‘Nurses Are Horrified’: Hospital-at-Home Programs Taking Flak, But Model’s Long-Term Growth Is Undeniable

“Resistance to change is proportional to how much the future might be altered by any given act.” The quote, a line from American horror author Stephen King, perfectly describes the situation in which hospital-at-home programs find themselves.

As of Nov. 11, 83 health systems and 187 hospitals in 34 states were participating in the Acute Hospital Care at Home initiative rolled out by the U.S. Centers for Medicare & Medicaid Services (CMS) about a year ago. Outside of fee-for-service Medicare, several organizations are also offering acute-level care in the home supported by partnerships with companies such as DispatchHealth, Contessa Health, Medically Home and others.

The COVID-19 pandemic triggered the proliferation of hospital-at-home programs out of necessity, with overcrowded and understaffed hospitals forced to shift services into the home, often with the support of home health agencies and non-medical home care providers.

“I am very impressed with the number of hospitals that stepped up to implement the program, and I think it has played a critical role in addressing hospital capacity and saved many lives,” former CMS Administrator Seema Verma told Home Health Care News in October.

For some, the hospital-at-home trend probably feels like it came out of nowhere. The concept, however, has been around for years, with its mettle tested through numerous pilots, projects and case studies.

“If this were a drug, it would be a blockbuster drug,” Johns Hopkins University’s Dr. Bruce Leff, a hospital-at-home pioneer, said during a 2018 American Academy of Home Care Medicine event.

Despite the momentum and documented benefits, I’ve noticed that hospital-at-home programs are now starting to take some serious flak, with the latest salvo coming from National Nurses United. The criticism may temporarily temper growth expectations, but I remain extremely bullish on hospital at home’s long-term outlook.

‘We are completely opposed’

National Nurses United — the largest union and professional association of registered nurses in the U.S. — slammed hospital-at-home models in a statement sent out on Nov. 4. While the union group opened fire on the concept itself, it specifically called out Kaiser Permanente.

Kaiser and the Mayo Clinic announced a joint $100 million investment in Medically Home, a company dedicated to shifting higher-acuity care into the home, in May.

“Nurses are horrified by Kaiser’s attempts to redefine what constitutes a hospital and what counts as nursing care,” the statement says. “Not only does this program endanger the imminent safety and lives of patients, it completely undermines the central role registered nurses play in the hands-on care that patients need to safely heal and recover.”

As part of its investment, Kaiser Permanente initially made hospital-at-home services available to patients in California and Oregon, utilizing Medically Home’s model. Leaders from the large health system told HHCN that they hope to add to those efforts moving forward.

“With the growing number of people who are aging over 65, we need to discover and implement programs that will address the needs of this population, at a scale,” Dr. Stephen Parodi, executive vice president of the Permanente Federation, told HHCN at the time. “Kaiser Permanente firmly believes that providing this type of care in the comfort of a person’s home is also a way to improve access, whether it is in an underserved or rural setting.”

Generally, National Nurses United has three main concerns.

For starters, the group believes hospital-at-home programs endanger participating patients, who may, at times, end up being monitored via technology instead of an in-person nurse.

“The entire reason for being admitted into a hospital is to benefit from the 24/7 monitoring, assessment and professional care that licensed registered nurses provide,” the National Nurses United statement continues.

The group additionally argues that hospital-at-home programs toss nurses aside to prioritize profits over patients.

“And as more and more patients are sent home, hospitals will use the lower patient census as justification to close in-patient beds and further cut RN staffing, leading to a self-fueling death spiral of your community hospital,” the statement notes. “Brick-and-mortar rural hospitals, already an endangered species, will certainly go extinct.”

Lastly, National Nurses United argues hospital-at-home models stress family caregivers and place undue burden on underserved communities.

Examining the evidence

It’s impossible to fully respond to the aforementioned criticisms in this HHCN+ update, but I did want to share my thoughts on a couple points.

First, National Nurses United is right to worry about patient care, as that should always be the No. 1 focus whenever a new way of doing things comes along. Yet hospital-at-home programs have repeatedly been found to be safer and more effective than traditional facility-based care.

A 2018 study of more than 500 participants, for example, found that compared to patients receiving in-patient care, patients receiving hospital-at-home care had shorter lengths of stay, lower rates of 30-day readmission, fewer emergency department visits and better care ratings.

