Hospital at Home: But why even start at the Hospital?

Ok, here is my #hottake.

“Hospital at Home” (HaH) is a great idea and is showing real promise in reducing costs, reducing bad health outcomes, and improving patient satisfaction.

Not much of a Hot Take. Except for this → The concept is coming from the wrong direction. You have to GO TO THE HOSPITAL to GET OUT OF THE HOSPITAL. This makes no sense … well actually it makes a lot of sense in how our current health system is structured.

Let’s talk first about what exactly a “Hospital at Home” program is and where it came from.

Origins of the Hospital at Home Program The concept of a “Hospital at Home” program was first envisioned by Dr. John Burton (Johns Hopkins School of Medicine) and Dr. Donna Regenstreif (John A Hartford Foundation). Their initial focus was on geriatric patients and they conducted a pilot trail with 17 patients over the course of 1996-1998.

The results were initially published in the Journal of American Geriatrics Society in 1999. The study focused on patients being admitted to the emergency room or for an acute care stay with one of four conditions - Congestive Heart Failure (CHF), Community Acquired Pneumonia (CAP), Chronic Obstructive Airways Disease (COAD), or cellulitis.

The study determined that it was possible to provide effective, acute care treatment for patients in their home while reducing costs and delivering better health outcomes.

This study was replicated on a much larger scale in the early 2000’s with results being published in the Annals of Internal Medicine in 2005. Similar to the initial study, they concluded that a HaH program delivered positive results with defined reduction in length of stay, fewer health complications, and lower costs of care compared to similar treatment in a hospital.

Throughout the early to mid 2000’s, a number of health systems developed HaH programs. With the onset of the COVID pandemic in 2020, the Centers for Medicare and Medicaid Services formally started reimbursing hospitals for services delivered in this program as an expansion of CMS’s Hospital Without Walls initiative.

HaH Program Concept and CMS Requirements

A Hospital at Home is where an inpatient facility provides a patient acute care-level care while at home. The adoption of this program accelerated with the initial CMS waiver in 2020 which has since been extended to the end of 2024.

CMS has authorized 133 Health Systems, representing more than 330 hospitals, across 37 states to operate a HaH model as of April 2024. It is estimated that 11,000 patients participated in a Hah program between 2021 and 2023. It is believed that the number of HaH programs will double by 2026 if CMS extends the waiver beyond 2024. [AHA: Providers Betting Big on Future of Hospital at Home ]

Requirements of a Health System for CMS to authorize a HaH program

• Patients can only be admitted from an ER or inpatient hospital bed, and an in person physician evaluation is required prior to starting services
• Appropriate screening to assess medical and non-medical factors
• Ability for physician or advanced practice provider and a registered nurse to evaluate the patient daily - in person or remotely
• Ability to have 2 in person visits by a registered nurse or paramedic (must be tied to patients nursing plan and hospital policies)
• Ability to immediately connect, on-demand via audio with an Acute Care HoH team member who can bring a physician or nurse to the conversation
• Ability to respond to a decompensating patient within 30 minutes
• Track multiple patient safety metrics weekly or monthly
• Establish local safety committee to review patient safety data
• Use accepted patient leveling process to ensure that only patients requiring an acute level of care are treated
• Providing or contracting for other services required during an inpatient hospitalization

Benefits of a HaH Program

The evidence today indicates that HaH programs reduce costs by approximately 30% and improve health outcomes for patients. Savings are generated from reducing excess inpatient days, decreasing the volume of clinical testing, and consultations, and cutting overhead costs. HaH programs have also been shown to help reduce readmission and incidents of hospital acquired infection.

It is expected that the average hospital can save approximately $3,000 per encounter for every patient admitted into a HaH program. At the same time, the HaH program creates opportunities for a hospital to move lower-acuity encounters outside of the facility and potentially replace them with higher-acuity (and higher reimbursing) encounters. If each HaH patient is replaced by a higher acuity patient, an average hospital can expect to generate an additional $10,000 per additional inpatient admission. [Guidehouse: The Value in Hospital Care at Home ]

Investment in Hospital at Home - A Digital Health Gold Rush

The HaH program is part of a broader movement to move care outside of traditional facilities. Whether this is done via telehealth, consumer health devices, or home health engagements it is clear that investment and innovation is pursuing decoupling care delivery from traditional brick and mortar facilities.

McKinsey & Company estimates that $256 Billion worth of care services for Medicare (FFS & Medicare Advantage) could shift to the home without a reduction in quality or access. This would represent approximately 25% of the total cost of care for these beneficiaries and does not encompass care for individuals in commercial or other plans.

7wireventures highlighted that investment in health at home solutions reached a high of $4.7 Billion in 2021. While investment in 2022 and beyond has been more muted, there continues to be strong interest in funding and growing digital health companies focused on engaging and delivering health at home.

Digital Health Companies focused on Home Health are the most aligned to the concept of Hospital at Home

Back to the Hot Take … Such as it is

There is clear evidence that programs such as HaH that move care from acute facilities back into the home have the ability to save money and improve outcomes.

There is also an obvious expectation that most hospitals will use a HaH program to simply “free up” beds for higher acuity patients which generate more revenue. This is probably a good thing in the sense that it may increase speed to treatment for those that really need it. At the same time there is the old axiom that “Nature abhors a vacuum” and hospitals are going to fill empty beds whether care is needed or not → so is this really a macro cost savings?

The question is not should these programs exist. We should be asking where should these engagements start and who should be responsible for helping engage the person holistically.

I wrote last week about the promise (and challenge) of the Patient-Centered Medical Home . I strongly believe that we are individually and collectively better when our primary care health system is strengthened. I would prefer to have a direct, and long term relationship with a healthcare provider that would help care for my general needs as well as help shepherd me through the complexity of more acute and speciality focused care.

Why would it not make more sense for my PCP to be the one to determine that I could benefit from acute care engagement that is delivered in my home. This does not mean that the PCP is necessarily the one delivering the care. There are a number of targeted digital health companies focused on just this engagement that could be leveraged for these specific acute care episodes. I do think, however, I would be better off having a trusted health provider (My PCP) helping coordinate and sitting on either side of these more acute care engagements.

I continue to be incredibly fascinated by the Direct Primary Care (DPC) movement. I have really been soaking up so much information over the past several weeks on this movement. Michelle Cooke, MD and Daniel Paull, M.D. have been two individuals worth following and reading on this topic, especially what it means from the perspective of practicing doctors.

It seems to be the purest form of what is intended by the concept of the “Patient Centered Medical Home.” Why would it not make sense for your DPC to be the initiator and coordinator of these more acute care engagements? I suspect the economics may be a challenge here given DPCs eschew insurance reimbursement (which goes back to why I think they are the purest form of a PCMH or rather a “Consumer Centered Medical Home” CCMH).

So Yes! Let’s embrace the concept of Hospital at Home. But let’s financially encourage primary care to be able to initiate, coordinate, and ultimately help manage my overall care. Let’s not simply reinforce acute care models that encourage hospitals to only expand to look for more ways to get me into the four doors so as to recoup revenue lost from programs such as these.