Hospital at Home: The Future of Care?

HOUSE CALLS were the norm not 100 years ago. When someone got sick, doctors provided dependable, personalized care in the comfort of patients’ own homes, and it cultivated a system of two-way trust. Patients knew their doctors, and doctors knew their patients. It wasn’t about meeting quotas or hedging lawsuits. Doctors treated their patients as people first, sick people second.

Times changed, and a confluence of factors shifted medical visits away from patients’ homes and toward centralized clinics and hospitals: Technology. Transportation. Education. Efficiency. And of course, healthcare reform. The Hill-Burton Act (also known as the Hospital Survey and Construction Act) of 1946 gave grants and loans to healthcare facilities for construction and modernization; Title XVIII and Title XIX of the Social Security Act established Medicare and Medicaid in 1965, which standardized care and gave birth to the fee-for-service model healthcare still uses today.¹ The result? Acute care hospitals became the new normal, offering patients a place to seek urgent medical care.

But the elephant in the room remains: Patients don’t really like going to the hospital, let alone staying there for an indeterminate amount of time. The food. The beds. The bureaucracy. Patients spend a lot of time waiting to see the doctor or get updates about the treatment plan, and often experience uncoordinated, fragmented care that makes them feel lost in the shuffle. And, hospital stays are riddled with risk, from misdiagnoses and medical mix-ups to hospital-acquired infections and depression. Hospital stays are stressful, and the hospital is not always the ideal place for healing to happen. Hospital at home (HaH) is a recent twist on a traditional practice that’s gaining steam as a viable alternative to brick-and-mortar inpatient settings, but the future of HaH remains uncertain.

A New Spin on an Old Practice

Even as hospitals became the norm, some experts still saw the value and potential of providing acute-level care to patients in the comfort of their own home and developed their idea into the precursor of today’s HaH model. The brainchild of John Burton, MD, of the Johns Hopkins School of Medicine and Donna Regenstreif, PhD, of the John A. Hartford Foundation, the HaH model was designed to provide safe, effective care to aging patients with common conditions that didn’t really need the intensive care hospitals provided. The idea was to equip patients to receive treatment from a physician who would oversee their care while they recovered at home. It wasn’t about turning patients away; it was about setting them up for success in the comfort of their own home. Bruce Leff, MD, developed eligibility criteria for patients and a clinical model for the program, and then designed a national study to investigate whether the idea could work.² A 17-patient pilot trial was conducted between 1996 and 1998 that showed the program was feasible, safe and cost-effective.³

Then, between 2000 and 2002, a National Demonstration and Evaluation Study was conducted in three Medicare managed care organizations and one Veterans Affair medical center. The study showed that compared to traditional inpatient hospital care, the HaH model had better clinical outcomes; a shorter average length of stay; higher patient and family satisfaction; fewer lab and diagnostic tests; fewer complications such as delirium, infections, need for sedatives or physical restraints; and lower care costs by up to 30 percent.² However, the hospitals received limited reimbursement, and the HaH model did not gain much steam.⁴

Then, COVID-19 hit in 2020. The public health emergency (PHE) overwhelmed the healthcare system with sick patients and caused a shortage of hospital beds. Treating sick patients at home became a solution to an acute problem. Many healthcare facilities were equipped with the technology to leverage telehealth and remote patient monitoring to manage patient care from a distance. The Centers for Medicare and Medicaid Services (CMS) quickly launched the Acute Hospital Care at Home program in November 2020; under its provisions, certain Medicare-certified hospitals were allowed to provide acute-level care to patients at home rather than in the hospital, providing 1) they had the equipment and infrastructure to do so and 2) patients were stable enough and willing to receive care at home. To participate in HaH, hospitals must submit a waiver request to CMS; the request specifically asks CMS to waive §422.23(b) and (b)(1) of the Medicare Conditions of Participation, which require 24/7, immediate availability of registered nursing services on the hospital premises to patients.⁵

The program was a success. In fact, once the PHE ended, the HaH initiative continued under the Consolidated Appropriations Act of 2023, which extended the waiver until Dec. 31, 2024.⁶ As of this writing, 331 hospitals provide HaH services, including flagship Johns Hopkins and three other highly influential hospitals in the United States: Mass General Brigham, Mayo Clinic and Mount Sinai Health System.⁷

But the waiver is set to expire — and soon. In fact, congressional action is needed and indeed is in progress as of this writing. Introduced in the House by Representatives Brad Wenstrup, R-Ohio, and Earl Blumenaur, D-Ore., and in the Senate by Senators Tom Carper, D-Del., and Tim Scott, R-S.C., the Hospital Inpatient Services Modernization Act seeks to extend the waiver for five more years, through the end of 2029. The American Hospital Association (AHA) supports extending the HaH program, describing it as “a safe and innovative way to care for patients in the comfort of their homes. This kind of care is well suited for medium acuity patients who need hospital-level care but are considered stable enough to be safely monitored from home.”⁸

How HaH Works

Each participating healthcare system may have their own process and procedure, but Johns Hopkins Medicine published the following steps a typical HaH program will follow:^9,10

1) Assessment. A patient who would typically be admitted to the hospital who is diagnosed with one of the valid HaH conditions is identified in the emergency department or ambulatory site. Staff assess if the patient is a good candidate for the program using validated criteria. Those best suited to HaH services include patients with community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease (emphysema), cellulitis, volume depletions/dehydration, urinary tract infection/urosepsis, deep venous thrombosis or pulmonary embolism, among others. Patients with these conditions who are otherwise stable can be treated outside of the hospital.

