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November 28, 2022

Is hospital-at-home care here to stay?

Daily Briefing

    During the pandemic, hospital-at-home care became more common. Many hospital leaders believe it could continue to ease high patient loads, reduce costs, and improve outcomes—however, CMS waivers for these programs may end soon, leaving their future unclear.

    We are in a 'hospital-at-home' revolution. How do we prevent it from becoming 'hospital 2.0?'

    More hospitals are investing in hospital-at-home care

    Although hospital-at-home programs first began 30 years ago, they remained relatively uncommon due to a lack of Medicare reimbursement. However, this changed during the pandemic as Covid-19 surges overwhelmed hospitals.

    In November 2020, CMS issued a waiver that would allow hospitals to be reimbursed for hospital-at-home care at the same rate as inpatient care while the Covid-19 public health emergency was in place. Since then, 114 health systems and 256 hospitals in 37 states have been granted waivers for hospital-at-home programs.

    For example, Mayo Clinic's Advanced Care at Home program, which began in January 2020 and was set up in partnership with Medically Home, has so far served almost 3,500 patients who have received roughly 7,500 days of at-home services.

    According to Mayo Clinic, the 30-day readmission rate for its hospital-at-home program is lower than the rates at its in-person facilities. In addition, 90% of the program's patients say they are satisfied with their care experience.

    Michael Maniaci, medical director of Mayo's hospital-at-home program, said the health system expects to save between 10% and 15% in costs as it implements the program at scale. "You have to take care of a good 25 to 30 patients as an average daily census to at least break even or make this affordable," he said. "But for now, we really want to push the care model and show that it works and it's a better way of caring for people."

    ChristianaCare also implemented hospital-at-home care and has seen benefits. Currently, the health system's 30-day readmission rate for hospital-at-home care is 8.9%, which is lower than the national average.

    In addition, Patty Resnik, VP of operations for the ChristianaCare Center for Virtual Health, said there have not been any unanticipated deaths or notable safety or quality issues through the hospital-at-home program.

    "We are confident that the initial and continued investment is well worth the cost as we transform how care is delivered," Resnik said.

    Although there is still not much data on hospital-at-home programs, research suggests they could be beneficial to patients overall.

    For example, studies have found that hospital-at-home patients spend less time as inpatients and in nursing homes, are less sedentary, and are more likely to rate their hospital care highly. In addition, a study found that Brigham and Women's Hospital's hospital-at-home patients had a 38% lower average cost per hospitalization compared to an inpatient control group.

    "It's not cheap to have amazing paramedics and nurses in the field, to have physicians available 24 hours a day, to have a biometric monitoring system," said David Levine, the medical director of Brigham and Women's Home Hospital program. "But compared to in-hospital care, there are substantial cost savings."

    What will happen to hospital-at-home care after emergency waivers end?

    According to the New York Times, the future of hospital-at-home programs is currently unclear. The waivers allowing many of them to be funded at the same level as inpatient care will be rescinded once the Covid-19 public health emergency ends, which is likely to be sometime next year.

    In a survey from the Hospital at Home Users Group, 27% of programs said they would be unlikely to keep offering hospital-at-home services without a waiver. In comparison, 40% said they were unsure, and 33% said their programs would continue.

    Outside of Medicare, which currently provides the bulk of hospital-at-home funding, private insurers have so far been hesitant to reimburse hospital-at-home care since there is limited outcome data. In addition, quality experts and nursing organizations are still unsure whether hospital-at-home care is a safe substitute for inpatient care.

    "We'll be more comfortable taking an official stance when there is more data out there," said Priyanka Shah, a senior project engineer on ECRI's device evaluation team. "There is not enough peer-reviewed research at hospital-at-home outcomes."

    However, other providers argue that new technology, combined with in-person visits at patients' homes, has allowed care to be transferred safely from the hospital to the home. Many health systems are advocating for CMS to extend its waivers and continue covering hospital-at-home services.

    "I know some have questioned whether hospital-at-home is an enduring strategy. I believe it is here to stay," said Robert Garrett, CEO of Hackensack Meridian Health, which recently partnered with Medically Home to expand its hospital-at-home program systemwide. "There are definitely some regulatory and reimbursement issues to overcome, but I am willing to take a little bit of risk upfront."

    According to Bruce Leff, a geriatrician at Johns Hopkins University School of Medicine, if CMS' waivers "were made permanent, you'd see at least a thousand hospitals in the next few years" implement hospital-at-home care.

    "Hospitals in the future will be big emergency rooms, operating rooms and intensive care units," Leff said. "Almost everything else will move to the community — or should." (Span, New York Times, 11/19; Kacik/Devereaux, Modern Healthcare, 11/22)

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