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America, and for that matter the world, is facing a growing challenge in caring for two expanding groups of patients — those 60 and older and patients with such chronic diseases as cancer, diabetes and obesity.

Across the globe, the 60-and-older population is increasing quickly and will surpass 2 billion by 2050, according to the World Health Organization. Meanwhile, caring for the 60% of U.S. adults who have at least one chronic disease accounts for $3.7 trillion in annual health care costs, states the Centers for Disease Control and Prevention.

The ability to monitor health and deliver care outside traditional medical settings could significantly reduce this expenditure, notes a recent CB Insights report. The analysis examines home care tech markets that providers should prioritize over the next three to five years.

We explore some technologies CB Insights analysts say providers should scrutinize over the next one to three years and what’s been happening in these sectors.

4 Home Care Technologies to Explore

1 | At-home Infusion

This technology enables patients to have intravenous treatments like dialysis at home. Wirelessly connected infusion pumps share data with providers to platforms that monitor treatment regimens. Providers are turning to these devices to support convenient, consumer-focused care. Investments in this tech sector are up significantly over the last two years, with mega funding rounds going to Somatus ($325 million), Quanta Dialysis Technology ($245 million) and Monogram Health ($160 million).

Key Takeaway

Providers should be selective before investing in this technology to ensure that comprehensive solutions support key considerations like ease of administration, infection monitoring and prevention, and tools to determine post-infusion status, the report states.

2 | Virtual Clinical Exam Rooms

Exam tools ranging from digital stethoscopes to comprehensive digital medical kits provide diagnostic-quality equipment to the home to support virtual visits. The virtual care equipment market was worth $3.5 billion in 2021, according to a Global Market Insights report and is estimated to grow at a compound annual growth rate of 17.3% through 2028.

Key Takeaway

Advanced exam tools, especially those with built-in artificial intelligence, will become a more prominent component to support remote diagnosis and treatment decisions.

3 | Digital Therapeutics

These solutions combine evidence-based research with digital technologies to provide treatment options for ongoing medical issues that can be addressed in the home. The technology provides apps and digital tools to support issues ranging from mental health to the management of diseases related to gastroenterology, endocrinology and cardiology. Digital therapeutics companies have received more than $1.1 billion in funding over the past five years and the sector is evolving quickly as Food and Drug Administration-approved, clinically validated therapies find their way to the market.

Key Takeaway

Monitor this sector to identify therapies that deliver benefits across multiple specialties and conditions. Evaluate the technology based on ease of use, whether the solutions provide easy-to-grasp content and meet the disparate needs of the populations you serve.

4 | Home Care Management Platforms

This technology supports the transition from an acute care setting to the home to help ensure effective care coordination. These platforms traditionally have focused on care for those with chronic conditions and the elderly, but newer solutions also focus on parents who are caring for infants. The technology ranges from supporting the scheduling of ongoing care to monitoring whether patients have been attending to existing care needs.

Key Takeaway

Evaluate these systems to ensure that investments will fit with your comprehensive growth strategy for managing multiple patient populations, including the elderly, patients with chronic diseases and acute care patients.

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The concept of hospital-at-home isn’t new, but it’s much more than an industry buzzword. It can be a game-changer for the healthcare industry if we are both innovative and realistic. It has the potential to transform the full experience for both providers and patients. Instead of requiring a patient to be onsite at a facility with immediate availability of a registered nurse, acute hospital care can be provided at home.

Let’s examine the opportunities as well as the concerns in making the hospital-at-home concept a reality.

Taking A Measured Approach

Any significant innovation comes with challenges, and healthcare can be especially demanding given the complications of structure, reimbursement, insurance, resource allocation, technology aversion, staffing shortages and the list goes on. For healthcare systems, the shift is slow simply because of bureaucracy, which can make it difficult to implement any new technology. And many hospitals are financially burdened without extra capital for investment. However, those same hospital systems are suffering from staffing shortages and could greatly benefit from implementing the full suite of remote monitoring technology and patient care outside of the traditional environment.

While the idea is to provide quality care outside a traditional hospital, patients must still be monitored, which requires both investments in equipment and technology and in people who can maintain the technology as well as actually use the systems. Quantity of staff depends on multiple factors from the number of patients involved to the quality and complexity of the system. It’s definitely a capital, educational and maintenance investment.

While this telemonitoring will likely be a gradual transition for most organizations, there will ultimately be more outpatient monitoring and management than we have today. In most cases, it will be a stepwise approach, starting with one department before the concept expands to an entire healthcare system or total hospital. At the onset, it’s important to consider the full compatibility of the technology to ensure it’s scalable at the enterprise level. It makes no sense for each department to have its own preferred solution.

