Hospital at Home Receives a New Lease on Life: A Promising if Uncertain Future

On March 20, 2020, faced with an ever-expanding COVID-19 pandemic, the Centers for Medicare & Medicaid (CMS) took the unprecedented step of announcing the “Hospital Without Walls” program.¹ In so doing, CMS assumed financial responsibility for a range of laboratory and telehealth services required by home-based patients.¹ However, the all-out provision of in-home care remained out of reach since CMS did not waive key inpatient requirements of the “Hospital Conditions of Participation.”¹ It was not until November 25, 2020, that CMS launched the “Acute Hospital Care at Home” (AHCaH) initiative wherein Medicare-certified hospitals were afforded the requisite “regulatory flexibilities to treat eligible patients in their home.”¹ Specifically, CMS waived Sections 42 C.F.R §§482.23(b) and (b)(1) of the “Hospital Conditions of Participation” which require the ongoing onsite availability of nursing services as well as the immediate availability of a registered nurse.¹ Though destined to sunset on May 11, 2023 at the conclusion of the 40 months-long federal Public Health Emergency (PHE), the AHCaH program was recently extended through December 31, 2024 by the Consolidated Appropriations Act, 2023 [Public Law: 117-328]. Having been granted a new, if temporary lease on life, the AHCaH program is now duty-bound to excel if it is to be granted a state of permanence by Congressional advocates. In this Perspective we review the tortuous evolution of the AHCaH concept, discuss its trajectory during the federal PHE, and explore the future prospects thereof.

The debate over the desirability and viability of the “Hospital at Home” concept has been underway for some time. A pioneering trial carried out in the United Kingdom in 1978 concluded that “for the majority of patients to whom a general practitioner is called because of suspected infarction, hospital admission confers no clear advantage.”² It was not until 1994, however, that comparable efforts were undertaken in the U.S. by Johns Hopkins Medicine.³ It was and remains the policy of the “Hospital at Home” program in question to dispatch teams of physicians, nurses, and other clinical personnel to call on and treat select elderly subjects at their place of residence.³ Further support for the “Hospital at Home” notion was afforded in 2016 by a Cochrane Review the conclusions of which were that “admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission.”⁴ Until recently however, few U.S.-based health care systems sought to implement “Hospital at Home” programs absent fee-for-service reimbursement by CMS. Limited exceptions of note include but are not limited to Medicare Advantage, the Veterans Health Administration, the Mount Sinai at Home program, and select Medicaid managed care programs. It was only upon the issuance of the CMS waiver for AHCaH on November 25, 2020, that a growing number of health care enterprises proceeded to establish “safe hospital care for eligible patients in their home.”¹

In reaching its decision to waive the “Hospital Conditions of Participation” in 2020, CMS paid special attention to the results of studies funded by the Center for Medicare and Medicaid Innovation (CMMI). In particular, note was made of a multi-institutional case-control study which concluded that “hospital-at-home care bundled with a 30-day post-acute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization.”⁵ Upon announcing its decision, CMS made note of its conviction that “more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols.”¹ Admission to the AHCaH program was to be limited to transfers from “emergency departments and inpatient hospital beds” subject to an “in-person physician evaluation.”¹ The CMS waiver further required that a “registered nurse will evaluate each patient once daily either in person or remotely” and that “two in-person visits will occur daily by either registered nurses or mobile integrated health paramedics, based on the patient's nursing plan and hospital policies.”¹

As of March 30, 2023, a total of 123 health care systems and 277 Hospitals in 37 states were approved by CMS to implement an AHCaH program. Recognizing the short time horizon of this fast-growing infrastructure, Sen. Thomas R. Carper (D-DE) introduced a bipartisan bill (Hospital Inpatient Services Modernization Act; S.3792) intent on extending the “Acute Hospital Care at Home Program under Medicare until two years after the end of the COVID-19 public health emergency.” An identical bipartisan House bill (H.R.7053) was sponsored by Rep. Brad R. Wenstrup [R-OH-2]. Both bills required the Secretary of Health and Human Services (HHS) to submit to Congress a waiver evaluation report along with any associated legislative recommendations within 90 days of the enactment of the bill. Although neither bill was enacted by the 117^th Congress, relevant language thereof was incorporated into Section 4140 of the Consolidated Appropriations Act, 2023 (CAA) which was signed into law by President Biden on December 29, 2022.⁶ The CAA Section in question titled “Extending Acute Hospital Care at Home waivers and flexibilities” sees to the extension of the Medicare AHCaH program until December 31, 2024.⁶ In addition, the CAA requires the Secretary of HHS conduct a study to “analyze, to the extent practicable, the criteria established by hospitals under the Acute Hospital Care at Home initiative” and “post on a website of the Centers for Medicare & Medicaid Services a report on the study” not later than September 30, 2024.⁶

Public opinion polls conducted by the Partnership for Quality Home Healthcare and the National Association for Home Care & Hospice reveal strong support for the notion of hospital care at home. Realizing this long-term vision, however, will ultimately require that the AHCaH paradigm be rendered permanent by Congressional legislators. It stands to reason that such affirmation of the AHCaH initiative will be markedly enhanced by its adoption by more U.S. healthcare systems and their constituent hospitals. All indications are that it will be the 118^th United States Congress that will ultimately decide whether or not the AHCaH option is to become a permanent feature of the American health care landscape. The popular sentiment will have it no other way.

Funding/Support

None

Declaration of Competing Interest

Professors Adashi and Mr. O'Mahony declare no conflict of interest. Prof. Cohen is a member of the ethics advisory board for Illumina and the Bayer Bioethics Council.