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Is Hospital at Home the Future of Health Care?

Acute-level care outside the traditional hospital setting is gaining momentum

spinner image Wayne Whitehouse and his wife Karon photographed in the living room of their home where Wayne was a “hospital at home” patient through Providence St. Peter Hospital.
Wayne Whitehouse and his wife Karon in the living room of their home where he was a “hospital at home” patient through Providence St. Peter Hospital.
David Ryder

Wayne Whitehouse knew he wasn’t feeling well, having had similar symptoms before. He went to the ER, had some tests, received IV antibiotics and opted to go home rather than be admitted to the hospital while awaiting results.

The next morning, tests revealed an infection, causing the hospital to summon him for in-patient care.

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“The hospital was way packed, and a lot of people were waiting for a room. I came in around noon and got a room at 11 p.m.,” says Whitehouse, a retired warehouse manager from Lacey, Washington.

The next morning Whitehouse, 73, heard that he’d be a good candidate for Hospital at Home (HaH), a program that Providence St. Peter Hospital in Olympia had launched the previous year.

“I just felt I’d probably do better at home,” he says. “I thought it would be a good move and possibly open a bed at the hospital.”

His wife Karon, also 73, agreed. Four days into HaH, Whitehouse was “released,” but was already home.

The benefits of Hospital at Home

That November Hospital at Home stay wasn’t the home health care that many know. HaH is a specific designation for acute patients who need hospital-level care but who are considered stable enough to receive it at home. Either they went to an emergency room and were considered suitable for HaH, or, after being in the hospital, are released to continue HaH. It can last days, weeks or longer, depending upon treatment. A medical team (including doctors and nurses or EMTs) makes home and virtual visits.

Advocates warn that hospitals aren’t always the safest places for some patients — particularly older adults who may become confused by unfamiliar surroundings. Others cite hospital-acquired infections, as well as interrupted sleep, among other negatives associated with in-patient care for those with stable conditions. However, limited research on the health benefits and costs of HaH has left questions about its long-term rollout. HaH is not widespread. Whether it becomes so largely depends on what happens as the U.S. health care system evolves.

“There are some things you can’t do in the home. ICU care is not going to happen in the home. We’re not doing surgery in the home,” says Mark Howell, director of policy and patient safety for the American Hospital Association.

Among the challenges for hospitals are developing a new program under current workforce shortages while aiming to close gaps in health equity.

In addition to good connectivity for remote patient monitoring, certain basics, such as a home needing heat, electricity and running water, as well as factors such as distance from a hospital, are necessary ingredients. Serving a rural population or an area without broadband complicates the ability to provide virtual care, a keystone of the model. If an HaH patient doesn’t have Wi-Fi,hospitals provide a hotspot and a tablet to communicate.

A pandemic jump-start

Geriatrician Bruce Leff, a trailblazer and advocate for HaH, has long said he believes most care in the future will be at home, with hospitals offering only emergency rooms, intensive care units and operating rooms. Leff started this work in 1995, later developing an HaH program. His early published studies — in 1999 and 2005 — show the model as “feasible, safe and efficacious.”

Not until “the pandemic unlocked everything” did HaH start to grow, he says.

“People didn’t want to go to hospitals and catch COVID or sit in waiting rooms. The perception of safety related to facility-based care changed,” says Leff, a professor of medicine at the Johns Hopkins University School of Medicine. “What became safe was home care.”

Changes to Medicare aided growth

Hospital-bed shortages aside, what really made HaH gain traction was Medicare reimbursement for HaH care at the same rate as inpatient care during the public health emergency. The Centers for Medicare and Medicaid Services (CMS) developed a waiver to allow hospitals to offer acute inpatient care at home. Although the health emergency officially ends May 11, the temporary waiver for the Acute Hospital Care at Home program was extended through the end of 2024.

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The most recent CMS-approved waiver list for hospital at home includes 123 systems, 277 hospitals in 37 states. However, the lag time between approval and launch of a program takes several months, so an approved program may not yet be active.

“There have been hospitals offering hospital at home care through other payors for several years prior to the waiver; fee-for-service Medicare and non-managed-care Medicaid patients were not included originally due to the absence of a mechanism for reimbursement,” CMS says in an email.

Whitehouse participated in HaH at Providence St. Peter Hospital, the only nonprofit Providence hospital with a CMS waiver in the system’s 52 facilities across seven states.

Slow to scale; high satisfaction rates

Obstetrician Eve Cunningham is its chief of virtual care and digital health. Providence launched its HaH at the end of 2021, six months after approval. Cunningham says it was “logistically complex,” requiring new technology and staff since hospital employees who treat on-site patients aren’t the same for HaH.

“It is not an easy thing to grow and scale,” Cunningham says. “Most hospital-at-home programs across the country are pretty small, even after six or seven years.”

Hospital staffing became so critical this year that various programs, including HaH, were put on “pause.” HaH restarted in early March, she says.

