Acute hospital care at home gets good grades from CMS research 

Photo: Luis Alvarez/Getty Images

Patients who received care under the pandemic's Acute Hospital Care at Home program had a low mortality rate and minimal complications related to escalations back to the brick-and-mortar hospital, according to a CMS research letter published in the Journal of the American Medical Association Health Forum.

During the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services granted waivers for hospitals for acute level care in patients' homes. The concept was not new. Johns Hopkins has been practicing Hospital at Home at least since 2002, and had trademarked the name.

But the pandemic necessitated the use of acute services to be provided outside of the hospital – where beds filled with COVID-19 patients – and in the relative safety of homes where people were already quarantining.

Acute care at home was a concept that found itself in the right place at the right time, and is said to have worked so well for both hospitals – which also realized a financial advantage – and patients that health systems have wanted to keep the model past the end of the public health emergency in May.

The Consolidated Appropriations Act of 2023 extended the CMS Acute Hospital Care at Home initiative through December 31, 2024. This law extends waivers and flexibilities for physical environment requirements in the home, telehealth flexibilities and the waiver that allows a hospital to provide routine services outside of the hospital.

WHY THIS MATTERS: THE RESEARCH

As of March 20 of this year, 277 hospitals across 123 systems in 37 states were approved to participate in the Acute Hospital Care at Home program. 

The initiative enables some patients in need of acute-level care to receive care in their homes, rather than in a hospital, the report said. 

A total of 11,159 patients were admitted under the waiver from November 25, 2021, through March 20, 2023, including 8,417 with Medicare fee-for-service insurance, 1,705 with non-managed care Medicaid insurance and 1,011 with both. 

The most common conditions treated, based on the primary diagnosis, were respiratory infections, heart failure and shock, and severe sepsis or septicemia, all with a major complication and comorbidity.

For Medicare patients, the median length of stay obtained from claims was five days. The overall proportion of patients transferred from home back to the hospital was 7.20%. 

During the study period, 38 unexpected deaths occurred in participating hospitals. Most unexpected deaths occurred in the setting of COVID-19 infection with the progression of more severe illness symptoms. With the exception of three cases, each of the patients who died had been transferred back to the hospital and received medical or intensive care unit–level care for several days prior to death, the report said.

THE LARGER TREND

On November 25, 2020, as part of the Hospital Without Walls initiative to address the COVID-19 public health emergency and concerns about hospital bed capacity, CMS launched the Acute Hospital Care at Home (AHCAH) initiative.

Through a Section 1135 waiver, AHCAH allows individual CMS-approved hospitals to provide inpatient-level care in the home environment for Medicare fee-for-service and non-managed care Medicaid beneficiaries.

CMS waived specific hospital Conditions of Participation (COP) that require 24-hour onsite nursing for patients and that patients' homes meet certain structural and physical environment criteria. 

Participating hospitals must demonstrate their ability to meet the additional hospital COP that were not waived under Section 1135 of the Social Security Act.

As part of the approval process, CMS performed an offsite review of hospital operations and processes to ensure that each hospital could satisfy the unwaived Conditions of Participation in the home environment. In addition to patient volume, hospitals agreed to self-report two data measures to CMS as a component of hospital participation. The report said study limitations include that there may have been substantial selection bias from hospitals that chose to participate and patients who had medical conditions for which care could be provided in their homes.

The law requires hospitals to provide additional data to CMS to monitor the quality of care and for CMS to undertake a comprehensive study of the AHCAH initiative by September 30, 2024. 

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org