Is Hospital at Home the Future of Health Care?

“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.

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.

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.

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.”