Multiple health news sources are reporting on positive findings from a study of what’s called Hospital-at-Home Care (HHC) conducted by Mass General Brigham’s Healthcare at Home program. The study, funded by the National Institutes of Health and published in the Annals of Internal Medicine, found that patients receiving HHC do well, and the approach is associated with fewer deaths or health emergencies. This includes people “hospitalized” at home with serious conditions like heart failure, COPD, cancer, and dementia.
News reports quote Dr. David Michael Levine, clinical director for research and development with the Mass General HHC program, as saying, “Home hospital care appears quite safe and of high quality — you live longer, get readmitted less often, and have fewer adverse events. If people had the opportunity to give this to their mom, their dad, their brother, their sister … they should.”
Although not widely known, hospital-level home care first became available to Medicare patients in 2020, when the Centers for Medicare and Medicaid Services (CMS) launched the Acute Hospital Care at Home Waiver initiative. To be eligible, hospitals must apply for this waiver and adhere to screening and safety protocols. At the time this was part of the federal government’s response to the COVID-19 pandemic. Since then, thousands of patients from 300 Medicare-certified hospitals in 37 states have been treated in their homes rather than in the hospital.
An Unexpectedly Wide Array of In-Home Services
This waiver is reportedly set to end in 2024 unless Congress acts. The study results are said to support a lobbying campaign by advocates to make the CMS waiver permanent. “For decades, home hospital care has been offered all around the world,” Levine said. “This is an important moment in the United States where we might see a paradigm shift in how we deliver a sizeable portion of health care.”
Thanks to technological advances, hospitals can provide an unexpectedly wide array of services at home, according to the American Hospital Association (AHA). People can receive X-ray imaging and sophisticated heart scans at home, be treated with intravenous medicines, have samples drawn for lab tests, and receive meals and medicines delivered to their bedside. For their study, Levine and his colleagues decided to examine how well patients nationwide have fared receiving hospital care at home.
They analyzed the Medicare claims of nearly 5,900 patients across the U.S. who were treated in CMS-approved Acute Hospital Care at Home (AHCaH) programs across the country and who thus received home care under the waiver program. The claims were filed between July 2022 and June 2023. Researchers found that the patients treated at home often had significant illness and health issues, many with medically complex conditions. Roughly 40% had heart failure; a similar number had chronic obstructive pulmonary disease (COPD); about one-fifth had cancer; and some 16% suffered from dementia.
In-Home Patients Fared Well
Despite such challenging health conditions, researchers found a 0.5% death rate among the patients treated at home, and only about 6% had to return to the hospital for care.
At-home patients also did well after their home care ended. Within a month of being “discharged” from home hospitalization, about 3% needed to be checked into a nursing facility, another 3% died, and about 16% required readmission to a hospital. In another positive vein, numbers from clinical trials that Brigham Health conducted in 2018 and 2020 of a pilot home hospitalization program it had launched showed that the readmission rate for home-hospital patients was 7% versus 23% for in-hospital patients.
Possible Reasons Why HHC Works Well
Levine pointed to a number of reasons hospital-level care can be better at home. He said people can have an easier transition when their hospitalization ends “since we show patients how to take care of themselves right in their homes, where they are also more likely to be upright and move more.” Delivering a person’s medical treatment at home also provides health care professionals a glimpse into their lives. They can spot things that might be making their health worse. They can discuss a patient’s diet right in the kitchen. They can link a patient with resources if the supply of food in the home is either inadequate or unhealthy for the patient.
Another revelation that emerged was that outcomes for at-home hospital care did not differ based on a person’s race or ethnicity, or whether they were disabled. This was significant because, Levine said, there are typically huge disparities in outcomes for traditional hospitalization. This suggests in-home hospital care can reach a diverse group of patients and families.
“For hundreds of years, since the inception of hospitals, we’ve told patients to go to a hospital to get acute medical care,” Levine said in a Mass General Brigham press release. “But in the last 40 years, there’s been a global movement to bring care back to the home. We wanted to conduct this national analysis so there would be more data for policymakers and clinicians to make an informed decision about extending or even permanently approving the waiver to extend opportunities for patients to receive care in the comfort of home. Home hospital care appears quite safe and of high quality from decades of research — you live longer, get readmitted less often, and have fewer adverse events.”