2) Admission. If a patient fits eligibility criteria and is willing to participate, the HaH team meets with the patient and caregiver to discuss the HaH program and assess the suitability of the patient’s home for HaH. For example, the patient must have electricity and running water. If the home is suitable, the patient is admitted to and treated by HaH until he or she is stable enough for discharge.

3) Equipment. A care team member brings medical equipment and communication devices to the patient’s home, sets them up and teaches the patient and his or her caregivers how to use the devices. The patient’s diagnosis, prognosis and treatment plans are also discussed.

4) Monitoring. The patient’s vital signs are monitored electronically by the care team via remote patient monitoring; the patient is evaluated daily by the HaH physician who completes an assessment and continues to implement appropriate diagnostic and therapeutic measures. The physician makes one or more home visits per day and is available 24 hours a day/7 days a week for any urgent or emergent situation. The patient also receives daily nursing visits according to the patient’s clinical need. Nurses are available 24 hours a day/7 days a week for any urgent or emergent situation.

5) Diagnostic studies and treatments. The patient can receive diagnostic studies such as electrocardiograms, echocardiograms and X-rays at home, as well as treatments, including oxygen therapy, intravenous fluids, intravenous antibiotics and other medicines, respiratory therapy, pharmacy services and skilled nursing services. Diagnostic studies and therapeutics that cannot be provided at home (such as computerized tomography, magnetic resonance imaging or endoscopy) are available via brief visits to the acute hospital.

6) Evaluation. The clinicians use care pathways, including illness-specific care maps, clinical outcome evaluations and specific discharge criteria.

7) Discharge. When the patient is discharged by the HaH physician, care reverts to the patient’s primary care physician.

Praise for HaH

Johns Hopkins says its HaH program costs less than brick-and-mortar hospital stays, and the length of stays are shorter. It also reports that cases of delirium were “dramatically lower” in HaH patients.¹¹

A 2019 study found that care for HaH patients cost 38 percent less than those receiving in-hospital care. HaH patients had fewer laboratory or imaging studies and fewer specialty consultations. They spent more time up and around and less time sedentary or lying down. HaH patients had better outcomes and fewer readmissions than those who received in-hospital care.¹²

But perhaps the best indication that HaH is a net gain for the healthcare industry is this: Patients like it. According to a survey conducted by Vivalink in June 2024, 84 percent of respondents reported they would participate in a HaH program if it meant they could go home sooner. Seventy seven percent said if their doctor recommended HaH monitoring, they would trust that opinion. Of those who have experienced HaH, 84 percent reported a positive experience.4 Most patients reported the ease and comfort of receiving medical care at home were important. “It’s clear that patients value receiving care in familiar environments, as survey results show strong support for HaH programs,” said Jiang Li, PhD, and CEO of Vivalink. “Policymakers should recognize the value of at-home care and seek to ensure its continuation, meeting the clear demands and needs of patients.”¹³

Pushback

And yet, not everyone in the industry is so sure HaH programs are a smart move. Some nurses are pushing back, saying it comes down to patient safety. Patients who qualify for HaH programs are too sick to be left alone, they say, and waiving the requirement of on-site, 24/7 access to nursing care puts acutely ill patients in jeopardy. “Acute care means that your condition is likely to change and you are likely to experience, or at high risk to experience, complications. So even if you’re feeling well, that could change quickly,” said Michelle Mahon, RN, assistant director of nursing practice for National Nurses United.11 For nurses like Mahon, 24/7 remote monitoring isn’t good enough.

Critics cite other concerns, too, including, but not limited to:^11,14

• Fears of hedge funds and private equity firms investing in the program without regulations
• Differing state rules regarding paramedics’ ability to provide acute hospital care in homes
• Difficulty recruiting nurses who are willing to go into patients’ homes in urban areas
• Physician reluctance to refer patients due to uncertainty of care quality and fear of malpractice
• Complexity of integrating medical equipment with electronic health records
• Lack of streamlined standards, logistics and regulation

A New Way Forward?

There are still plenty of kinks to work out when it comes to creating a viable HaH program that works for patients and providers alike. Providing acute care outside a brick-and-mortar hospital setting carries some inherent risk, and building a successful HaH system involves investment in infrastructure and personnel. But proponents of HaH say the risk is small and the investment is worth it because hospitals are often at-capacity and short-staffed, and are treating conditions that don’t require intensive inpatient care, not to mention that many patients would rather be at home. “In most cases, if you do a good evaluation of appropriateness, the home is a safer place for most patients, so they also tell us that’s where they want to be,” explained Colleen Hole, BSN, MHA, FACHE, and vice president of clinical integration and population health at Atrium Health. With the way technology is advancing, better connectivity and increasing convenience may very well continue to make HaH a viable option for hospitals to ease the burden of balancing capacity with patient care.