Technology Tailored For Unique Clinical Needs

In some cases, a hospital could only be interested in a particular therapeutic area such as Cedars-Sinai and cardiac rehab while a leading children’s research hospital wanted a more comprehensive solution to address congestive heart failure, diabetes and renal failure. MD Anderson concentrated on oncology applications. (Full disclosure: Vivalink is actively working with these hospitals.)

The big picture is understanding that the technology exists to accommodate remote monitoring for a broad array of healthcare specialties—which in turn potentially benefits a variety of healthcare providers and, ultimately, patients. In one JAMA study, while patients receiving hospital-at-home care had a slightly longer average treatment period, they also had a lower percentage of readmission and lower rates of depression and anxiety than traditional in-hospital patients with chronic disease who started in emergency care.

Since 2016, Mass General Brigham has cared for more than 2,000 acutely ill patients and saved 10,000 hospital bed days since implementing a hospital-at-home program. More than half the patients enrolled were more than 65 years old, so the technology interaction had to be accommodating and unintimidating to make it viable. But it’s worked. A comprehensive system assigns and delivers resources and allocates tasks across a team of providers. Sensors provide continuous vitals monitoring so the communication is as comprehensive as that of inpatient care. According to Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, it’s estimated that 15%-30% of inpatient care could be delivered at home within the next 10-15 years.

“Delivering hospital-level care at home is complex and multiple factors contribute to its success, including the need to remotely monitor patients’ vitals and ensure such data is secure and easily accessible to clinicians,” says Conley.

Data from Brigham and Women’s Hospital further supports the positive impact with a randomized controlled trial of hospital-at-home care, reporting 38% reduction in costs, 70% reduction in readmissions and 50% improvement in patient mobility.

Ensuring Success For Patients and Providers

We know there are multiple metrics to gauge success. Two that are paramount are patients’ willingness to participate and financial feasibility for providers. Experience validates that if the hardware and software are easy for patients to use and not unduly burdensome, they will adhere to the protocol. Increased use of telemedicine since the Covid-19 pandemic helped ease the way for patients to be more comfortable with the idea. The provider side is more complex. The technology must be user-friendly and the care eligible for reimbursement.

Updated G-codes via the Centers for Medicare and Medicaid Services (CMS) open the door for remote patient monitoring and home health monitoring using synchronous telemedicine to be reimbursed as part of a defined patient care plan. If a provider can be reimbursed for delivering a service equal to that offered in-facility while more efficiently caring for patients, it removes a significant obstacle to at least trying the hospital-at-home concept for acute care scenarios.

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by David Collins, MHA, CPHQ, CPHIMS, FHIMSS, CLSSGB, Senior Manager Home and Community, VCU Health System | Richard Foor, CTO, Givens Communities | Dan O’Neil, CHCIO, MBA, VP, CIO, Care Dimensions

In the wake of the pandemic, telehealth quickly became an integral part of care delivery by increasing access to care. This proved to be just as effective as in-person care for many diagnoses, especially with supportive legislation providing waivers and reimbursement changes.

Under the telehealth umbrella, the use of remote patient monitoring (RPM) technology has shown tremendous value in managing the care of patients who reside outside the hospital. This article provides a general overview and entry level description of RPM—an RPM 101 for the long-term and post-acute care (LTPAC) community.

In its simplest form, RPM involves the use of electronic monitoring devices to record objective data (heart rate, blood pressure, etc.) and subjective data (symptoms, daily surveys, etc.) for a patient typically at home or in a long-term care facility, and they are reviewed by a provider or clinical team at another location. These devices rely on the internet to communicate information to clinical portals or through direct interfaces to a provider’s electronic health record (EHR). The information and associated alerts are typically monitored and managed by a clinical triage team.

RPM use is usually offered in several spheres of care to provide a more comprehensive care management monitoring program for patients who reside outside of an acute care setting. The spheres covered in this article include:  

• Transitional RPM or tRPM: 0-30 days post discharge until stabilization
• Chronic care RPM: Used in both pre- and post-acute care management
• Hospital at home: Daily acute monitoring 3-5 days, followed by either recuperative home hospital care or tRPM up to 30 days

Examples of RPM

RPM involves the reporting, collection, transmission and evaluation of patient health data through electronic devices, such as: ¹

• Wearables: Watches, strap monitors, glucose monitors
• Mobile devices: Weight scale, O2/heart rate pulse oximeter, BP, glucometer, atrial fibrillation (a-fib), EKG
• Smartphone apps: Patient reported outcomes
• Internet-enabled computers

The most common conditions that benefit from RPM include persons with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes (DM), hypertension (HTN) and chronic kidney disease (CKD).² 

Across those four conditions, the objective health data set that is most commonly captured are vital signs: body weight, heart rate (HR), blood pressure (BP), temperature, oxygen level (O2) and respiratory rate (RR). Additional variables commonly measured were oxygen saturation and blood glucose. Subjective data most captured includes pain level, symptoms (via daily questionnaire) and physical activity.