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What the American Hospital Association (AHA) Says About Hospital-Level Care at Home
(The following information is excerpted from AHA’s online information. It addresses in-home hospital-level care in general and is not limited only to in-home care paid for by Medicare.)
The structure and implementation of hospital-at-home care (HHC) varies based on the needs and capacity of the hospital and its patient population. Some hospitals run the program out of the emergency department and admit eligible patients to their homes, while others rely on community paramedics or specialty clinics to refer patients into the program. Hospitals may focus on a specific patient population for HHC, such as providing oncology care or post-surgical monitoring at home, enabling a planned “home admission” to replace or shorten an inpatient stay.
Though the structure of HHC models may vary, programs share many things in common. HHC is well-suited for medium acuity patients who need hospital-level care but are considered stable enough to be safely monitored from their homes. While HHC is not appropriate for all patients, it is a particularly good fit for patients who have conditions with well-defined treatment protocols, such as pneumonia, congestive heart failure, chronic obstructive pulmonary disease (COPD), or diabetes. Though the patients are not physically at the hospital, they are never far from health care providers. They are consistently connected to their care team through a combination of in-person visits, video visits, and continuous biometric monitoring via telehealth technologies.
Hospitals can provide a wide array of services in the home setting, including:
• Diagnostic studies such as electrocardiograms, echocardiograms, and x-rays;
• Treatments such as oxygen therapy, intravenous fluids, intravenous antibiotics and other medicines;
• Services such as respiratory therapy, pharmacy services and skilled nursing services.
Based on the patient’s needs and care protocols, care team members visit the patient at least once daily to provide treatment. Providers also need to ensure that the patient’s home is conducive to HHC, with adequate internet access, cooling/heating, and social support. Receiving hospital-level care in the home setting creates an opportunity for providers to identify a patient’s social needs and address any shortcomings.
A Sample Step-By-Step Look at How HHC Works
AHA cites the model in use by Johns Hopkins Medicine to show how HHC can work. Key steps include:
• Using the hospital’s eligibility criteria, the Emergency Department or physician identifies a patient sick enough to require hospital-level care but stable enough to be treated at home. Doctors review the case to confirm.
• The Hospital-at-Home team meet with the patient and family to discuss the program and assess the suitability of the patient’s home for HHC, including what the patient’s overall living situation is.
• Responsibility for the patient’s care is assigned to a physician from the hospital, and other care team members are identified based on the patient’s needs. The care team discusses the treatment protocol with patient and family. This may include a videoconference with the assigned physician. Medical supplies are transported and delivered to the patient’s home.
• Orders are written and healthcare providers visit to administer services. The patient’s vital signs are monitored electronically by the care team. Care team members provide the services that the doctor ordered and set up biometric monitoring so that the HHC team can remotely observe the patient’s condition.
• A care provider visits the patient daily to observe his/her condition and provide treatment. The physician connects with the patient daily, either in person or via telemedicine. Each day, at least one care provider visits with a family member, if one lives with the patient.
• When the patient is stabilized and the assigned doctor is satisfied with his/her progress, patient is “discharged” from HHC and goes on to receive outpatient follow-up care from his/her primary care and specialty care physicians.
AHA mentions that as rural hospitals close or consolidate, some rural residents are experiencing reduced access to hospital care. The University of Utah Health helped develop a Rural Home Hospital Program to test how HHC could be delivered in rural areas. In this model, a local paramedic travels to the patient’s home while a hospital-based physician video conferences in to guide the paramedic’s care provision and set up of any medical equipment in the home. The goal is to leverage technology and the local workforce to safely and effectively treat acutely ill rural patients in their homes.
