital-at-home model. Dr. Leff and Elizabeth Madigan, PhD, RN, FAAN, former associate professor of Nursing at Case Western Reserve University, co-chaired the 2014 workshop that was convened to explore how home healthcare might fit into the future of the U.S. healthcare system. In the workshop summary report, Dr. Madigan described four drivers of need for integration of home-care services as an option for some acutely ill older adults:

1. Policy

2. Payment

3. Technology

4. Demographics.

The COVID-19 pandemic brought each of these factors into play.

Recently, Dr. Leff keynoted Transforming Care Delivery with Hospital at Home—a Modern Healthcare virtual briefing. Summarizing the model’s evolution, Dr. Leff highlighted study results that support its feasibility, safety, and efficacy. Additional studies, including a multi-year demonstration study funded by the Center for Medicare and Medicaid Innovation, have shown multiple benefits from programs that deliver hospital-level at-home care for select older patient populations, including high-quality care, shorter length of stay, fewer readmissions, lower costs, and improved patient quality of life. 

While this concept is not new and will not solve the many complex challenges facing the U.S. healthcare system, it may be a piece of the puzzle. As a consequence of the COVID-19 pandemic, the hospital-at-home model is gaining traction and increased health system and payer interest. 

CMS Acute Hospital Care at Home Waiver

On November 25, 2020, the Centers for Medicare & Medicaid  Services (CMS) announced the Acute Hospital Care at Home Program waiver that permitted eligible hospitals to provide hospital-equivalent care to patients in their home. The COVID-19 pandemic resulted in conditions that called for a program outside the bricks-and-mortar-facility hospital “for beneficiaries who require acute inpatient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis.”

In its announcement, CMS stated that “the program clearly differentiates the delivery of acute hospital care at home from more traditional home health services.”

At the time of the program’s launch, the agency approved six health systems “with extensive experience providing acute hospital care at home:"

• Brigham and Women’s Hospital (Mass.)

• Huntsman Cancer Institute (Utah)

• Massachusetts General Hospital (Mass.)

• Mount Sinai Health System (N.Y.)

• Presbyterian Healthcare Services (N.M.)

• UnityPoint Health (Iowa).

By May 2022, the number of approved facilities for the Acute Hospital Care at Home program grew to 35 states, involving 97 health systems and 225 hospitals. However, the CMS waiver will last only as long as the COVID-19 Public Health Emergency (PHE). In remarks during the Modern Healthcare virtual briefing, CMS Deputy Administrator and Director of the Center for Medicare, Meena Seshamini, MD, PhD, made it clear that CMS has limited legal authority to extend the waiver beyond the PHE. 

“We want to evaluate all innovations during the pandemic to move care upstream and keep people healthy,” said Dr. Seshamini. “I want to challenge innovators to not just replace an in-person visit with one using audio/video technology but to create technologies that will fundamentally drive better care, smarter spending, and healthier populations. Where can new technologies keep people healthy and out of the hospital? Where can they reach people who have thus far not been able to access care?”

During other virtual briefing sessions on “Trends and Models of Excellence in At-Home Care” and “Advancing Acute Care into the Home,” panelists shared how some health systems and programs are already answering Dr. Seshamini’s challenge. However, no one is saying hospital-at-home is a simple, one-size-fits-all solution. In fact, implementation complexities—which some systems were able to surmount in response to pandemic-driven needs—are many.

As a champion for hospital-at-home care, Dr. Leff is dedicated to “trying to diffuse, disseminate, and spur adoption of this care model” with a goal to “mainstream and scale the hospital at home model.” He is also realistic about the model’s barriers, calling home-based care, generally, “a square peg in the round hole of our health delivery system” because providers are hard-wired to deliver care in-person within healthcare facilities.

In addition to the culture change required for widespread adoption of this model, Dr. Leff named two other key challenges: 

1. Payment (once the PHE ends) 

2. Supply chain issues. Currently, the supply chain is designed for facility-based care, not care in the home.

Despite these barriers, Dr. Leff sees the hospital of the future as “a big ER, ORs, and ICUs. I think all other services will move into the home.” It’s an assessment supported—for the most part—by the virtual briefing panel on “Trends and Models of Excellence in At-Home Care.”

“Healthcare at home is probably the most significant change to our healthcare system in the last few decades,” said Cory White, Chief Commercial Officer, Stericycle.  

"Care in the home did not start with the COVID-19 pandemic,” said Tara B. Horr, MD, outpatient clinical service chief, Division of Geriatric Medicine and medical director at Vanderbilt University Medical Center. “Patients want to be at home where they are comfortable.” 

But provider uncertainty about the acuity-level of patients who are appropriate for care outside a hospital is a barrier. “COVID-19 [pushed] providers into making these decisions,” said Dr. Horr. “It showed hospitals that patients could thrive receiving care in their home environment.” And Courtney Midanek, managing director at Kaufman Hall, agreed that the home is becoming the third site of care—inpatient, outpatient, and now home. 

Stay tuned for more on the real-world barriers to extending hospital-level care to the home, insights on what is needed to succeed, and technology to support models of at-home care delivery.