Acute Care in the Home Gets Waiver Extension

The hospital at home model of providing acute-level healthcare in the residences of patients who are sick enough to meet hospital admission standards continues to generate interest from hospitals, payers, and policymakers. But uncertain regulatory footing, lack of coverage by many private insurers, reluctance by some physicians to refer, and low patient volume for even well-established programs have raised questions about its viability.

One big piece of the puzzle was resolved for now when a version of the Hospital Inpatient Services Modernization Act (S3792) was included in the omnibus $1.7 trillion Consolidated Appropriations Act of 2023, which Congress passed on December 23 and that was signed into law by President Biden.

The new legislation will extend for 2 years (until December 31, 2024) the 2020 COVID-era public health emergency order waiving Medicare’s requirement that acute hospital care must include 24-hour nursing presence. It also directs the Department of Health and Human Services to evaluate outcomes from the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home program and report the findings. Advocates now have 2 years to try to make the waiver permanent.

Pilots and Innovation Grants

As of November 15, at least 256 hospitals in 37 states had applied for and been granted Acute Hospital Care at Home waivers from CMS, although it is not known how many of them are actually providing this care. For some, the model has represented a pressure valve for high-occupancy COVID surges.

For others, it’s a whole new orientation to care, especially for older patients who could benefit from avoiding a hospital admission and its exposure to potential hospital-associated harms. “The patient feels better, has a more pleasant experience, and can heal faster when getting a decent night’s sleep [at home],” said Michael Nassif, MD, a cardiologist at Saint Luke’s Health System in Kansas City, Missouri. He is the medical director of Saint Luke’s Hospital in Your Home program, which launched in August of 2022.

Dr Michael Nassif

The first hospital at home program in the US, which follows established models from Europe and Australia, opened at Johns Hopkins Medicine in Baltimore, Maryland, in 1996. Numerous subsequent studies have consistently demonstrated favorable outcomes for the model in terms of quality, safety, effectiveness, rates of hospital readmissions, and patient satisfaction.

“Before, hospital at home was a series of pilots and a couple of innovation grants from the Centers for Medicare and Medicaid Innovation,” Nassif said. “But I think we’re now on the cusp of where this could become a permanent program [under Medicare], and then more people will be excited about participating,” he said. The data are fairly convincing that for the right patient, hospital at home is better care.

“I can tell you that for Saint Luke’s, we have four metro area hospitals ready to participate. We now have a daily census of 10 patients receiving acute, hospital-level care at home, but that could quickly triple when all four hospitals are on board.” One of the biggest impediments, he said, is lack of coverage by private insurers. Today, hospital at home is mostly covered by Medicare and some Medicare Advantage plans, leaving only about 1 in 3 patients admitted to Saint Luke’s eligible to participate.

Truly Acute-Level Care

Nassif wants clinicians to understand that the care his program provides truly is hospital-level acute care. Services provided in the home include x-rays, ultrasound, electrocardiography, intravenous therapies, laboratory services, and rehabilitation therapy. “A lot of our turnaround time on test results is not that different from a bricks-and-mortar hospital,” he said.

The needed medical equipment is driven to the home in SUVs by specially trained community paramedics, who also set up a technology kit to ensure that the patient has a working tele link to the hospital-at-home command center. The paramedics make many of the required twice-daily in-person clinical patient visits, while a crew of virtual nurses is accessible via telehealth 24 hours a day from the command center.

A physician makes a virtual visit to enrolled patients every day, just like making rounds in the hospital, and a nurse practitioner visits the patient’s home every other day. When needed, patients can get up to five in-person visits per day, for example, to check for decompensation, to administer IV fluids, or to witness medication administration, Nassif said. A nurse practitioner’s face-to-face visit with the patient might last 90 to 120 minutes.

“The logistics are challenging, but we invest a lot of resources in order to juggle all of that,” Nassif said. “We have a person who is just in charge of the supply chain and service network,” which includes backup alternative service providers. Service coordinators work 12 hours a day, 7 days a week, just to manage the visit schedule. Couriers are dispatched to deliver medications multiple times a day.

Still a New Concept

Hospital at home is still a new concept for a lot of clinicians, even though the model has been around for decades, said Linda DeCherrie, MD, who helped to establish a pioneering hospital at home program at Mount Sinai Health Care in New York City before taking a position as vice president of clinical strategy for the Boston-based acute home care company Medically Home.

Dr Linda DeCherrie

Although hospital at home programs typically are developed by hospitals, many are turning to partnerships with entrepreneurial companies that are better positioned to mobilize the various pieces of the required care continuum in the home. Even established hospital at home providers, such as the Mayo Clinic and Kaiser Permanente, are following this path. In May 2021, they announced an investment of $100 million in a partnership for hospital at home with Medically Home.

“We cooperate with systems like Saint Luke’s — with their physicians, their nurses, their patients, their electronic medical records,” DeCherrie said. “We support the whole operation of the supply chain, with knowledge of how to quickly set it up. That’s our goal — we are ongoing partners, not consultants.” Other companies seeking to service the growing hospital at home market include Vituity, Dispatch Health, Conduit Health Partners, and Contessa Health.

Hospital at home programs typically focus on general medical patients, but some may emphasize care for oncology or postsurgical and postprocedural patients, DeCherrie said. Typical admissions include patients with congestive heart failure, cellulitis, chronic obstructive pulmonary disease, and urinary tract infections with acute medical needs. The challenge is to anticipate things that might happen, just as for a patient on the hospital floor.

Some enrolled patients might need to return to the hospital building, or even be placed in an intensive care unit. “How do we make that happen safely, working through the work flow?” she said. “We need to make sure the home is a safe environment, with electricity, and where we are able to provide safe care.” Being able to see patients in the home also makes it possible to observe the administration of medications, as well as the patient’s diet, relationships, caregiver support, and other determinants of health.

Natalie Schibell, MPH, vice president and research director for the analytics firm Forrester  Research, co-authored a recent report that called “acute home care” — a broader term for in-home, hospital-level healthcare, including hospital at home — “the best medicine for US hospitals.” But she also highlighted challenges of sustainability, scalability, and reproducibility, including the lack of a standardized operating model.

Natalie Schibell, MPH

Current infrastructure varies widely, and a program’s form is shaped by the patient population it serves and by available resources, with varying frameworks, delivery methods, and technologic systems, including electronic medical records, Schibell told Medscape. “Healthcare organizations should know that you need to make this a robust, comprehensive program, without compromising quality.” Partnering with a skilled vendor can help, although their role is to supplement, not replace, the hospital clinicians who provide the clinical care.

Hospital at home is not in every hospital in the country yet, DeCherrie said. “Not everyone is talking about it. How will we reach every cardiologist and every nephrologist to know that this service is available in their hospital? That will take some time and some work,” she added. “But once they have had one of their patients come through the program, they can immediately see the benefit and how smoothly it runs. Then the floodgates will start to open.”

No relevant financial relationships have been reported.

Larry Beresford is an Oakland, California–based freelance medical journalist with a breadth of experience writing about policy, financial, clinical, management, and human aspects of hospice, palliative care, end-of-life care, death, and dying.

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