Last year, Providence had 121 patients in HaH. Cunningham says less than 5 percent had to move to in-patient, higher-level care. As for patient satisfaction in 2022, 64 percent of in-hospital patients and 100 percent of HaH patients report being satisfied with the care.

Other lessons have been learned. 

Initially “we home-grew our program,” Cunningham says of the decision not to use a partner. Now, she says, “We believe in order to scale and grow we do need to work with partners. It’s important for health systems to be open to that.”

Significant staffing and financial outlay

Unlike Providence, ChristianaCare’s HaH program partnered with consultant Medically Home from the start, designing its program and providing the technology for the CMS-approved Wilmington and Newark locations.

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Internist Sarah Schenck, medical director of virtualist medicine for ChristianaCare’s Center for Virtual Health, says its HaH patient count of 458 is everyone since the virtual doors opened in December 2021.About 30 individuals comprise the hospital’s HaH team.

“The program is definitely an investment for any hospital, with up-front costs of the technology, hiring and training staff. There are savings when you can scale the program,” Schenck says.

More work to be done

The nonprofit patient safety advocacy group ECRI, an independent authority on health-care technology, is taking a wait-and-see approach.

“While we’re generally very supportive of the concept of Hospital at Home, a lot of things need to happen to make it safe and effective,” says anesthesiologist Marcus Schabacker, the group’s president and CEO.

“They haven’t done that work. We believe Hospital at Home is a way to make health care more accessible, but it needs to be right,” he says, citing a host of issues, including technology, which was designed for in-hospital use but is now used for HaH.

“Devices get transferred to the home that are not designed for the home,” he says, noting that when a pump or device shuts down and sounds an alarm in a hospital, there is a nurse or technician nearby to do a quick reset. That's “not OK when it takes an hour for person to arrive” to aid a family caregiver in a HaH setting. “Devices are not designed with safety features for lay personnel to use in a home,” he adds.

Research has focused on safety and cost-savings but not on caregiving. Two studies, both published in medical journals in 2021, conducted reviews of previous work. A study in BMJ Open (which provides research relevant to patients and clinicians)found “for suitable patients, HaH generally results in similar or improved clinical outcomes compared with inpatient treatment.” Another study in JAMA (Journal of American Medical Association) Network Open found that patients receiving hospital-at-home care had a slightly longer length of treatment, a similar mortality risk and a 26 percent lower risk for readmission, relative to the in-hospital group. Patients also had lower depression and anxiety scores than those receiving in-hospital care.

Theresa Clendening, of Wilmington, Delaware, says her 87-year-old mother, Edna Alvini, had double pneumonia last fall and was hospitalized for four days at ChristianaCare in Newark before being offered HaH.

“She was able to get up and move about in her own home and it was more private at home,” says Clendening, 68, a retired health-care technician. “In the hospital, she had a roommate.”

Alvini lives independently in her own home in New Castle, about 20 minutes from her daughter. She came home with an oxygen tank and was in the program about a month with remote and in-person medical visits. HaH provided a hotspot and tablet for virtual communication since her mother didn’t have such service, Clendening says.

spinner image Wayne Whitehouse and his wife Karon
Wayne and Karon Whitehouse
David Ryder

Karon Whitehouse says the medical staff at Providence didn’t ask her to assist in her husband’s home care. After his experience, Wayne recommends HaH to others if offered the opportunity.

“You’re sleeping in your own bed. You’re in your own house. You’re not going anywhere anyways,” he says. “And I felt it probably helped in the recovery process.”

Questions to Ask as a Family Caregiver: Hospital at Home 

​​If you are the caregiver of a parent, spouse or other loved one set to receive “hospital care at home” (HaH), before the care begins here are questions to consider asking as recommended by the AARP Public Policy Institute.​

  • What is this kind of hospital admission?
  • Who will be coming into the home? How often? Do I need to be there to let them in if the person I support (the “patient”) cannot get to the door?
  • What are the expectations for me as a caregiver? How do I get assistance if the patient has a change in condition outside of the regular scheduled care visits for HaH or after hours? How quickly will a medical professional respond? Will that response be virtual or in-person?
  • The patient may need the kind of assistance that they would get in the hospital, such as help with bathing, dressing, toileting, changing the sheets, getting meals (especially a special diet).  Is the expectation that I will provide that assistance? Are there home health or personal care services available through the HaH program for that care? 
  • How will medications related to the HaH episode be provided? Are they delivered to the patient’s home in a timely manner? If the patient needs help taking them, who will help?  
  • Will someone assist with setting up any equipment and supplies needed for the HaH care? Does the program provide training for any technology I may be expected to use?
  • Will all supplies needed for the HaH care episode be provided? Will they be delivered to the patient’s home or is the caregiver expected to find and purchase supplies?
  • If the patient needs more care after the official “discharge” from HaH, what care coordination is available?  Will the HaH program set up referrals to follow-up care after discharge? Are there any continuing coordination services provided after discharge and for how long?​

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