‘Par for the Course’: Why Hospital-at-Home Models Took So Long to Catch On

“This really isn’t a new model.” That’s what many home-based care operators and health systems think after they’re asked about the recent hospital-at-home boom in the U.S.

In actuality, hospital-at-home models surfaced in the 1990s. Early adopters included Johns Hopkins University, which pioneered its own concept — and proved that it worked — decades before the current buzz.

In-home hospital care feels new to many in 2021, however, because widespread adoption has been historically thwarted by the lack of a reliable reimbursement mechanism. That was the case until the COVID-19 crisis forced the U.S. Centers for Medicare & Medicaid Services (CMS) to roll out a dedicated waiver last November.


Dr. Bruce Leff, a geriatrician and a health services researcher, began working on a hospital-at-home model the first day he joined Johns Hopkins in 1994. The value of such initiatives was the same then as it is now, Leff told Home Health Care News.

“We found that when older adults got acutely ill, a fair number of them would refuse to go to the hospital because they had previously had bad experiences in the hospital,” he said. “And often as geriatricians, I think we recognized the potential problems with hospital care and the potential dangers and illness that comes from being in the hospital.”

Conditions like pneumonia and heart failure could be treated in the hospital, of course. But Leff and others worried that those patients may end up worse off as a result of their hospital stay.


In part, Johns Hopkins was able to confirm its hypothesis after participating in multiple demonstrations, some on a national scale. After receiving hospital-level care in the home, patients typically had lower rates of mortality, delirium and other adverse health outcomes, while caregivers experienced less stress.

Combined, those benefits additionally tended to lead to lower costs overall.

Armed with these and other findings, hospital-at-home advocates have long advocated for payment support. CMS has paid for the model off and on during demonstrations, but never on a permanent basis.

Even with the new CMS waiver and the strong interest it has generated, permanent fee-for-service payment is still not a sure thing moving forward. As of March 3, 48 health systems and 109 hospitals in 29 states had been approved for the CMS program, which is set to last only for the duration of the public health emergency.

‘A wildly successful demonstration’

Organizations that had prior experience with hospital-at-home models were granted a go-ahead under the waiver program at an expedited pace. A few of those groups had originally worked with Johns Hopkins to launch their models, too.

Leff and Johns Hopkins had worked with Arizona-based Presbysterian Healthcare Services — a not-for-profit health system and insurer — since 2008. Likewise, New York-based Mount Sinai Health System had worked with Johns Hopkins on a CMS demonstration from 2014 to 2017.

“That was a wildly successful demonstration,” Leff said. “But once the demo was over, that payment went away. So Mount Sinai took their hospital-at-home model and then started to develop risk contracts with Medicare Advantage plans in the New York market, thus sustaining their hospital-at-home.”

Mount Sinai, which has a network of eight hospital campuses, now works with the Nashville, Tennessee-based Contessa Health to facilitate its program.

These and others have found ways to keep their hospital-at-home programs alive despite a lack of reimbursement because the concept works so well, Leff said. Hospital-at-home has been particularly applicable during the COVID-19 pandemic, as patients have shied away from institutional-based settings and hospital capacity has been of grave concern.

Par for the course

The U.S. continues to be a laggard when it comes to hospital-at-home models. Plenty of countries in Europe have banked on this type of in-home care for years now.

But Leff is hoping that the COVID-19 crisis will be the tipping point that leads to widespread adoption.

“I think it’s just par for the course, in some ways, for health care delivery and innovation, in general,” Leff said. “It usually takes 17 or 18 years for innovation implementation to set in. But there are dozens and dozens of randomized, controlled trials of hospital-at-home. When you put them together … , the results for hospital-at-home are actually quite stunning.

Now that hospital-at-home has piqued the interests of health systems across the country, each has a decision to make: whether to build their own program or license the framework from someone else.

Johns Hopkins enables providers to license out its model, but that decision really should be made on a provider-by-provider basis, experts say.

Illinois-based Quincy Medical Group, for example, did elect to license out the Johns Hopkins model. In its nearly three-year implementation of hospital-at-home, it wanted to lean on the original innovators, QMG Interim CMO Dr. Rick Noble told HHCN in December.

“This way, we won’t have to reinvent the wheel,” Noble said. “We basically purchased their best care protocols that we’re going to implement.”

There is a lot of information on best practices that is publicly available, however. And on top of that, home-based care organizations — especially ones like Contessa Health — are often great partners in helping launch hospital-at-home programs.

Not licensing out also allows organizations to customize their own model, in line with their own operations.

The backwards bicycle

The hospital-at-home model works. So why hasn’t it been widely adopted and supported sooner? Leff likened it to learning how to ride a bicycle backwards.

Although it seems like a straightforward challenge, it’s not a simple learning process. The implementation of hospital-at-home is similar, in the sense that providers have to re-learn how to deliver care completely, which takes a long time.

“It’s sort of the difference between understanding you need to change, knowing how to change and making the change, because some things are just so hardwired into systems,” Leff said. “Rewiring health care, health care delivery and attitudes — all of that is hard.”

It’s why home-based care providers have faced frustration over the years as their care delivery systems proved to be superior to others, but still weren’t widely adopted or recognized.

“It’s not just hospital-at-home, but home-based care delivery, in general,” Leff said. “But I do think that’s starting to change, especially as the value discussions change. And it’s all about leadership leading culture change, and moving things forward. So yeah, it’s been frustrating, sure. But I think persistence has been helpful.”

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