Designing and Launching Hospital-at-Home Models: Strategic Imperatives for Health System Leaders
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.
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:
- 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.
- 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
- 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.
- 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
- 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.
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.
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/.