Within the wearables category, one common device example is the use of an Apple Watch to detect irregular heart patterns atrial fibrillation (Afib), etc., and perform an electrocardiogram in 30 seconds that can easily be transmitted to physicians.

Different Types of RPM

There are three different recognized types of RPM deployed for different patient populations with specified diagnoses and chronic care conditions that aim to help patients avoid unnecessary emergency visits and readmissions to the hospital.

Transitional RPM (tRPM) is used to monitor high-risk patients, immediately upon discharge from an inpatient stay. It is typically used for 30 days post-discharge. An RPM kit can include a tablet to facilitate video virtual visits, a Bluetooth blood pressure cuff, Bluetooth pulse oximeter, Bluetooth scale and thermometer. The kit is often provided prior to discharge or immediately following discharge to ensure timeliness of initiating RPM the next day. The benefits of such tRPM programs can decrease the average length of hospital stay and reduce the likelihood of a patient returning to the hospital within 30 days. This is an important value based insurance design and quality measure. If a patient does need to return for inpatient care, the close monitoring of the patient provides for pro-active escalation, which benefits the patient by getting more intensive care in a more timely manner.   

Chronic Care RPM is used as a preventative method to monitor patients who have high-risk chronic conditions to reduce the risk of hospitalizations, or as part of a longer-term transition post-hospital discharge. For high-risk patients living at home or in a long-term care (LTC) facility, providers may elect to continue chronic care monitoring long-term to help manage symptoms and reduce the incident of re-hospitalization. For high-risk hospital discharged patients, they are often educated about the advantages of being monitored at home remotely by a nurse prior to leaving the traditional brick-and-mortar facility.  Post-acute chronic care RPM is typically monitored for up to 90 days, with frequent check-ins by a nurse to provide coaching and encouragement to ensure engagement and sustainability.

Hospital-at-Home Programs are used to manage acute care patients who are typically transferred directly from the emergency department—or from an initial inpatient stay—to their own home for hospital-level care. Only select diagnosis are appropriate for this type of monitoring and patients are screened for the appropriateness of this level of care based on their condition and home environment. This model has grown significantly in the wake of the pandemic. RPM is the backbone of the technology that makes hospital-at-home possible. In these programs, patients are typically monitored for three to five days and are classified under RPM as an inpatient, in their home. They are then discharged from inpatient RPM to a transitional RPM program for up to 30 days to ensure their wellness and success with a goal of avoiding unnecessary ED visits or readmissions.⁶

In this category of RPM, more advanced hospital level devices are used to provide real-time monitoring with the care team back at the hospital. For example, smart intravenous (IV) pumps and vital sign devices are tightly integrated with active alerts that are monitored by a hospital level triage team. Clinical staff visit the patient in their home to deliver care.

The hospital-at-home care model has been in place for more than 20 years across the world, most notably in Australia, with success in quality outcomes, patient satisfaction and lower cost of care than traditional brick-and-mortar hospital inpatient stays.

In addition to these three more common types of RPM, a new form of RPM is emerging in the LTPAC sphere that is focused on proactive care and predictive diagnosis of chronic health conditions. Although this type of RPM does not have an official term, it is often referred to it as remote resident monitoring (RRM).

RRM refers to the technology used to monitor and create baseline data on the environmental settings of a resident’s home, social interactions and general activities of daily living (ADLs). Residents typically reside in an independent setting and use RRM as a part of their home care, home health services or services offered by a life planning community. Generally, there are three categories of monitoring technology that currently constitute this use case.

• Home monitoring: Environmental monitoring of heating, ventilation and air conditioning (HVAC), lighting usage and movement radars to create a baseline of the resident’s usual habits in these areas.
• Social interactions: the use of LTC social engagement software connected to devices like Alexa that enable residents to remain active and connected to their community, friends and family. This software can also create a baseline of resident activity data as well.
• General ADL monitoring:⁷ the use of technology such as wearables (bio monitoring watches, pendants, etc.) to track ADL data and create a baseline of the resident’s activity pattern.

