Hospital-at-Home Holdouts: Why In-Home Acute Care Isn’t for the Faint of Heart

After making gradual inroads over the past few years, the hospital-at-home model has seemingly had its breakthrough moment. That came in November, when the U.S. Centers for Medicare & Medicaid Services (CMS) introduced its “Acute Hospital Care At Home” wavier program.

The creation of CMS’s wavier — a COVID-19 relief measure — has created a path forward for hospitals already working in the in-home care space, as well as those looking to enter for the first time. Despite widespread interest, some hospitals are still gun shy, focused more on their brick-and-mortar operations than the hospital-at-home concept.

Although it has been around for a while, the hospital-at-home model seems tailor-made for the current time.


Generally, hospital-at-home programs attempt to provide acute, hospital-level care in the home as an alternative to hospital admission, which can be costly. To do so, programs try to identify eligible patients whose medical conditions can be cared for in the home setting through coordinated nursing and clinician visits, plus necessary testing and treatment.

The hospital-at-home model falls in line with the growing preference for home-based care and the move away from institutional settings.

Furthermore, the COVID-19 emergency has emphasized the importance of decentralizing the way that care is delivered.


In some shape or form, the hospital-at-home model has existed for more than 20 years, though in that time reimbursement remained a major roadblock that limited the widespread adoption of the model. Even now, there is no permanent mechanism in fee-for-service Medicare to pay for these services.

Dr. Bruce Leff, a professor at the Johns Hopkins University School of Medicine, believes that CMS’s wavier is a good first step when it comes to addressing hospital-at-home reimbursement.

“I think CMS wanted to develop something that was relatively simple, relatively understandable, relatively uncomplicated in terms of what the payment would look like,” Leff told Home Health Care News. “What they chose to do is basically create a process where hospitals that could attest to being able to provide hospital-at-home services … would be able to get paid a standard hospital DRG payment in a fee-for-service context.”

World-renowned Johns Hopkins has been exploring the hospital-at-home model since the early 1990s. Johns Hopkins doesn’t currently operate a program, but the organization is generally considered to be a pioneer in the space.

As of March 16, 109 hospitals in 29 states have been approved for the CMS waiver. Just a handful of participants were approved when the initiative was first announced.

CMS’s wavier resolves what many health care experts believe was one of the biggest challenges surrounding the model, but some hospital leaders are likely wondering how long this will last.

“If CMS doesn’t create a method to either make the current waiver permanent or come up with a new form of payment that goes beyond the public health emergency, the current payment will expire,” Leff said. “There may be some systems that are saying, ‘I don’t know if I want to make changes in our health care delivery when it’s possible that the payment will only last for the duration of the public health emergency.’”

Indeed, setting up and maintaining a successful hospital-at-home program is no easy task. Moving into this space requires an organization to have a strong clinical staff and operational support in place.

“Having high-acuity care in the home is such a transformation for the hospital systems,” Rami Karijan, Medically Home’s CEO, told HHCN. “It’s not for the faint of heart.”

Offsetting some of the more daunting aspects of setting up a hospital-at-home program has created space for companies like Medically Home, which has raised tens of millions of dollars since launching.

Boston-based Medically Home has built a model that allows organizations to provide acute services in the home. To do so, Medically Home helps its partners coordinate in-home clinician visits, in addition to any necessary technology, equipment or other supplies.

“There are 18 different services patients receive in the hospital today that need to be configured to go into the home 24/7, within an hour’s notice, with great levels of care and quality,” Karijan said. “Getting that ecosystem — we call it acute rapid response — set up within a city or state is really hard work. It’s not a side project.”

Another reason some hospitals might be holding off when it comes to hospital-at-home programs is the overall culture of health care. Leff, however, believes that this will eventually change.

“My own sense is that in the future, what we call the hospital now is going to end up being a big emergency room, operating room and intensive care unit,” he said. “I think everything else will ultimately end up getting pushed out to the home and community. I don’t know if that’s 10, 20, or 30 years from now, but I think everything will start to move in that direction. But you do see powerful forces that always want to bring things back to what they were.”

It’s hard to know what CMS’s next move will be, but officials will probably factor hospitals’ performance under the wavier into any decision-making about the future.

“I think that CMS will be trying to evaluate the experience of the waiver,” Leff said. “I think they’re thinking about a lot of the future issues and how to take advantage of the changes that came in the wake of the pandemic.”

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