Hospital-at-Home Care Model: What it is and Why it Works 

December 28, 2022 - Though providing hospital-level care at home is not a new concept, the popularity of such programs grew during the COVID-19 pandemic. 

As cases of the deadly coronavirus began surging in March 2020, healthcare organizations nationwide halted various types of in-person care due to capacity constraints and fears of exposing people to the virus. As they pivoted to virtual care strategies to manage patient care, hospital-at-home programs emerged as a key tool. 

Today, with backing from federal agencies, healthcare organizations are continuing to rely on hospital-at-home programs even though in-person care has largely resumed. This is mainly due to the patient care benefits afforded by the hospital-at-home model and its potential to help rein in costs. 

A HISTORY OF HOSPITAL-AT-HOME

Widely regarded as one of the pioneers of the hospital-at-home care model, Baltimore-based Johns Hopkins Medicine began testing it in the early 2000s.

In 2005, Bruce Leff, MD, and a team of researchers published a study in the Annals of Internal Medicine showing that the hospital-at-home care model is "feasible, safe, and efficacious for certain older patients."

The study revealed that the hospital-at-home model care met quality standards at similar rates to acute inpatient care, with hospital-at-home patients experiencing a shorter length of stay (3.2 days) versus those receiving inpatient care (4.9 days). Further, the mean cost was $5,081 for hospital-at-home care compared with $7,480 for acute inpatient care.  

In the decades that followed, the model was adopted by numerous healthcare organizations across the country, including Veterans Affairs medical centers.

When the COVID-19 pandemic began, implementation of the model reached new heights.

KEY CHARACTERISTICS OF THE HOSPITAL-AT-HOME MODEL

The hospital-at-home model enables the delivery of acute-level care in patient homes. Though they may vary depending on the needs of the organization deploying them, most programs have similar characteristics.

These include eligibility criteria, the use of remote patient monitoring tools, and telehealth and at-home visits by clinicians.

Eligibility criteria are a vital aspect of any hospital-at-home program, as provider organizations must ensure that enrollment in the program is a clinically appropriate option for a patient and that the patient has access to the needed social and digital infrastructure required to participate.

For instance, some organizations do not enroll patients facing housing instability in their hospital-at-home programs.

"For instance, at this point in time, we are not taking patients who are homeless, although I hope to change that in the future," said Vivian Reyes, MD, regional medical director of strategic inpatient initiatives, the Permanente Medical Group, and national position lead for Kaiser Permanente Care at Home, the Permanente Federation, during a virtual conference keynote. "Also, patients who do not have running water are not eligible for the program. This is really because we want to make sure that they have an environment that they can heal in."

With regard to the technology needs of patients, by and large, provider organizations provide the devices required. These include devices for biometric monitoring, such as blood pressure cuffs and thermometers, and audio-visual conferencing tools.

Patient vital signs are typically measured continually when enrolled in a hospital-at-home program. This is accompanied by virtual rounding via telehealth or in-person visits at the patient's home by the care team.

But with the use of technology comes challenges like digital health literary gaps. Healthcare organizations are addressing these in various ways, including deploying interpreter services to support patients with low digital health literacy and provide education as needed.

"It was a consistent interpreter service that we had available ⁠— over 200 languages," said Sherene Schlegel, executive director, telehealth clinical operations at Providence Health, at a virtual event. "And then we also made sure within our EMR, when we went live at various sites, we looked to make sure that we had the predominant speaking languages for that area available."

PATIENT CARE BENEFITS OF THE MODEL

As use shot up during the COVID-19 pandemic, the model was tested in numerous scenarios. As a result, clinical studies on at-home hospital-level care have grown, largely showing that the model can be effective.

A study published in JAMA Network Open in 2021 showed that patients in hospital-at-home programs had similar mortality risk, a 26 percent lower readmission risk, and a lower risk for admission into a long-term care facility compared with their in-hospital counterparts. But the hospital-at-home patients also had an average length of treatment that was 5.4 days longer than that of in-hospital patients.

The study included an analysis of nine studies, providing data on 959 participants. The participants were at least 18 years old with a chronic disease and visited the emergency department. The hospital-at-home intervention involved at least one home visit by nurses or physicians who provided treatment that would have otherwise been administered in the hospital,

The researchers concluded that the hospital-at-home intervention was "a viable substitute to an in-hospital stay for patients."

Other research has focused on specific clinical use cases for hospital-at-home programs. For instance, the University of Utah Health's Huntsman Cancer Institute provides an at-home hospital program for cancer care.

Patients receive both on-site and telehealth-enabled nurse practitioner visits and on-site registered nurse and physical therapy visits, Kathi Mooney, PhD, co-leader of Cancer Control and Population Sciences at Huntsman, told mHealthIntelligence. The program also includes remote cardiovascular monitoring.

Since its inception, 2,000 patients have been treated through the program.

An analysis of the program, published in the Journal of Clinical Oncology, found that it reduced the odds of unplanned hospitalizations by 55 percent and healthcare costs by 47 percent over one month.

ONGOING FEDERAL SUPPORT 

The patient care benefits, as well as the need to expand access to hospital-level care during the COVID-19 pandemic, led the Centers for Medicare & Medicaid Services to launch the Acute Hospital Care at Home initiative in November 2020.

Per the initiative, hospitals can apply for a waiver that will allow them to care for Medicare beneficiaries at home. When a hospital's application is approved, the Medicare Hospital Conditions of Participation are waived for that hospital, suspending the requirement for nursing services to be provided on premises 24 hours a day, seven days a week, among other rules. Facilities providing hospital-at-home services are paid the same as if they are providing traditional inpatient services.

As of Dec. 16, 259 hospitals in 37 states had been approved for the waiver.

But, as with many regulations enacted during the pandemic, the fate of the waiver program following the end of the public health emergency was unclear.

Healthcare stakeholders advocated heavily for the waiver to be made permanent, with some prominent organizations, including Mayo Clinic and Kaiser Permanente, forming the Advanced Care at Home Coalition. The coalition's goals include expanding access to acute-level care at home by mitigating legislative and regulatory barriers and sharing best practices.

The recently passed $1.7 trillion spending bill extends the Acute Hospital Care at Home waiver program through Dec. 31, 2024, even if the pandemic is declared over before then.