Data collected from RRM technology can create a baseline of information over time. Changes in a resident’s baseline in one or more of these monitored areas are reported automatically to caregivers who can quickly investigate the deviations in the resident’s movement or behavior. Proactively investigating these changes can aid in an early diagnosis of a chronic condition, such as Alzheimer’s,⁸ or an early prevention of an impending fall,⁹ or physical injury that could drastically and suddenly diminish a resident’s quality of life.

These types of proactive RRM technologies are gradually being adopted and tested by healthcare providers with the goal of becoming an essential part of enabling residents to fulfill the goal of a longer and higher quality of life.

Benefits of RPM

In an LTPAC setting, patients often go months without seeing their providers. RPM allows for earlier detection of health complications and identify patients who need to seek medical attention prior to in-person appointments. The primary benefit of RPM is the ability for clinicians to identify escalating symptoms and provide medical intervention earlier than they normally would without monitoring. The result of better controlled symptoms leads to higher quality of care, higher patient engagement, higher patient and caregiver satisfaction, less incidents of hospitalizations, and lower total medical expenses.³ Moreover, RPM helps supplement clinical staffing and create workflow efficiencies for staff, especially during the current nursing staffing challenges.

In one study, the use of pulse oximetry monitors to monitor oxygen levels resulted in reduced costs and improved outcomes, resulting in 87% fewer hospitalizations and 77% fewer deaths among patients with access to remote pulse oximetry monitoring.⁴ Another study also indicated increased physical stamina as well as greater overall patient satisfaction and emotional well-being.⁵

CMS Reimbursement

In 2019, Centers for Medicare & Medicaid Services (CMS) established RPM Current Procedural Terminology (CPT) billing codes, which provides the opportunity to make RPM a net neutral, if not a revenue opportunity. Additional insight into these CPT codes and related reimbursement are available from two of the national telehealth resource centers: Mid-Atlantic Telehealth Resource Center and the Center for Connected Health Policy.

Summary

As these examples convey, RPM can bring value to a patient’s care through technology, providing a preventive tool to monitor, sustain and even improve their health. RPM is becoming more of a mainstay of a patient’s continuity of care, allowing for earlier discharge from the hospital, and better odds of the patient healing at home and avoiding being readmitted to the hospital setting.

References

1. NEJM Catalyst. (2018). What is telehealth? The New England Journal of Medicine. Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268
2. American Telemedicine Association. (n.d.). Resources. Retrieved from https://www.americantelemed.org/resource/
3. Kariuki , F. (2022, November 3). The top 13 benefits of Remote Patient Monitoring. HRS. Retrieved from https://www.healthrecoverysolutions.com/blog/the-top-13-benefits-of-remote-patient-monitoring
4. Young, M. (2022, October 1). New studies suggest benefits of remote patient monitoring. Relias Media Continuing Medical Education Publishing. Retrieved from https://www.reliasmedia.com/articles/new-studies-suggest-benefits-of-remote-patient-monitoring#:~:text=The%20program%20reduced%20costs%20and,to%20remote%20pulse%20oximetry%20monitoring
5. NEJM Catalyst. (2018). Patient Satisfaction Surveys. The New England Journal of Medicine. Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0288
6. American Hospital Association. (2020). Creating Value by Bringing Hospital Care Home. Retrieved from https://www.aha.org/system/files/media/file/2020/12/issue-brief-creating-value-by-bringing-hospital-care-home_0.pdf
7. Zhang, Y., D’Haeseleer, I., Coelho, J., Vanden Abeele, V., & Vanrumste, B. (2021). Recognition of bathroom activities in older adults using wearable sensors: A systematic review and recommendations. Sensors, 21(6), 2176. https://doi.org/10.3390/s21062176
8. (2022, July 21). Early Alzheimer’s detection up to 17 years in advance. Retrieved from https://www.sciencedaily.com/releases/2022/07/220721132038.htm
9. S. Department of Health and Human Services. (n.d.). Falls and fractures in older adults: Causes and prevention. National Institute on Aging. Retrieved from https://www.nia.nih.gov/health/falls-and-fractures-older-adults-causes-and-prevention

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Advocates for telehealth kept pressing Congress to ensure access for virtual care, and it appears lawmakers got the message.

Lawmakers are working on final approval of the $1.7 trillion federal spending bill before the government is slated to shut down at the end of the week. Senate leaders included a provision to extend telehealth waivers for healthcare providers through 2024.

The news was music to the ears of Kyle Zebley, senior vice president of public policy for the American Telemedicine Association.

