During surges of Covid-19, providing hospital-level care in the home was a good alternative to receiving care in hospitals strained by historic staffing shortages and populated by people infected with SARS-CoV-2, the virus that causes the disease. Rather than fading away with the pandemic, this form of care needs to be seen as an integral part of health care in the United States.
Hospital-level care in the home is delivering remarkable results. People with complex diseases such as sepsis, pneumonia, and congenital heart disease, who required admission to a hospital only a few years ago can — and do — receive high-quality, acute care in the safety and comfort of their homes. But this kind of care will stall without action by Congress to extend flexibilities for this care beyond the public health emergency. That will provide the stability and certainty that health plans and systems need to offer the personalized at-home care that patients prefer.
In-home hospital care is led by physicians who collaborate with skilled community care teams to deliver a mix of in-person visits, telehealth services, and remote monitoring. Hospital-at-home programs typically supply the equipment and staff needed to communicate with patients and their family members, and manage intravenous lines, perform diagnostic tests, and provide other services. They also rely heavily on physicians and nurses to manage care remotely.
Health systems and health plans began experimenting with this model long before the pandemic emerged, building on lessons learned from same-day surgeries, virtual visits, interdisciplinary care teams, and community outreach programs. The regulatory environment, however, which included a requirement that care services be provided in the home 24 hours a day, seven days a week in order to be reimbursed by Medicare made a comprehensive approach difficult to scale nationally. Most systems that could have provided high-quality, at-home care simply didn’t have the resources to abide by pre-pandemic regulations.
Then Covid-19 arrived, and with it a mandate to keep everyone but the sickest people out of hospitals. Overnight, telehealth went from nice-to-have to essential. Policymakers granted Medicare and Medicaid flexibility to connect vulnerable patients with care previously delivered exclusively in brick-and-mortar facilities.
So far, more than 240 hospitals in 36 states — including Kaiser Permanente (which one of us, S.P., works for) — are approved for the waiver program, but only a fraction of these hospitals are actually providing this care. Why? Many health systems and hospitals are reluctant to invest in staffing and resources while the regulatory support for this model is uncertain.
The Acute Hospital Care at Home Waiver will end when the public health emergency expires unless Congress acts quickly on bipartisan legislation to extend it. This legislation would create stable access to home-based hospital services for patients who want them and who are able to safely receive this kind of care. Extending the waiver would provide the assurance that providers and health plans need to invest in resources for the long-term success of person-centered “care anywhere.”
Clinical care teams know that patients, even those with complex conditions, benefit and thrive from receiving care at home. This type of care can also increase access for patients experiencing social barriers, such as transportation and food insecurity.
Home is where patients and their families want to be. Kaiser Permanente Northwest’s in-home hospital care program had higher patient satisfaction scores than the national average for brick-and-mortar hospitals included in the most recent Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
According to internal Kaiser Permanente data, patients using the system’s hospital-at-home services said their care teams were more responsive (85% vs. 67%), experienced smoother care transitions (76% vs. 52%), and had overall better experiences (80% vs. 71%) than patients who received traditional inpatient care.
These scores reflect a larger trend of patient satisfaction for in-home care delivered by hospitals and health systems across the United States. In a 10-month evaluation period, patients of Intermountain Healthcare were more likely to recommend the system’s in-home hospital care when compared to brick-and-mortar hospital care (85% vs. 78%). Patients enrolled in Mount Sinai’s hospital-at-home program were more likely to rate their hospital care highly than those treated in the traditional hospital setting (69% vs. 45%). A study of multiple Medicare-managed care health systems and a Department of Veteran Affairs medical center found that a higher proportion of patients were satisfied with the treatment they received from hospital-at-home care than those who received traditional inpatient care in several domains, including satisfaction with their physicians, comfort and convenience of care, and the overall care experience.
The hospital-at-home approach is also associated with better quality care. When compared to data collected by the federal Agency for Healthcare Research and Quality, internal Kaiser Permanente data showed that Kaiser members receiving in-home hospital care fared better than the average U.S. hospital patient. In a cohort of 769 patients studied from August 2020 to August 2021, the death rate for in-home patients was zero compared to the national average of 2% for inpatient care. Similarly, just 0.1% of in-home patients acquired an infection compared to 8.6% of all hospital patients.
The long-term outlook for patients receiving in-home hospital care patients is better, too. Less than 9% of patients in the Kaiser Permanente Advanced Care at Home program needed additional hospital-level care either in their homes or in a hospital within 30 days of being discharged from the program — a number that compares favorably to the average national readmission rate of 13%.
Delivering hospital-level care in the comfort, convenience, and safety of patients’ homes is well suited to value-based health care systems in which physician groups and hospitals work with health plans that incentivize quality. By contrast, a fee-for-service approach, in which physicians and other health care providers are paid a fee for each service rendered, would make in-home care too expensive and deprioritize outcomes.
The Covid-19 public health emergency has posed many challenges. If there is a silver lining, it is that it spurred innovation and the ability to provide high-level health care services where people want them. It’s time for Congress to guarantee this progress and flexibility are here to stay.
Stephen Parodi is an infectious diseases physician, executive vice president at The Permanente Federation, and an associate executive director for The Permanente Medical Group. Ceci Connolly is the president and chief executive officer of the Alliance of Community Health Plans.
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