Home care instead of hospital care: Congress should extend a crucial waiver

Hospitals can be places of healing and, at times, harm, particularly for older adults with complex medical conditions. For appropriately selected patients requiring hospital care, home hospital care offers the benefits of hospital care in the comfort and safety of the home and facilitates better understanding of patients’ medical and social context.

Home hospital programs across the country expanded after the Centers for Medicare and Medicaid Services began to pay for these services in November 2020 as a remedy for the pressures hospitals faced during the pandemic.

Since launching in August 2021, our UMass Memorial Health home hospital team has cared for nearly 300 patients with acute medical conditions who would otherwise have spent days in the traditional hospital. Mirroring results from randomized controlled clinical trials, our home hospital program has demonstrated excellent quality, safety, and patient satisfaction outcomes.

Yet home hospital programs across the United States are at significant risk of contraction unless Congress acts to extend the Acute Hospital Care at Home waiver.

Here’s an example of how the program works: Late one afternoon our home hospital team at UMass Memorial Health evaluated a patient we’ll call Joe. He came to the emergency department with a severe kidney infection requiring hospital admission for close monitoring, specialist consultation, and intravenous antibiotics. Joe’s case was complicated by the fact that, at age 62, he has diabetes, kidney disease, and underwent a kidney transplant several years ago. After his evaluation in our emergency department, it was clear that Joe required ongoing hospital-level care. Our home hospital nurses and physicians reviewed his medical record, performed a home safety screen to understand and mitigate any risks, and determined that Joe was a good candidate for home hospital care. After hearing about our home hospital program as an alternative to traditional hospital care, Joe chose to be admitted into our home hospital program.

Joe was transported to his home by ambulance, met in his home by a hospital nurse, and introduced to his hospital physician by telehealth. On admission, Joe was connected to his home hospital care team through remote vital sign monitoring devices that monitor his heart rate, oxygen level, blood pressure, temperature, and weight and convey the information via a tablet that enables 24/7 responses from nurses and physicians with in-home rapid response by clinicians in minutes if required. These connections between Joe and his care team were facilitated by wireless technology that we brought to the home. This technology does not require the patient to have internet service, which is important because 22 million older adults across the country do not have broadband internet access at home.

With the home hospital program, Joe and patients like him have access to the same services offered in a traditional hospital, but in familiar surroundings without the associated risks of hospitalization for older adults — confusion, falls, and infections. In addition to 24/7 monitoring and care, physicians see him every morning by video, and nurses visit him at home at least twice a day.

There’s another benefit to home hospital care: By caring for Joe in his home, our team was able to identify and address barriers to health, including challenges with following a complex medication regimen, a decline in memory, and financial resource limitations.

As Joe’s kidney infection improved, we were able to coordinate a simpler medication regimen, develop a plan for closer family support, and connect Joe with community resources.

The tragedy is that Joe, and other medically complex and socioeconomically disadvantaged patients who have traditional Medicare or Medicaid, will soon lose access to the home hospital care option unless Congress acts to extend the CMS Acute Hospital Care at Home waiver prior to the end of the federal public health emergency.

Home hospital care is not new. In fact, home hospital care has been studied and delivered to patients in the United States for nearly 25 years. For appropriate patients, home hospital care reduces mortality by 20-30%, readmissions by 20-30% and the need for patients to be transferred to rehabilitation facilities after the hospital stay by 80-90%, with associated improvements in total 30-day costs. Patient satisfaction with home hospital care, meanwhile, is higher relative to traditional hospital care.

Before the emergence of Covid-19, home hospital programs were generally small. Traditional Medicare — the largest health insurer in the United States — did not pay for home hospital care. As a result, home hospital programs were more likely to be instituted in health systems with global budgets, like the Veterans Health Administration, or those with resources to invest in home hospital development before payment certainty. Less wealthy safety-net health systems, which typically serve more patients on Medicare and Medicaid and whose patients could have benefited from this program, were often unable to make investments in these programs because of the absence of reimbursement for the cost of administering this type of care from insurers like Medicare.

The Covid-19 pandemic dramatically accelerated the growth of home hospital programs in the United States from fewer than 50 prior to the pandemic to greater than 200 today. In November 2020, in the midst of surging hospitalizations across the country, CMS announced the Acute Hospital Care at Home waiver program to help expand hospital capacity. For hospitals that applied and were approved for this waiver program, CMS waived certain conditions of participation for traditional Medicare and Medicaid, enabling hospitals to provide and be paid for providing home hospital care while holding them accountable to quality and safety reporting.

Health systems embraced home hospital care for their patients. The more than 200 CMS-approved home hospital programs across the country provide safe and effective care with reporting mandates in place to ensure maintenance of the same highly favorable outcomes seen in earlier published clinical trials of home hospital care. Patients covered by traditional Medicare or Medicaid are now routinely offered the choice to receive the same care they would have received in the traditional hospital in the comfort of their homes, an option that did not exist prior to the CMS waiver.

Every patient with an eligible condition — severe Covid pneumonia, bacterial pneumonia, heart failure exacerbation, lung disease exacerbations, skin and soft tissue infections, etc. — who requires hospital-level care should have access to home hospital care. Unfortunately, uncertainty regarding payment for home hospital services now threatens to slow the growth of this safe and effective care model. Many health systems cannot afford to take the risk of building out new home hospital programs knowing that payment for those services may disappear within just a few months when the federal public health emergency ends.

In our home hospital program, 32% of patients have traditional Medicare, 25% of patients have Medicaid, and 18% of patients have both Medicare and Medicaid, representing some of the most medically complex and socioeconomically disadvantaged populations we serve. When the federal public health emergency expires, so will the Acute Hospital Care at Home waiver program, and our patients who have traditional Medicare, Medicaid, or both will lose access to home hospital care, creating a major equity challenge in the distribution of this safe and effective care model for our safety-net health system.

The bipartisan Hospital Inpatient Services Modernization Act, introduced in the Senate and House of Representatives earlier this month, provides hope for the future of home hospital programs. By extending the CMS Acute Hospital Care at Home waiver, this legislation will help ensure that all patients — regardless of race, ethnicity, or socioeconomic status — continue to have access to safe and effective inpatient-level care in their homes.

Constantinos Michaelidis is a hospitalist and medical director of the UMass Memorial Health Hospital at Home program. Candra Szymanski is a nurse and associate vice president of the UMass Memorial Health Hospital at Home program.