With the possible exception of the federal government expanding virtual care shortly after the arrival of COVID-19, “This is the biggest federal success the telehealth community has had, arguably ever,” Zebley told Chief Healthcare Executive in an interview Wednesday morning.

“It’s a real bipartisan example of the stunning levels of support we have built up over the years,” Zebley said.

The Senate approved the omnibus spending package Thursday, and the House passed it Friday. President Biden is expected to sign it Friday.

Advocates are grateful for the two-year telehealth extension, and are looking for longer-lasting reforms down the road.

“It is a sign that we’re on the road to permanency,” Zebley said.

Racing the clock

Healthcare groups emphasized that extending telehealth access was near the top of their list of priorities before Congress adjourns for the year. It wasn’t just an arbitrary deadline. 

A new Congress will take office in January. If lawmakers didn’t approve the telehealth measure, the legislative process would have to begin anew in 2023, with a new bill being introduced and requiring several steps to clear both the House and Senate, or get inserted into another spending package.

The House of Representatives overwhelmingly approved a bill in July to extend telehealth coverage through 2024. The House passed it with a 416-12 vote, an unusually wide margin in the highly charged partisan environment in Washington.

The measure also had strong support in the Senate, but health advocates said Senate passage wouldn’t be a lock because of the short amount of time left in the congressional session.

Health systems were given waivers to extend telehealth services early in the COVID-19 pandemic, which was a necessity since many providers had curbed in-person services in the first few months of the pandemic.

Advocates expected the telehealth legislation would have to be included in a broader spending package, and healthcare groups sought to get it into the omnibus bill, even as the end of the year rapidly approaches.

“For something like this, everybody that’s been fighting to get something included in a massive package like this … It’s a race against time,” Zebley said.

The telehealth waivers are largely tied to the federal government’s COVID-19 public health emergency, generating uncertainty as to how long those waivers would be in effect. The emergency looks to stay in place through the early months of 2023, healthcare advocates say, but it’s difficult to predict how long it will last. Health systems warned of an impending cliff for telehealth.

Congress and President Biden approved a safety net early last year by allowing telehealth waivers to continue for about five months after the end of the emergency designation.

But health systems pressed lawmakers for a longer period to continue telehealth, which has become a valuable service for providers and for patients, particularly those who don’t live near a practice or hospital.

Key provisions

The spending package includes a two-year delay in implementing the Medicare telemental health in-person requirement, a key issue for behavioral health providers. Healthcare leaders have said telemedicine is a critical way to expand mental health services, particularly with the shortage of clinicians.

It also includes a two-year extension to offer telehealth in High Deductible Health Plans, the American Telemedicine Association said.

The spending package would also provide a two-year extension for hospital-at-home programs, another top issue for health systems. More hospitals have been launching home-based acute care programs. Across the nation, 259 hospitals in 37 states are offering acute care at home, according to federal data.

Home hospital programs are “one of the most innovative test programs that has come out during the pandemic,” Zebley said. “That’s included and it’s a huge victory.”

In addition, audio-only telehealth services would be covered, which Zebley said is important in communities where video telehealth services aren’t widely available.

However, the spending package didn’t include a provision healthcare advocates had sought.

Telemedicine advocates had pushed for an extension of the waiver for the remote prescription of certain controlled substances, including some medications for substance use disorder. But that provision didn’t make the final cut.

The remote prescription waiver is tied to the public health emergency, so that waiver could end shortly after the emergency designation is phased out.

“There’s a big outlier … I’m very concerned about what happens when the public health emergency ends for that community,” Zebley said.

The spending package directs the Drug Enforcement Administration to develop regulations specifying when telemedicine may be used for remote prescriptions of certain substances. And health groups will continue pushing for a more permanent solution, Zebley said.

Looking ahead

Assuming Congress gets the spending package done, health groups are looking forward to pressing ahead with permanent telehealth reforms.

There will be a new Congress, with Republicans holding a narrow majority in the House and Democrats holding a slim edge in the Senate. Zebley said he’s optimistic that there will continue to be strong support for telehealth across party lines, and healthcare groups will be pushing for legislation to craft lasting coverage for telehealth.

“We’re one of those rare issues that had extraordinary support in the Trump administration, which carried over into the Biden administration,” Zebley said.

This wasn’t a new, last-minute effort to wedge telehealth expansion into a big spending package, Zebley said. Telehealth advocates have been pressing Congress for years, building credibility and support with lawmakers. Health groups spoke “with one voice in support of telehealth … which is no small thing,” Zebley said.

“Getting everyone on the same page is also important,” Zebley said.

