Is hospital-at-home running out of time?

The hospital-at-home program at UMass Memorial Medical Center in Worcester, Massachusetts is thriving. But it could be running out of time. 

Justin T. Precourt, chief nursing officer at UMass Memorial, said the hospital is treating 15 patients per day through the program, which is in its second year. The health system relies on a care at home platform from Current Health, a Boston-based digital health startup, to treat acute-care patients within their home. It also uses telehealth to connect patients virtually.  

The feedback to the program has been remarkable, Precourt said, particularly from patients and providers. Importantly, it has helped the hospital deal with the physical constraints it faces with limited beds, he said. 

“Because of capacity constraints, we end up having patients waiting in our emergency departments and in ambulatory clinics. They’re not receiving the timely care that they need,” Precourt said. “The hospital-at-home program gives us an opportunity to provide a low-cost, high-level of care to patients in their home and expand our overall capacity.” 

But that could all go away when the public health emergency ends. The program has been buoyed by a November 2020 waiver from the Centers for Medicare and Medicaid Services that pays hospital diagnosis-related group payment for hospital-at-home patients. The waiver is in place for the duration of the PHE. When the PHE ends, hospital-at-home will have a 60-day grace period and then the waivers will expire. 

Precourt said he is nervous about the ticking clock. 

“We're not in a situation where we could continue down the same route without the waivers and without the reimbursement,” Precourt said. “So, we are looking at alternative models, which would be a bit different from what we've been doing.” 

An uncertain future 

Like UMass Memorial, most of the other 244 other hospitals across 36 states involved with the program face the same reality. Their hospital-at-home programs have been worthy investments because of CMS’ flexibilities around payment. But as Precourt said, most health systems are operating “razor-thin margins,” and some are deeply in the red. The only way to support a hospital-at-home program long-term is reimbursement from government and private payers, he said. 

While some private payers do negotiate hospital-at-home care, reimbursement has been varied. For CMS to make the program permanent would require legislation. The only proposal that has come up that would fully continue the program, Hospital Inpatient Services Modernization Act, went nowhere. 
The Advancing Telehealth Beyond COVID-19 Act of 2022, which passed the House 416-12, would extend one component of home-based care. There is still a lot to sort out, said Blair Cantfil, partner with Manatt Health, a Los Angeles-based law firm. 

“There is widespread agreement that allowing hospital-at-home is the best thing from a patient perspective,” Cantfil said. “The sticking point, as it relates to passing legislation, is figuring out whether continuing these flexibilities will increase costs to the Medicare program or create program integrity concerns.”

In theory, Cantfil said allowing patients to receive appropriate care in the home can simply replace the care provided in the hospital, except in cases where the availability of home-based services increases access to people who would otherwise forgo needed care. She said it’s up to Congress to continue the program flexibilities beyond the PHE. 

Michael Skaff, chief information officer at Jewish Senior Living Group, a San Francisco-based long-term living company, said research has been positive in terms of reduced readmissions rates, lower mortality, better outcomes and lower costs. Despite this, Skaff said he would like to see a short-term year extension of the program to gather more data around cost.  

“The early data is promising but the question is, are [organizations] cherry-picking case load and the types of conditions that they’re serving? Scale will prove to be the great equalizer,” Skaff said. “Once we see larger populations and different types of conditions, both chronic and acute, we'll really know if this is going to be a lasting trend or not.” 

Skaff would like to see CMS formalize a quality program that can be used to determine the long-term future of hospital-at-home. Until this happens, he said the survival of the program will be determined on a week-to -week basis.  

Blessing Health

Blessing Health System, a rural health system based in Quincy, Illinois, isn’t as big as UMass Memorial but faces similar capacity challenges. It launched a hospital-at-home program in February, with some additional grant funding from Ariadne Labs, a joint center for health system innovation between Boston-based Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.

Dr. Mary Frances Barthel, chief quality and safety officer at Blessing Health System, said the program ultimately aims to reduce capacity constraints across its three hospitals.  The health system uses a combination of telemedicine, in-home visits from nurses, as well as remote monitoring biosensors and analytics from Boston-based Biofourmis to operate the program.

Rural patients can benefit from the arrangement, Barthel said. “We have some patients who live 60 minutes from the hospital,” she said. “The benefit to the patient’s family is they don’t have to drive back and forth, two hours total, every day to check on their loved one and communicate with their doctor or nurse.”

The program is not without its challenges. Finding staff available to drive up to two hours to treat a patient isn’t easy, Barthel said. There is also a learning curve with how to provide hospital-level care for a patient within their home. It’s also been hard to integrate the workflows from hospital-at-home into a doctor’s schedule.

Despite this, overall patient reactions have been positive, Barthel said.  Working with Brigham has been a huge help too, she said. The Boston-based hospital, which also uses Biofourmis, has been involved with hospital-at-home for five years and was able to verify nearly 40% cost savings in one of its pilots. 

“Just using the processes that they had in place has been huge,” Barthel said. “There's complexity in offering acute care in the home. Which medications are we able to get to the patient when they need them?  What kind of escalation plan is in place if the patient needs a higher level of care while they're in the home? They had it all mapped out for us.”

Through her conversations with Brigham, Barthel is optimistic the hospital-at-home program will survive. “They’re confident that COVID has been the catalyst for this and Medicare as well as other insurers recognize the value,” she said.