In November 2020, with the COVID pandemic severely stressing hospital capacity, CMS implemented the Acute Hospital Care at Home waiver and enabled hospitals and health systems to deliver hospital-level care in patients’ homes.
Since the authorization, more than 300 hospitals in 37 states have obtained this payment waiver. The waiver was due to expire at the end of the pandemic-associated public health emergency, but Congress extended the waiver. However, without additional congressional action, the waiver and the ability of hospitals to deliver acute hospital care in patients’ homes will expire at the end of 2024. It’s time to extend the waiver once again and continue to expand access to innovative hospital-at-home care.
In the last 18 months, we learned that health systems and hospitals across the country can establish hospital-at-home programs while also generating a range of important benefits for patients, their families, and healthcare providers. A report from CMS published in JAMA Health Forum looked at more than 11,000 patients who received their hospital care at home and found low rates of emergency returns to the hospital, referrals to skilled nursing facilities, 30-day hospital readmissions, and mortality. A review in Annals of Internal Medicine found patients receiving at-home hospital care who were dually eligible for Medicare and Medicaid or had a disability or dementia, had similar and sometimes even better outcomes than the general hospitalized population.
Hospital-at-home programs have had positive outcomes, in part, because their design embodies the tenets of the Age-Friendly Health Systems movement, which promotes the reliable delivery of evidence-based care that reduces harm and is aligned with what matters to patients and their family caregivers. Age-Friendly Health Systems follow what is known as the “4Ms Framework,” focusing on what matters and addressing patients’ needs related to their medications, mind, and mobility. Hospital-at-home programs are built on these essential elements of optimal care for older adults.
Age-friendly hospital-at-home programs have broad support, including from clinicians. Research from both before and after the waivers began finds that healthcare professionals have positive experiences working in these programs. Major health professional organizations, including the American Medical Association and the American Hospital Association, have endorsed hospital-at-home.
Not surprisingly, patients are in favor of avoiding the hospital, and it can be safer for them, too. What matters most to patients is often found in their homes — their loved ones, pets, and personal items. Hospitals are a challenging environment for many patients and their families, and adverse events — such as infections, physical deconditioning, and episodes of delirium — are common in some patients. Family caregivers of hospital-at-home patients also report similar or better experiences and lower levels of stress than family members of patients in hospitals.
The pandemic-era waiver that unleashed a wave of hospital-at-home programs has led to a better understanding of implementation strategies that can scale up to cover many more patients. This growth, however, cannot happen without the sort of certainty that a more durable payment waiver will provide.
A recent report from the Bipartisan Policy Center recommended a 5-year extension for the Acute Hospital Care at Home waiver, noting that it would not only foster more hospital-at-home programs, but would also provide the opportunity for the federal government to provide technical assistance and do further research that would improve care quality, safety, and cost savings.
Even with the continued waiver, hospital-at-home programs must remain attentive to issues of access and equity, ensuring that patients both with and without family caregivers can receive care in their homes. Today, only about a dozen state Medicaid programs have approved hospital-at-home care, a major impediment to equitable hospital-at-home care for the vast majority of the nation’s low-income residents. Health systems have already begun to find ways to make hospital-at-home care practical in rural and other underserved areas, but more work is necessary to ensure that everyone who could benefit has access to hospital-at-home programs.
Building on the challenges presented by the pandemic, hospital-at-home has turned into an “overnight” success story in the U.S. — albeit one supported by decades of experience here and abroad. A continued payment waiver will assure that older adults receive care where they feel (and ultimately heal) their best: in their own homes.
Terry Fulmer, PhD, RN, is the president of The John A. Hartford Foundation in New York City, a national foundation dedicated to improving the care of older adults and an early supporter of hospital-at-home programs in the U.S. A practicing nurse, she continues to round at Mount Sinai Hospital in New York City.
Disclosures
The following studies or initiatives cited in this article received John A. Hartford Foundation funding: Acute Hospital Care at Home in the United States: The Early National Experience (Annals of Internal Medicine); Age-Friendly Health Systems; Health care provider evaluation of a substitutive model of hospital at home (Medical Care); Satisfaction with hospital at home care (Journal of the American Geriatrics Society); Comparison of stress experienced by family members of patients treated in hospital at home with that of those receiving traditional acute hospital care (Journal of the American Geriatrics Society). The Foundation also provides funding to the Hospital at Home Users Group.