Telehealth usage soared early in the COVID-19 pandemic, and while use of telehealth has dipped from peak levels, many patients like having virtual options. More than one in three Americans (37%) used telehealth at some point in 2021, according to the Centers for Disease Control and Prevention.

With broad usage of virtual care, strong legislative support and a two-year extension, Zebley said advocates can work with lawmakers on crafting thoughtful legislation to continue telehealth services.

“Even in a divided Congress, even during a divided time, even as we gear up for the 2024 election, this continues to be an issue that garners bipartisan support,” Zebley said.

“I think the vast majority of these programs are on the road to permanency,” he said. “I’m very optimistic.”

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Lawmakers rolled out a roughly $1.7 trillion year-end spending bill Dec. 20 to fund the U.S. government through most of 2023, tacking on proposals to extend telehealth and hospital-at-home flexibilities while leaving out other healthcare asks.

Lawmakers have until the end of Dec. 23 to clear the 2023 Omnibus Appropriations bill or federal funds are set to run out, bringing key agencies and programs to a halt. The package consists of all 12 annual appropriations bills Congress must pass and would fund the government through the remainder of fiscal 2023, which runs through September.

Eight healthcare- and hospital-specific notes out of the 4,155-page bill: 

1. The legislation curbs a scheduled cut of nearly 4.5 percent to the Medicare physician fee schedule that was set to take effect in 2023, narrowing the cut to 2 percentage points in the year ahead with a scheduled cut of 3.25 percentage points in 2024. The American Medical Association, which lobbied against the cuts, said it is “extremely disappointed and dismayed” with the cuts that made it to the bill. 

2. While physicians did not get the relief they sought with complete aversion of fee schedule payment cuts, the spending bill would avert the 4 percent Statutory Pay-As-You-Go reduction, which would have amounted to cuts of approximately $36 billion, from taking effect in 2023. 

3. The legislation extends incentives under the alternative payment model, which were set to expire this year, but reduces the amount from 5 percent to 3.5 percent. The incentive is designed to offset losses in revenue physicians may incur as they move from fee-for-service to participation in value-based care models.

4. The package extends Medicare telehealth flexibilities through 2024. The deadline for these flexibilities has been tied to 151 days after the end of the COVID-19 public health emergency, meaning the precise date was unclear as HHS has continued to renew the PHE in 90-day increments. Under the legislation, providers would be able to lean on flexibilities guaranteed throughout 2024. 

5. The package extends acute hospital care at home waivers and flexibilities for two years through 2024. Similar to telehealth flexibilities, the deadline for hospital care at home waivers was tied to the status of the PHE. CMS has approved more than 250 hospitals to participate in the acute hospital care at home program.

6. The legislation extends the low-volume hospital payment adjustment and Medicare-dependent hospital programs through fiscal year 2024, or Sept. 30, 2024. 

7. The legislation includes $118.7 billion — a 22 percent increase — for VA medical care. Other healthcare end medical allotments include $47.5 billion for the National Institutes of Health (a 5.6 percent increase); $9.2 billion for the CDC; $1.5 billion for NIH’s second-year Advanced Research Projects Agency for Health and $950 million for the Biomedical Advanced Research and Development Authority, according to Senate Appropriations Committee Chairman Patrick Leahy.

8. The American Hospital Association expressed satisfaction with a number of measures in the legislation, including the extension of telehealth, hospital-at-home and programs to help rural hospitals, but signaled toward the work that remains to garner funding for hospitals. 

“In the new year, we will continue to advocate for Congress and the administration to take action to address patient discharge backlogs, support our current workforce and increase the pipeline into the future, hold commercial health insurers accountable for policies that compromise patient safety and add burden to care providers, and strengthen hospitals that care for a disproportionate number of patients covered by government programs or are uninsured, to name a few of our priorities,” association President and CEO Rick Pollack said in a statement shared with Becker’s.

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In communities that otherwise would lack access to care, essential hospitals reach outside their walls to meet patients’ needs. Telehealth services have proved to be an important tool in the provider arsenal to increase access to care for underserved populations. The COVID-19 pandemic has underscored the need for flexibility to provide patient-centered care that best meets the unique needs and circumstances of individuals and communities.

In addition to leveraging telehealth, many essential hospitals have benefited from an innovative program — the Acute Hospital Care at Home waiver — to provide hospital-level care in patients’ homes. Of particular relevance to essential hospitals, hospital-level care in the home provides a unique opportunity to understand patients’ social context and to identify barriers to health, including challenges to medication adherence, worsening memory impairment, and resource limitations.