Overcoming Barriers to Adopting HHC
Costs. AHA notes that most private payers do not cover hospital-level care in the home setting. So how it gets paid can pose a problem. AHA says Veterans Affairs has been able to manage payment, and the current Medicare waiver provides for payment by that program if all eligibility criteria are met. (But, again, that Medicare waiver will end in late 2024 unless it is extended by Congress.) As far as costs go, studies have consistently found that HHC incurs considerably less expense than in-hospital care. A University of Utah study found that patients receiving HHC were 58% less likely to be admitted for an unplanned hospital stay, and those who were admitted to the hospital had a shorter length of stay. These patients had 48% lower cumulative charges for clinical services when compared to the control group. Presbyterian Hospital at Home Services in New Mexico found that the cost of an HHC admission is 42% less than an equivalent hospitalization. Brigham Health found that the cost of treatment for a group of home-hospital patients was lower than a control group of in-hospital patients by 38%. AHA concludes with the simple statement: “Providing hospital-level care in the patient’s home is a lower cost care setting than the hospital. On average, hospital-at-home care has a 25% lower cost of stay.”
Implementation logistics. Implementing HHC does require logistical and technical work, with an investment of time, staff and money, which can burden hospitals. Some hospitals have partnered with companies, such as Medically Home or Contessa, that can provide the technology, manage logistics, or provide care coordination to facilitate implementing a hospital-at-home program.
Reluctance to use. There has at times been a degree of hesitancy regarding whether HHC can deliver the level and quality of care a patient needs. But AHA says this may be changing. As patients more and more are reluctant to go to the hospital and telehealth capacity is growing, HHC is becoming a more desirable option for providers and patients. AHA adds that a meta-analysis of 61 studies found that patients that have received HHC have a 20% reduction in mortality, while another randomized control trial found that acutely ill patients admitted to HHC through an Emergency Department were three times less likely to be admitted to the hospital within 30 days compared to standard care patients.
Constantinos Michaelidis, medical director of the Hospital at Home program at UMass Memorial Health, says his program has helped patients avoid nearly 4,400 days in the hospital since it was launched in 2021. He reports the program has halved the patient mortality rate and reduced 30-day readmissions by 20% to 30%. He says the key to the program’s success is the patient’s clinical experience. He says roughly 90% of the patients surveyed after going through the program have given it high marks. “These patients are getting one-on-one care for a few hours each day,” Michaelidis points out, noting that is often more time than a patient would get in a hospital. Family members, meanwhile, are grateful that they don’t have to go to the hospital to see their loved ones and appreciate the support they get with caregiving duties.
AHA says surveys consistently show that people most often prefer to receive care in the comfort of their homes. AHA asserts that “Hospital-at-home patients are more likely to report a higher level of satisfaction with their physician, comfort and convenience of care, admission process, and the overall care experience.”
In its “Conclusion” about hospital-at-home care, AHA says: “Hospital-at-home care has the potential to innovate how and where hospitals provide care to their patients. By identifying home as the best location for their patients to receive care and leveraging available technology, hospitals can improve value while keeping their patients safe and satisfied.”
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Hospital-At-Home Care in Colorado
Our search through the HHC data of the Centers for Medicare and Medicaid Services did not find any hospitals in Colorado formally enrolled in a Medicare-qualified HHC program. However, there are numerous opportunities throughout the state to access selected basics of the HHC model and take advantage of their benefits. The most widespread source may be the home health care agencies available across Colorado. It’s true these agencies do not provide the full array of services in the Medicare-paid HHC programs discussed above and do not have quite as robust involvement and monitoring by medical professionals. But the home health services provided can nonetheless in many instances enable people to avoid hospitalization while having care needs met in the home. A good place to begin your search for Colorado home health agencies is on this site of the Colorado Department of Public Health and Environment: https://cdphe.colorado.gov/home-care-agencies.
New Models Being Explored in Colorado
Some Colorado healthcare institutions are exploring new models for care delivery that incorporate aspects of HHC. As just one example, UCHealth’s Memorial Hospital Foundation in Colorado Springs is funding a hospital-to-home program in the hospital’s joint venture with The Independence Center. Program components include meals in the home, transportation, setting up home health care, occupational therapy, physical therapy, respiratory therapy, setting up homemaking services like housekeeping and grocery pickup, receiving and setting up durable medical equipment and helping with medication delivery and funding. Social workers call on The Independence Center when a patient is medically ready to go home from a hospital, but can’t because of social determinants. The Independence Center provides case management and resources to improve living conditions that help patients leave the hospital and then remain at home.
