New Technologies, Ideas Push the Hospital at Home Concept Forward

With a Medicare-supported model as a blueprint, health systems are finding a lot to like in an acute care at home strategy. But they also have plenty of room to be creative.

Healthcare is embracing the trend of shifting care from the hospital to the home, and forward-thinking health leaders are finding there's plenty of room for flexibility.

Hundreds of hospitals across the country have launched an acute care at home program, focused on treating patients at home versus in a hospital bed. Many of those hospitals are following the Acute Hospital Care at Home model developed by the Centers for Medicare & Medicaid Services (CMS), which sets strict guidelines for in-person care to qualify for Medicare reimbursement.

This strategy, which combines virtual care with in-person services, could be a mainstay in healthcare. But it's a complex process, with an ROI that may take years to show itself.

At a recent HealthLeaders NOW virtual summit, participants from eight different health systems said the future may lie in modifying the model to suit each organization's specific care needs and resources, even if that means bypassing Medicare reimbursement for now.

"We're constantly tweaking it," said Eve Dorfman, vice president of NYU Langone Health, which stood up an acute care at home program less than a year ago that focuses solely on acute care rather than post-acute care. "It's very much a hybrid model."

Dorfman said it took a while to iron out the wrinkles, including infection prevention at home and remote patient monitoring. The health system even used a simulation lab to help nurses "look at the healthcare delivery model differently."

"This is a collaboration," she said. "It is different."

[See also: Assessing the Evolution of Remote Patient Monitoring Programs.]

While acute care at home programs have been around for more than a decade (one of the first was launched at Brigham and Women's), the strategy burst onto the mainstream during the pandemic, when health systems created programs to treat COVID-19 patients at home and reduce stress on overtaxed inpatient services.

The CMS Acute Hospital Care at Home program was launched in November 2020 to address those needs. The program sets rigid rules for Medicare reimbursement and requires hospitals to apply for a waiver of the Hospital Medicare Conditions of Participation, which mandate round-the-clock nursing coverage on the premises.

More than 270 hospitals in more than 120 health systems are currently following that model, with the CMS waivers remaining in place until the end of 2024. Lobbying efforts are underway to make those waivers permanent, but the uncertainty of continued Medicare support is affecting how health systems map out scalability and sustainability.

Because the concept is so new, some states haven't caught up to it yet. Eve Cunningham, MD, MBA, group vice president and chief of virtual care at Providence, said its program was almost shut down before it started because Washington state law has strict definitions on hospital-level care. And Penni Kyte, digital care strategy officer for Ballad Health, said her health system had more problems working with Tennessee state officials to OK a program than they did with CMS.

Lauren Hopkins, MPH, assistant vice president of virtual care and community engagement at Augusta University Health, said the health system started with an all-virtual platform to treat COVID-19 patients and has since pivoted to focus on the transition from acute care to post-acute care, including chronic care management. The health system hasn't applied for CMS waivers yet, she said, because Georgia hasn't amended its state laws to accommodate the care model.

[See also: 5 Lessons From Building an Acute-Care-at-Home Program.]

With the uncertain policy and regulation landscape as a backdrop, health systems are developing their own acute care at home programs. Some are using their own nurses for home visits, while others are partnering with home health or mobile integrated health programs. Some are monitoring patients around the clock, while others are collecting data from patients at certain times of the day. Some are using wearables, and some are integrating pharmacists, physical rehab, even health and wellness services to address social drivers of health.

And not everyone is going with the CMS model. Cunningham says some programs are seeing success with bundled payment models and other services that payers are willing to reimburse.

In a separate interview with HealthLeaders, Tina Burbine, vice president of care innovation and enterprise analytics at HealthLink Advisors, which has advised many health systems—including negotiating with payers—to set up these types of programs, said there's no set definition of acute care at home.

"There are many different flavors of care at home," she said. "And hospitals are seeing a lot of success … as long as they mindful of incorporating their value-based care goals."

"There's so much learning that has to happen" with the CMS model, adds Burbine, who recommends that hospitals start small and build up their program slowly and incrementally with lesser-acuity patients, to see whether high-acuity care will work for them. "This has become such a competitive market that we're even seeing payers compete with health systems."

Some say the acute care at home model will evolve significantly as COVID-19 fades away and hospitals take back some of those inpatient services to bolster their bottom line. In that scenario, the platform shifts more toward post-acute care, including rehabilitation and chronic care management.

Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, said during the HealthLeaders virtual summit that acute care at home may eventually surpass inpatient care as the highest quality acute care platform. The challenge lies in navigating the complexities to create a program that fits well within the health system.

"Think of this as building another brick-and-mortar hospital," he added. "It is very challenging work, but it is so beneficial."

Christopher Subject, MD, a physician with Kaiser Permanente, noted that patients as well as providers are supporting the program.

"They've really been helping to drive this," he said of KP's provider base. "There's a general excitement to do this."

Burbine says the model could someday replace the rehabilitation center as a better and more cost-effective post-acute care pathway and create better alternatives to skilled nursing facilities. It might also be used in prisons, substance abuse treatment programs, and for other populations where hospitalization is difficult.

"Ideally, we want our patients' care to be managed by their health system," she said. "And we're seeing new ideas [for] how that can be done. It changes not only the definition of a hospital, but the definition of a home."