‘A Huge Opportunity’: Behind Health Systems’ Home-Based Care Initiatives

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Health system and hospital leaders are increasingly seeing more opportunities in the home.

Organizations like Upstate University Hospital and Intermountain Health exemplify the more active role that health systems and hospitals are taking when it comes to shifting care into the home.

At Upstate University Hospital, this began when the organization started to think of ways to expand the care it delivers in the community, and beyond the hospital.


“What we wanted to do is make sure that we’re addressing the health care needs of our community, and sometimes it takes going into the home to be able to adequately address those needs,” Diane Nanno, director of transitional care at Upstate University Hospital, told Home Health Care News.

Upstate University Hospital is Syracuse, New York-based teaching hospital. The hospital operates under the Upstate Health System umbrella.

One of the major ways Upstate University Hospital has accomplished this was through its hospital-at-home program, which launched after the availability of the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care At Home waiver program.


Nanno launched the program, and Upstate University Hospital had its first hospital-at-home patient in March 2022. The program focuses on patients that meet the low- to medium-acuity threshold.

“These are patients who are stable enough to be monitored from home,” Nanno said. “They are patients who have conditions with well-defined treatment protocols.”

This means patients with conditions such as COPD, CHF, urinary tract infections that require IV antibiotics and pneumonia. The program also looks to care for seniors that are in a position to receive services in the home setting.

Building out home-based care services

On its end, Intermountain Health is no stranger to at-home care.

Similar to Upstate University Hospital, Intermountain operates in the hospital-at-home space.

The health care system — which is one of the largest in the country — has also cemented its place in the home-based care space through a number of other programs and initiatives, though. Those include a home care agency, a home-based primary care program, remote patient monitoring, tele-specialty care and more.

One area where the organization has seen resounding success is home-based primary care, according to Dr. Nathan Starr, who serves as the medical director of home services for Intermountain.

Over the last year and a half, Intermountain has seen a 35% reduction in avoidable emergency department visits for that patient population. The health system has also seen a 7.5% reduction in medical expenses — its initial goal was to hit 5%.

“We’ve accomplished this by really keeping patients out of the emergency department,” Starr said. “Since they have the support, they don’t need to go there for all the reasons they have been.”

Intermountain’s hospital-at-home program is also seeing growth. The programs’ readmission rates are roughly 40% lower than patients whose entire stay in the hospital, according to Starr.

Upstate University Hospital is also seeing that success when it comes to hospital-at-home. The organization tracks 30-day readmissions. So far, the organization has zero.

The program currently has three patients in the program.

But, despite seeing positive outcomes, hospital-at-home care does come with challenges.

“It takes a huge amount of coordination,” Nanno said. “This was a coordination of the home care agency, the hospital, our pharmacy, an infusion company, a durable medical equipment company. We need transportation, we draw labs, so we needed couriers to get our labs back and forth. We also have contracted with a portable X-ray company, so they can do X-rays and ultrasounds at home.”

This meant that Upstate University Hospital partnered with a home-based care agency to beef up its program. The agency does the nursing visits at home, as well as any therapy visits that are needed.

“I’ve been a nurse for 43 years,” Nanno said. “This is the most complex project I’ve ever done, just because of the coordination.”

Intermountain has also seen its share of challenges when shifting care into the home.

“The current regulatory status of these in-home programs is challenging,” Starr said. “We’ve yet to see a lot of clarity from CMS and Joint Commission about hospital-at-home, for example, and other programs. That always makes everyone a little nervous. We’re not sure if we go down a certain path, and we’re doing patient care, if they’re going to come back later on and say, ‘No, that’s not going to work. You have to change it.’ That just leads to having some systemic caution as we try to move forward.”

Starr also called reimbursement for home-based care programs and initiatives “the elephant in the room.”

“How do we get appropriately paid for this?” he said. “One reason we’ve really pushed our programs on the value-based care side is because we know that if we just focus on reducing cost and providing great quality care, we can show that we do come out ahead, but it’s super challenging.”

Despite this, Intermountain still has its eyes on the home. In fact, in-home ED might be the next area the organization ventures into.

“We’re just starting to look at that, and I know a lot of systems have done more work than we have,” Starr said. “We’ve been a little bit limited, because Utah had really strict paramedic statutes that have just been changed within the last year. We now can do more community paramedic work.”

Right now, Intermountain has an emergency medicine program in place that it hopes to eventually expand into the home.

Upstate University Hospital has expansion goals for its hospital-at-home program, too. The hospital also has set its sights on moving into other areas of at-home care, such as home-based primary care, in the future.

Looking ahead, Starr believes that more health systems will be building out robust home-based programs.

“If a health system doesn’t, there are many other companies really diving into this, whether it’s Walmart, Walgreens or Best Buy,” he said. “I think there’s some really smart people that have recognized that this is a huge opportunity.”

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