Similarly, a 2020 study found that Brigham Health Home Hospital’s patients saw fewer readmissions and experienced more physical activity at home, which is a key component to the overall recovery process.

“We know from our research, as well as from others’ research, that things like readmission rates are decreased,” Dr. David Levine, an assistant professor of medicine at Harvard Medical School and the leader of Brigham Health Home Hospital, told me last year. “People have really great experiences at home. People move more at home. These are all patient-centered things that people want when they’re sick.”

As part of its extensive efforts, Johns Hopkins has found that hospital-at-home patients experience better clinical outcomes and lower rates of mortality, while also needing less sedatives and fewer restraints.

And when it comes to patient care, it’s important to note that hospital-at-home programs aren’t for everyone. Most hospitals are extremely selective in identifying patients eligible for in-home care, with patients usually given the final say as to where they recover.

The National Nurses United statement makes it seem like hospitals are sending their entire census home. In reality, hospital-at-home volume is pretty small (more on this in just a second), with some programs set up to only care for a handful of patients.

As for eliminating or reassigning hospital-based RN positions by shifting care into the home, I’m not sure that will actually happen on a widespread basis.

Because of the pandemic, there has been a dire nursing shortage across health care settings. But that shortage has continued even as the COVID-19 situation has improved. Look at what’s happening at rural hospitals, for instance.

Vox on Monday reported on a new survey of rural hospitals from the Chartis Group. Nearly 99% of the rural hospitals surveyed said they were experiencing staffing shortages, with 96% saying they were having the most difficulty finding nurses.

Almost half of the hospitals in the survey, according to VOX, said staffing problems had prevented them from accepting new patients in the previous 60 days.

If those hospitals had technology-assisted hospital-at-home programs able to safely monitor people at home with fewer nursing resources, maybe they could have accepted those patients.

National Nurses United said it believes hospital-at-home programs will “prove to be a gold mine” for the hospital industry. For-profit hospitals have a bad reputation for being too profit-driven at the expense of quality, so I don’t entirely disagree that there’s a very real concern here.

But hospital-at-home programs aren’t exactly inexpensive investments, and delivering hyper-targeted, one-on-one care in the home can require more resources than treating dozens of people all in the same place.

“Depending on how you build your program and how sick your patients are — you’ve got to be able to touch them,” Levine told HHCN. “If they are too far away and your team is too spread out, it’s not going to work.”

The hospital-at-home forecast

So what does the hospital-at-home model actually look like today? Honestly, despite all the attention and pushback, it’s still probably smaller than you’d think.

There are 187 hospitals approved to take part of the CMS Acute Hospital Care at Home initiative, but some of them haven’t even admitted a single patient yet. A source familiar with the market mentioned this to HHCN at our FUTURE event, and I followed up with CMS to confirm.

“CMS is currently working through the process to publicly release data on Acute Hospital Care at Home waivers, so we do not have any information to share at this time,” an agency spokesperson told me. “Our waiver team does track data elements for all hospitals that have been approved for the waiver. CMS is aware that there are programs that have been approved but have not admitted an in-patient at this time.”

It is important to note that there may be a delay between when hospitals are approved for Acute Hospital Care at Home waivers and their initial admissions, the spokesperson added.

The Advisory Board recently brought together over 400 health care leaders from across health systems, health plans and elsewhere for its Site-of-Care Shift Summit. Shifting in-patient volume into the home was among the many topics discussed.

About 60% of the attendees said they had seen less than 1% of their in-patient volumes shift into the home. That’s partly because of the hospital-at-home model’s inherent challenges, such as supply-chain management, reimbursement, patient uptake and C-suite buy-in.

Contessa co-founder and CEO Travis Messina touched on that later point during FUTURE 2019.

“We have to have the buy-in of all of the leadership,” Messina said. “The one thing I don’t like about health care is that it takes everyone to approve [an idea] — and one to kill it. We have seen instances where 15 people have said, ‘This is an amazing idea. We need to move forward,’ and then one person says ‘nope,’ and that kills it.”

About two-thirds of the Site-of-Care Shift Summit attendees predicted that more than 10% of their in-patient volumes would be shifted to the home by 2024.

Growing the hospital-at-home model will be a steady, long-term process, but that growth is undeniable, in my view. The U.S. health care system needs to change, especially as the nation becomes older and more medically complex.