In response to the intense pressure put on hospital capacity during the COVID-19 pandemic, the U.S. Centers for Medicare & Medicaid (CMS) used its emergency authority to waive several regulations to clear the way for alternative options for hospitals to care for patients. One of those alternatives, Acute Hospital Care at Home (AHC@H), was introduced in November 2020 and allowed hospitals to consider hospital-at-home as a viable solution during unprecedented times.
Hospital services have been provided in the home in the United States for over 25 years, driven by the pioneering work of Dr. Bruce Leff, geriatrician and professor of medicine at Johns Hopkins University School of Medicine. That said, there has been slow adoption due to very few reimbursement options from traditional government and commercial payers. The hospital-at-home model has also been part of the healthcare ecosystem in European countries, and it was credited by the Victorian Health Department in Australia as representing capacity in their health care system equal to that of a 500-bed hospital.
A Quick Tutorial on AHC@H
You may be wondering, what’s the difference between providing hospital-level care at home and traditional home care services? The main differences are underscored by the waiver requirements and CMS approval process. Given the rapid processing of the waiver opportunity in response to the pandemic, only hospitals with a CMS certification number could apply for AHC@H. This ensured that there were existing quality and reporting structures in place to support program development.
AHC@H programs are required to meet hospital CMS Conditions of Participations standards, except for the waived requirements of 24/7 on-site nursing. The waiver also limits the entry point for the program – after being seen in a hospital emergency department or after a short stay in a brick and mortar hospital, a referral can be made to the hospital-at-home program.
In addition, AHC@H waiver recipients are required to submit weekly or monthly data to CMS based on their waiver granting-status. The hospital-at-home MD/APP in-person visit on initial admission and two in-person visits daily by an RN or Community Paramedic in the home are combined with 24/7 on-demand remote and audio support from the clinical command centers. Programs also are required to develop and implement a detailed operational structure that can deliver all the services that could be needed during a hospital stay, either directly or through contract (i.e., pharmacy, respiratory care, labs, physical, occupational and speech therapy, social work, food service, transportation, etc.).
It's important to acknowledge the logistical and technical work needed to deliver hospital-at-home, and the correlating investment of time, staff and money. In order to establish a strong foundation for hospital-at-home, hospitals must re-wire their traditional processes and rethink everything from logistics and care delivery to remote interactions and response. As one hospital-at-home physician said, “The medical part is easy. It’s all the other things that need be rethought.”
Through the pandemic, with the reimbursement challenge removed, hospitals and systems invested talent and resources to develop and/or partner on the technology chassis, staffing models and clinical care protocols that could safely deliver 24/7 hospital-level services in the home. Continued advances in technology services and equipment in the home provide connectivity and information needed for care teams to deliver high-quality, responsive services to patients.
One unexpected, but real, benefit shared by care givers in this model is the opportunity to experience the home environment of their patients. Instead of asking questions in the hospital regarding any post-discharge concerns or needs, nurses and providers alike experience their patients’ home environments during the inpatient care relationship. Are there any barriers that can be removed to improve/accelerate recovery? Are there other support services that can be added to prevent a recurrence or readmission due to a chronic condition? Are there factors related to the social determinants of health that need to be addressed outside of the clinical diagnosis? Using technology in the home informs clinical decision-making during the inpatient home stay – but the personal relationship with patients and their families for the hospital-at-home admission adds another layer of understanding that is beneficial to both patients and providers.
So…will the model remain with CMS support?
As the pandemic emergency declarations expired, the CMS AHC@H waiver program was extended through December 31, 2024, through the Consolidated Appropriations Act of 2023, in addition to other telehealth flexibilities.
CMS also published an initial review of data from the AHC@H waiver initiative in November 2023 covering 11,159 patients – the largest analysis of hospital-at-home patients yet in the literature. One of the takeaway points highlighted in the hospital-at-home community is this: “Patients who received care under AHC@H had a low mortality rate consistent with the hospital-at-home literature and minimal complications related to escalations back to the brick-and-mortar hospital.”
With one year remaining in the AHC@H Waiver, there will be much conversation regarding the initial data, analysis, challenges, and opportunities to expand this model. We anticipate questions to arise around such things as:
- Program quality
- Cost framework
- The development of an accreditation program specific to hospital-at-home
- Other potential access points other than hospital ERs or inpatient units
- The future reimbursement model and its impact on traditional hospital services
- Should a broader demonstration project through the CMS Innovation Center with continued reimbursement be a next step
- And many more
At the end of it all, the tailwinds seem to be pushing in the right direction to continue the use of hospital-at-home as a part of our health care ecosystem in the U.S. Patients and hospitals have benefited from having this option during the pandemic. Organizations and providers, nurses, ancillary staff and technology partners have invested time, expertise and know-how to provide needed care and services in a meaningful way to patients, and there is more data, outcomes and experiences to be shared. 2024 is shaping up to be a busy year!