America’s Essential Hospitals commends the flexibility Congress has provided to date, as hospitals respond to this unprecedented public health crisis. This flexibility has allowed hospitals to leverage technology to provide effective access to care and increased capacity through alternative care sites. As Congress continues to consider legislation during and after the pandemic, it should make permanent policies that allow providers to expand access to care, including telehealth and hospital-at-home, to improve the health of their communities.

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Introduction

Hospital-at-home programs enable patients to receive acute care in their home environment. These programs have proliferated due to the COVID-19 pandemic and subsequent surge in hospitalizations, which has stressed hospital capacity nationally. The model has been well-tested, and studies have shown that hospital-at-home programs can reduce length of stay, improve quality, lower risk of readmission, improve patient satisfaction and lower costs.^1,2,3

Health systems across the country are actively deploying or evaluating hospital-at-home models for a wide range of conditions and acuity levels. With advancements in and continued adoption of remote patient monitoring (RPM) solutions, ongoing staffing and capacity challenges, and an aging population, hospital-at-home presents an opportunity for health systems to transform care delivery and meet organizational challenges.

Prior to designing and launching a program, it is critical to build internal alignment and support. Experience from leading organizations suggests culture, leadership and organizational readiness are critical to the success of establishing and advancing a hospital-at-home model. This includes:

• Identifying executive, clinical and administrative accountability and champions
• Articulating the purpose of and business case for the program
• Establishing a realistic scope and initial metrics for the program
• Building alignment with other home care initiatives and in-person clinical departments
• Maintaining flexibility and enabling iterative operations as the team learns and evolves

This article shares key strategic imperatives for health systems to consider when designing and launching a hospital-at-home program.

Strategic Imperatives

1) Understanding the Business Case for Hospital-at-Home

Hospital-at-home programs are most successful when viewed as a means to advance enterprise strategic goals, such as:

1. Optimizing hospital resources and reducing lengths of stay: Hospital-at-home programs that incorporate home hospital services and tools enable health systems to reserve bed and staffing capacity for higher-acuity cases. Conditions that hospitals are able to monitor and support at home include congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), acute kidney disease and urinary tract infection (UTI), among others. Physical plant resources can also be optimized, particularly for health systems with urban service areas that need to expand services but lack the land to do so. This will be particularly important as the U.S. population ages and both acute and chronic care demands grow.
2. Improving performance under value-based payment arrangements: Health systems with accountability for the total cost of care in one or more of their patient populations can enhance profitability through hospital-at-home programs. One randomized controlled trial experienced a 38% decrease in costs per acute episode as a result of its program.⁴
3. Addressing provider shortages: With persistent staffing shortages at health systems, hospital-at-home enables a more flexible work environment and an ability to support a broader group of patients remotely.
4. Supporting needs of an aging population: This U.S. population is aging. The number of adults over 65 will grow from 52 million in 2018 to 96 million by 2060. Hospital-at-home programs can take pressure off hospitals and long-term care facilities while giving patients a quality experience in their own homes.

2) Understanding Federal and State Regulatory Considerations

The proliferation of hospital-at-home programs today has been driven by the COVID-19 epidemic and resulting waivers from CMS using its emergency authority. These waivers allowed for the creation of the Acute Hospital Care at Home (AHCaH) initiative in November 2020. The AHCaH waiver initiative permits Medicare-certified hospitals to provide inpatient-level care at their patients’ homes. It is the first time CMS has permitted payment for at-home, inpatient-level care for Medicare Fee-for-Service and non-managed Medicaid beneficiaries.⁵

Waiver considerations took into account several factors, including the experience of the institution, patient safety, nursing oversight, physician and advanced practice provider care, and electronic medical record practices. Hospitals that meet the waiver criteria are still required to meet applicable state regulations. In response, several states introduced specific waivers to align with the CMS waiver, including the nation’s largest Medicaid program, California’s Medi-Cal, which serves one in three Californians.⁶

On March 10, 2022, the U.S. Senate introduced the “Hospital Inpatient Services Modernization Act” (S. 3792), while the U.S. House introduced companion legislation (H.R. 7053). These bills would extend CMS’ AHCaH waivers for an additional two years following the expiration of the COVID-19 public health emergency. As of this writing, no legislation has been signed into law. Should enabling legislation move forward in Congress, states must also ensure continued alignment with relevant state hospital licensure laws. As of July 2022, more than 240 hospitals across 36 states are approved for the waiver program, though few are providing hospital-at-home services due to regulatory uncertainty.⁷