“This is a way that we can extend our care and serve the community,’’ says Joe Foecking, director of the inpatient rehabilitation care unit at Memorial Hospital Central. Foecking also serves as chairman of the board of The Independence Center. UCHealth said Foecking presented the pilot program to Memorial Hospital leaders who recognized how it would improve patients’ lives. UCH quotes Foecking as saying the program shows how its designers are seeking ways to help people and reduce costs at the same time, while freeing up hospital resources for other people who are acutely ill and need a hospital bed. Says Foecking: “This lessens the cost of health care and serves the community. These individuals don’t want to be in the hospital; they want to be home.’’ Patricia Yeager, CEO of The Independence Center, adds: “We’ve set out to prove we can transition people with disabilities out of the hospital to home after an acute episode rather than to a nursing home.” The Independence Center offers extensive information on Hospital-to-Home services at https://www.theindependencecenter.org/home-health/hospital-to-home-resource-page/.
Existing Colorado Programs Offer Benefits
The Colorado Department of Health Care Policy & Financing (DHCPF) provides service-delivery options that enable Health First Colorado (Colorado’s Medicaid program) members and their families to direct and manage the long-term care services and supports they need to live at home. The In-Home Support Services (IHSS) lets you direct and manage the attendants who provide your personal care, homemaker and health maintenance services, along with support from the agency. Through IHSS, you are able to select, train and manage attendants of your choice to best fit your unique needs. Or you may delegate these responsibilities to an Authorized Representative. See https://hcpf.colorado.gov/in-home-support-services for details.
The Elderly, Blind and Disabled waiver is available to Colorado seniors aged 65 and older who are blind or functionally impaired. This program is open only to those requiring long-term care to live within their communities safely. Among the services covered are the following:
- In-home care
- Home health care
- Home modifications
- Home-delivered meals
- Personal care
- Respite care
To qualify for this waiver, seniors must meet the age and health care requirements mentioned above and have an income that’s less than three times the current Federal Supplemental Security Income (SSI) limit.
To apply, seniors enrolled in Health First Colorado (Colorado’s Medicaid program) can contact their local county-by-county Single Entry Point. Those who aren’t enrolled should start by applying for Health First Colorado online.
Another resource, the Program for All-Inclusive Care for the Elderly (PACE), helps seniors aged 55 and above access managed care services. It is operated in part by DHCPF and monitored by the Centers for Medicare & Medicaid Services (CMS). It provides free or low-cost care based on a sliding scale, with services that include:
- In-home care
- Home health care
- Primary care and specialty services
- Hospital care
- Rehabilitative therapies
- Case management
- Home-delivered meals
- Companion services
- Non-medical and medical transportation
To qualify for PACE, seniors must be at least 55 years old, live within a PACE service area and require a nursing care level but be able to live in a community setting if provided personal care or health care services at home. See PACE for additional details.
The above are just a few selected examples of Colorado resources and initiatives targeted at enabling people to receive healthcare services in the home. Always feel free to ask your physicians, other healthcare professionals, and social workers about options you might have.
What Else Coloradans Can Do
If you as a patient, or as a caregiver for someone else, prefer to have even complex care for serious health conditions provided at home, you can ask healthcare providers if something like hospital-at-home care is a viable option for you or your loved one. Certainly not every set of circumstances fits an HHC model, but it doesn’t hurt to ask.
You can also do your own online research into care-at-home programs by searching terms such as “Colorado home care” or “Colorado home healthcare agencies” or similar terms.
Regarding the formal Hospital Care at Home Waiver that currently allows for Medicare coverage of hospital-at-home care services, you can consider contacting your elected representatives to encourage them to extend that Waiver beyond the December 2024 expiration date it now has. Chances are the longer that Medicare coverage lasts, and especially if it would become a permanent Medicare benefit, the more hospitals and other eligible healthcare institutions would enroll in the program. Given the positive patient outcomes seen thus far in waiver-approved programs, and the net cost savings, more healthcare institutions may be inclined to join this approach to providing care in ways that patients favor by wide margins.
