The ‘Tipping Point Is Coming’ For Hospital-At-Home Care In The US

Empirical evidence suggests that hospital-at-home care is safe and effective. Anecdotal evidence suggests that the model is still not nearly as widespread as it should be, however, with patients regularly asking their health care providers about the option.

“Not a week goes by now where we don’t hear a story of a patient or a family member asking for hospital at home,” Dr. Pippa Shulman, the chief medical officer at Medically Home, told Home Health Care News. “The word is out, and that gets me really excited. But the health care system more broadly needs to catch up with where patients and families are at. That tipping point is coming.”

Based in Boston, Medically Home is an at-home, high-acuity care enabler and provider. It has been on the forefront of the hospital-at-home movement from the get-go in the U.S. Right now, it is operating in 22 states and cares for more than 32,000 patients across its care programs. Besides hospital at home, the company also has ED-in-home and post-surgical programs.


Shulman is the clinical architect of the Medically Home model.

The company has grown rapidly over the past few years while navigating significant regulatory hurdles. Because its care models are still relatively new in the U.S., payer sources have had a hard time keeping up with the innovation and scaling of those models.

“Health care regulation varies greatly state by state, it’s not uniform or consistent,” Shulman said. “And that can be pharmacy regulation, scope of practice regulation for staff in the model, or the licensing challenges state by state. It’s not an insurmountable challenge. But it’s something that we have to learn for each state we enter into.”


More uniform measures and guardrails for hospital at home would be a welcomed development for all parties involved.

After all, the model has shown time and again it is as effective as hospital-based care – for certain patients – and also can provide superior outcomes in select areas.

An analysis of the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home waiver found that, of the 11,159 patients who received in-home care from November 2021 to March 2023, only 7.2% were transferred to the hospital. Shulman also highlighted a study which showed that at-home Kaiser Permanente patients were 64% less likely to experience delirium compared to those treated in the hospital.

The Acute Hospital Care at Home waiver was extended through 2024, and most expect for it to be extended again before the year’s end. But there still remains some uncertainty, despite strong bipartisan support for the model and waiver.

“While reimbursement has expanded greatly, and the national payers are incredibly supportive of acute care in the home – as is CMS – there is a low level of uncertainty that remains because the waiver expires at the end of 2024,” Shulman said. “While we have high confidence the waiver will be renewed or extended, that depends on Congress.”

That bipartisan support was on display last week, as Sens. Marco Rubio (R-Fla.) and Tom Carper (D-Del.) introduced the At Home Observation and Medical Evaluation (HOME) Services Act.

That bill would expand the scope of hospital at home to include more eligible patients.

Broadly, there are two types of statuses for hospital patients: “observational,” which generally requires a day or two in the hospital; and “inpatient,” which generally requires two or more overnight stays in the hospital.

Right now, the patients that fall under the latter group are the only ones being admitted into CMS-sanctioned hospital-at-home programs. The Rubio and Carper bill, if passed, would change that to include observational patients.

“I think this is a big deal,” Shulman said of the bill. “You can imagine what an advantage it would be for someone to be able to avoid us waiting until they’re sick enough, and to actually just provide the care they need in the home and skip the facility altogether. So, I think it’s a huge opportunity.”

As an organizer of hospital- and ED-level care in the home, Medically Home also works with other types of home-based care providers.

For instance, the home care provider BrightStar Care is one of the company’s national partners.

“Medical care in the home is inherently a team sport,” Shulman said. “In order to provide the highest-quality acute care in the home, we take advantage of a lot of different providers who are already working in this space. … We are able to bring those folks in, in certain markets, to make sure that whatever a patient needs is brought into the home on demand in a timeframe equivalent to the hospital. For instance, when a patient is admitted to a hospital, their plan of care may include daily infusion, visits for medication, meals, labs and daily therapies, and those can all be delivered by different groups of people.”

It’s likely that more home-based care companies will be brought into the fold as health systems continue to scale their hospital-at-home programs.

Given that patients are now becoming aware of the option, from a regulatory and resource perspective, providers are going to need all the help they can get.

“There’s a tremendous amount of excitement [around this],” Shulman said. “Some people think of that as an obstacle. But I think of that as something that we’ve really turned into an advantage.”

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