Acute Hospital at Home Programs: Benefits and Challenges

The Hospital at Home (HAH) model provides acute hospital-level care to adults in the home setting. Variations of the HAH model have been in place for many years in countries including Great Britain, Canada, Australia, and Israel. The model was introduced to the United States in 1995, when the Johns Hopkins Schools of Medicine and Public Health conceived and began to develop their Hospital at Home® program.

Until recently, the Centers for Medicare and Medicaid Services (CMS) and the majority of private insurance companies have not paid for home-delivered hospital care. In November 2020, however, CMS established its Acute Hospital Care at Home (AHCAH) program to help health systems and hospitals increase available inpatient bed capacity during the COVID-19 pandemic. Under this program, Medicare-certified hospitals can submit a waiver request for Medicare fee-for-service reimbursement. Although the waiver is in effect only for the duration of the COVID-19 public health emergency, CMS continues to receive positive feedback from program participants. CMS will use information gained from this experience to determine the program’s future.

As of March 17, 2022, 92 health systems and 204 hospitals across 34 states have been accepted as participants in the AHCAH initiative.

The HAH Model in Action

While models vary, typical HAH programs deliver daily on-site acute care in the patient’s home setting, with oversight by physicians and/or advanced practice professionals who are on call 24/7. Programs provide a combination of in-person, video, and telehealth visits and employ therapies such as intravenous medications and fluids, physical therapy, and respiratory treatments.

One example is Home Based Acute Care (HBAC), an initiative of the St. Paul, Minnesota-based HealthPartners health system. Coverys had the opportunity to interview the HealthPartners team following successful implementation of their HBAC program to learn more about the structure, successes, and challenges of the program. On September 28, 2021, interviews were conducted with Jack Dressen, MHA, Director of Hospital Medicine at HealthPartners; Tia Radant, MS, NRP, Director, Community Paramedicine at Regions Hospital; and Chrisanne Timpe, MD, Medical Director at HealthPartners Hospital@Home. The program, which was spearheaded by the medical director of HealthPartners’ geriatric program in conjunction with hospitalists and emergency medical services providers, spent six years in development.

Operating in a busy urban center, HealthPartners utilizes existing triage processes within the traditional hospitalist care delivery model to identify and enroll patients. Eligible patients include those with urinary tract infections, cellulitis, or acute exacerbations of cardiopulmonary diagnoses such as congestive heart failure or chronic obstructive pulmonary disease. The program has also treated patients with COVID-19.

HealthPartners' care team comprises the director of hospital medicine, program director, medical director, hospitalists, and a group of specially hired paramedics. A hospitalist is on call 24/7. Under the hospitalist’s direction and oversight, paramedics provide acute care in the home at least once and sometimes twice daily, typically via telehealth and remote monitoring devices. Nurses answer the program’s dedicated phone line.

Program leaders review each case to gather data about the number of hospital days saved and the resultant number of acute hospital beds opened. This data is then submitted to CMS under the current waiver for Medicare patients.

HealthPartners has an average daily census of five patients that are seen in a variety of settings, including private homes, assisted living centers, apartments, and homeless shelters. The program aims to build its census to 20 patients per day.

Advantages of HAH 

Some established and pilot programs have already demonstrated cost savings of 30% or more while delivering better outcomes and fewer complications than hospital-based care. Many of the hazards of hospitalization, especially for older adults, including delirium and bowel complications, occur less frequently in the home setting. In satisfaction surveys, patients and family members have rated the quality of care in these programs higher than that provided in the hospital.
 
According to the HealthPartners team, their program has experienced similar results from HBAC. Based on their retrospective analysis of cases, HealthPartners has noted that the return on investment varies depending upon the patient’s health plan. For that reason, they engage in active negotiations with private payers. According to the team at the time interviews were conducted, the advantages of the program include: 

• Average length of acute home stays is 2 to 2.5 days, less than inpatient stays for similar diagnoses.
• Excellent patient satisfaction scores.
• Increased availability of inpatient acute care beds in a time when beds may reach capacity. 

The Future of HAH

David Levine, medical director of strategy and innovation for Brigham Health Home Hospital, expects that the new CMS waiver will help these programs “thrive and spread” and that their success will lead to formalization of the waiver into a rule that is much more permanent and final. Beyond that, he states that there will be a need for commercial payers to follow that lead to see the full fee-for-service structure embrace home hospital care.
 
A well-designed HAH program can deliver high-quality care, provide patient satisfaction, and improve outcomes. Consider the following when developing a HAH program at your organization: 

• Determine whether HAH is right for your organization. Implementation of an HAH program requires commitment, innovation, and effort. Organizations that are seeking to implement an HAH program should ensure that conditions in their organization are optimal and that resources are available. Consider the readiness assessment used by Johns Hopkins to determine whether your organization is ready for HAH.
• Develop patient eligibility criteria. Careful patient selection is essential to optimize HAH program outcomes. While patients with medical conditions that require numerous office visits or specialty care may not be good candidates for HAH, those with conditions that require routine, protocol-directed treatment, such as heart failure or pneumonia, may be ideal for enrollment in the program. While the presence of a family member or other caregiver may be helpful, it is not a requirement of the program, as long as the patient can perform necessary self-care activities.
  
  The HealthPartners team has learned that patients and/or family members who do not engage with their healthcare practitioners in the hospital are even less likely to engage satisfactorily in an HAH program. Some patients express that they would feel safer in the hospital. These patients are typically not program candidates. 
• Define roles, assess competencies, and consider credentialing/privileging. Job descriptions for each member of the care team should clearly define roles and responsibilities and be based on scope of practice and reimbursements guidelines. Once roles are defined, evidence-based competencies for specific job duties should be established and assessed before the provision of patient care and at regular intervals thereafter. Evaluate the need for credentialing and privileging providers who provide treatment and perform procedures in the home setting. 
• Anticipate environmental challenges. Consider the safety, security, and accessibility of the home setting. The HealthPartners program uses paramedics to assess and troubleshoot any issues within the home that might lead to risky HAH care. Enrolled patients should be located no more than 30 minutes by vehicle transport from an acute care facility in the event of a sudden change in condition.
  
  In some parts of the country, weather conditions can pose unique challenges. HealthPartners notes that despite Minnesota’s long and snowy winters, most road conditions are not an issue for the field paramedics, who are trained to respond in adverse weather. However, special procedures had to be developed for donning personal protective equipment (PPE). It was difficult to don PPE inside a vehicle when heavy winter or waterproof outerwear was necessary. Creative solutions included donning PPE while sheltering from the rain in the vehicle’s tailgate or the patient’s garage. 
• Identify and monitor quality indicators. Well-defined, evidence-based quality measures enhance the ability of organizations to deliver safe and efficient patient-centered care regardless of the setting in which care is delivered. While specific quality indicators may vary among organizations, they should be evidence-based, specific to the population served, and applicable to the HAH setting. Once quality indicators are selected, they should be monitored by regular data collection and analysis and used to develop program quality improvement initiatives.

With the explosion of telehealth technology, select patients with certain acute conditions can be safely cared for at home. Careful planning that includes a commitment from leadership, a dedicated team of practitioners, an inventory of available technology, a defined patient selection process, and a home environment assessment can result in a successful and satisfying acute care at home experience for patients and their families.