Hospital care at home signifies an important innovation in acute care delivery

CMS’s Acute Hospital Care at Home (AHCH) program is intended to support advance models of home-based acute care based on existing models implemented by a few leading U.S. hospitals and health systems. The program expanded the agency’s Hospital Without Walls initiative, launched in March 2020 as “a part of a comprehensive effort to increase hospital capacity, maximize resources, and combat COVID-19 to keep Americans safe.” Since CMS announced the AHCH program in November 2020, public health emergency (PHE) waivers have allowed for Medicare beneficiaries to receive coverage for hospital-at-home care. But it is uncertain whether such coverage will continue to be available after those waivers expire.

The AHCH program creates flexibility to allow certain traditionally inpatient healthcare services to be provided within patients’ homes. Eligible patients must be admitted to the program from an emergency department or inpatient hospital bed, and an in-person physician evaluation is required before services at home can begin.

Program shows exciting promise

Although the  AHCH program is still early in its development in the U.S., early adopters show evidence of the program’s exciting promise, including:

• Positive impacts on health outcomes
• Better patient, family and provider experience
• Reductions in costly care
• Overall healthcare savings

Give the proven ability to achieve such results with a hospital-at-home initiative, hospital and health system leaders should educate themselves about this program and track and support its further development.

Program requirements

Health systems that have adopted the program report that physician buy-in, support and understanding of the program’s potential benefits are vital to its successful implementation. Hospital’s also must meet several requirements to participate. Hospital staff, mainly case management, must perform environmental and psychosocial assessments of the home environment before care and then continue to manage these environmental aspects during care. To be eligible for the program, patients must live in a supportive and clean environment that allows for treatment to be delivered until they are discharged from the program to their primary care provider or into another setting appropriate for their care.

Other program requirements listed by CMS include:

• Having appropriate screening protocols in place to assess both medical and non-medical factors
• Having a physician or advanced practice provider evaluate each patient daily, either in-person or remotely
• Having a registered nurse evaluate each patient once daily either in-person or remotely
• Having two in-person visits daily by either registered nurses or mobile integrated health paramedics, based on the patient’s nursing plan and hospital policies
• Having the capability of immediate, on-demand remote audio connection with an AHCH  team member who can immediately connect either an RN or MD to the patient
• Having the ability to respond to a decompensating patient within 30 minutes
• Tracking several patient safety metrics with weekly or monthly reporting, depending on the hospital’s prior experience level
• Establishing a local safety committee to review patient safety data
• Using an accepted patient-leveling process to ensure that only patients requiring an acute level of care are treated
• Providing or contracting for services required during an inpatient hospitalization

Program outlook

Because CMS authorized the AHCH program on a PHE basis, the agency agreed to reimburse for acute care at home as though the patient were in a bed at the healthcare facility. However, reimbursement and quality metrics associated with acute-care-at-home admissions will be top of mind if the agency and providers choose to continue to program after the PHE period ends. As with most new programs, one can assume policymakers and healthcare experts will be poring over encounter data to determine the extent to which the AHCH program has benefited the healthcare system and patient care, before ruling on the program’s post-pandemic future.

Building on precedent

Many countries such as Australia, France, Italy, Israel and the United Kingdom have been leading the way in acute care at home for decades. In the U.S., as of July 2, only 66 health systems and 145 hospitals in 32 states were participating in the AHCH services under the Medicare fee-for- service waiver. The program relies heavily on telemedicine to monitor and check-in real time with acute care patients remotely, but it has not expanded as quickly as telehealth services in general. Building infrastructure for the AHCH program has been more difficult for hospitals than expanding telehealth during the pandemic because hospitals already had telehealth platforms built and ready for expansion but often had to start AHCH services from the ground up.

In the U.S., one group of providers has been studying and building AHCH programs since the mid-to-late 1990s. A multistate study at U.S. Department of Veterans Affairs medical centers operating in collaboration with John Hopkins University in Baltimore has yielded great success as a pilot for the program. The multistate program has seen decreased complications when treating patients under their AHCH program. Results include the following:

• A 75% rate of reduction in delirium
• Reduced mortality rates
• Declined use of restraints and sedative medications
• Improved patient and caregiver experiences
• Better functional outcomes
• Cost savings of 19% to 30% compared with traditional inpatient care

Although still a relatively new patient care concept with healthcare providers in the U.S., the hospital-at-home service has been provided by Johns Hopkins since 2015, by Mount Sinai in New York since 2014 and by Presbyterian Hospital in New Mexico since 2008. These providers and others began expanding their models into Medicare Managed Care after Mount Sinai received the CMMI Healthcare Innovation Award for their program in 2014, drawing attention to the program and its successes.

Healthcare providers interested in exploring Medicare’s current AHCH program should visit the program’s webpage. Hospitals also can access a hospital-at-home toolkit developed by John Hopkins to support local adoption and implementation of such a program.