3) Coordinating With Other “At-Home” Programs and Services

There are several environmental factors leading to more care being provided in the home. The population is aging, the use of virtual care is growing, new technologies offer increasingly sophisticated remote clinical capabilities and patients/providers experience benefits from the convenience. As health systems design and build hospital-at-home programs, it is important to take a broad view and consider how the hospital-at-home program connects with their overall “at-home” strategies and related services ecosystem. Non-hospital-level services that are shifting into the home should be thoughtfully integrated into hospital-at-home programs to create a connected and seamless patient experience. These could include, among others:

• Primary and specialty care
• Chronic care (through RPM initiatives)
• Urgent and emergency care
• Infusion
• Dialysis
• Lab and imaging services
• Home pharmacy
• Physical, occupational and speech therapy
• Nutrition, social work and other ancillary services

These programs should be built to complement each other so that health systems develop synergistic and efficient “at-home” delivery capabilities and leverage, where possible, centralized tools and infrastructure (e.g., logistics, medical equipment, staffing, technology).

4) Considerations for Program Organization and Staffing

Health systems launching hospital-at-home programs will need to consider various options for organization and staffing. Program leaders need to consider options, including:

• Program organization: It is critical for organizations to decide which services to insource and which to outsource to reliable vendors. Considerations include the geographic region, staff capacity, network providers, vendor relationships and availability, organizational culture, technology platforms, and operational needs. Some organizations will choose to use a vendor to support the program overall, while others will develop a home-based platform.
• Physician staffing: Some organizations have dedicated “virtualists” to support the hospital-at-home program, while others pull clinicians from a rotating pool of hospitalist staff. Others may outsource the “virtualist” role.
• Virtual staff and ratios: Organizations need to consider the right mix of clinicians and the appropriate ratios. Typically, the virtual hospital staff consists of physicians, advanced practice providers (APPs), RNs, case managers and coordinators.
• In-person vs. virtual care: Organizations need to consider the mix of in-person vs. remote services for patients in the home hospital and create the appropriate communication and care coordination channels.
• Physical space: Organizations may consider how they want to set up the hospital-at-home program. For example, some organizations have an in-person command center where clinicians colocate, while others may have a remote team.

5) Considerations for Scaling

Hospital-at-home programs are still relatively new, with small patient volumes; health systems are in learning and experimentation mode. Even those that have scaled or have plans to scale are still relatively small compared to future expectations. Scaling operations is a significant undertaking. Scaling the program will require thoughtful evaluation of an organization’s services, capabilities and gaps related to:

• Technology platforms and technology service supports to enable communication, care management, remote care, and diagnostics and imaging services
• Remote care logistics and transportation, including equipment/medical supplies, food and pharmacy delivery
• Procurement and vendor management to support vendor relationships and supply needs
• Staffing needs, including home-care services, clinicians, case managers and program management/oversight
• Leadership commitment and resourcing to scale and operate the program

Successfully evaluating the system’s capabilities and sub-capabilities hinges on qualitative and quantitative considerations that are best generated in a bottom-up fashion.

Conclusion

While the outlook for care beyond the four walls is bright, hospital-at-home programs are challenging to design and implement at scale. Indeed, only a small handful of programs have achieved any meaningful scale to date. Navigating through the complexity of designing and implementing a high-performing hospital-at-home program requires health system leaders to take a thoughtful and deliberate planning approach in order to realize the full potential that home care has to offer.

_{¹ Shepperd, S., Doll, H., Angus, R. M., Clarke, M. J., Iliffe, S., Kalra, L., Ricauda, N. A., Tibaldi, V., & Wilson, A. D. (2009). Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ: Canadian Medical Association Journal, 180(2), 175–182.}

_{² Federman, A. D., Soones, T., DeCherrie, L. V., Leff, B., & Siu, A. L. (2018). Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences. JAMA internal medicine, 178(8), 1033–1040.}

_{³ Levine, David M., et al. “Hospital-level care at home for acutely ill adults: a randomized controlled trial.” Annals of Internal Medicine 172.2 (2020): 77–85.}

_⁴ Ibid.

_{⁵ Acute Hospital Care at Home. CMS Qualitynet. (n.d.). Retrieved August 23, 2022, from https://qualitynet.cms.gov/acute-hospital-care-at-home}

_{⁶ Department of Health Care Services. The Acute Hospital Care at Home Program. Acute Hospital Care at Home Program. Retrieved August 23, 2022.}

_{⁷ Parodi, S., & Connolly, C. (2022, July 14). Congress: Don’t let hospital care at home shrivel when the public health emergency ends. STAT. Retrieved August 23, 2022, from https://www.statnews.com/2022/07/15/congress-dont-let-hospital-care-at-home-shrivel-when-the-public-health-emergency-ends/.}

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