As an increasing number of health systems implement "hospital-at-home" (HaH) programs to increase their traditional hospital capacity, the Centers for Medicare & Medicaid Services (CMS) has given the movement a boost by changing its regulations to allow acute care to be provided in a patient's home under certain conditions.
CMS announced last week it was launching its Acute Hospital Care at Home program "to increase the capacity of the American health care system" during the COVID-19 pandemic.
At the same time, the agency announced it was giving more flexibility to ambulatory surgery centers (ASCs) to provide hospital-level care.
CMS said its new HaH program is an expansion of the Hospitals Without Walls initiative that was unveiled last March. Hospitals Without Walls is a set of "temporary new rules" that provides flexibility for hospitals to provide acute care outside of inpatient settings. Under those rules, hospitals are able to transfer patients to outside facilities, such as ASCs, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving Medicare hospital payments.
Under CMS' new Acute Hospital Care at Home, which is not described as temporary, patients can be transferred from emergency departments or inpatient wards to hospital-level care at home. CMS said the HaH program is designed for people with conditions such as the acute phases of asthma, congestive heart failure, pneumonia, and chronic obstructive pulmonary disease. Altogether, CMS said, more than 60 acute conditions can be treated safely at home.
However, the agency didn't say that facilities can't admit COVID-19 patients to the hospital at home. Rami Karjian, MBA, cofounder and CEO of Medically Home, a firm that supplies health systems with technical services and software for HaH programs, told Medscape Medical News that several Medically Home clients plan to treat both COVID and non-COVID patients at home when they begin to participate in the CMS program in the near future.
CMS said it consulted extensively with academic and private industry leaders in building its HaH program. Before rolling out the initiative, CMS noted, it conducted successful pilot programs in leading hospitals and health systems. The results of some of these pilots have been reported in academic journals, the agency said.
Participating hospitals will be required to have specified screening protocols in place before beginning acute care at home, CMS announced. An in-person physician evaluation will be required before starting care at home. A nurse will evaluate each patient once daily in person or remotely, and either nurses or paramedics will visit the patient in person twice a day.
In contrast, Medicare regulations require nursing staff to be available around- the-clock in traditional hospitals. So CMS has to grant waivers to hospitals for HaH programs.
While not going into detail on the telemonitoring capabilities that will be required in the acute hospital care at home, the release said, "Today's announcement builds upon the critical work by CMS to expand telehealth coverage to keep beneficiaries safe and prevent the spread of COVID-19."
More Flexibility for ASCs
The agency is also giving ASCs the flexibility to provide 24-hour nursing services only when one or more patients are receiving care onsite. This flexibility will be available to any of the 5700 ASCs that wish to participate, and will be immediately effective for the 85 ASCs currently participating in the Hospital Without Walls initiative, CMS said.
The new ASC regulations, CMS said, are aimed at allowing communities "to maintain surgical capacity and other life-saving non-COVID-19 [care], like cancer surgeries." Patients who need such procedures will be able to receive them in ASCs without being exposed to known COVID-19 cases.
Similarly, CMS said patients and families not diagnosed with COVID-19 may prefer to receive acute care at home if local hospitals are full of COVID patients. In addition, CMS said it anticipates patients may value the ability to be treated at home without the visitation restrictions of hospitals.
Early HaH Participants
Six health systems with extensive experience in providing acute hospital care at home have been approved for the new HaH waivers from Medicare rules. They include Brigham and Women's Hospital (Massachusetts); Huntsman Cancer Institute (Utah); Massachusetts General Hospital (Massachusetts); Mount Sinai Health System (New York City); Presbyterian Healthcare Services (New Mexico); and UnityPoint Health (Iowa).
CMS said that it's in discussions with other healthcare systems and expects new applications to be submitted soon.
To support these efforts, CMS has launched an online portal to streamline the waiver request process. CMS said it will closely monitor the program to safeguard beneficiaries and will require participating hospitals to report quality and safety data on a regular basis.
Support From Hospitals
The first health systems participating in the CMS HaH appear to be supportive of the program, with some hospital leaders submitting comments to CMS about their view of the initiative.
"The CMS has taken an extraordinary step today, facilitating the rapid expansion of Hospitalization at Home, an innovative care model with proven results," said Kenneth L. Davis, MD, president and CEO of the Mount Sinai Health System in New York City. "This important and timely move will enable hospitals across the country to use effective tools to safely care for patients during this pandemic."
David Levine, MD, assistant professor of medicine and medical director of strategy and innovation for Brigham Health Home Hospital in Boston, was similarly laudatory: "Our research at Brigham Health Home has shown that we can deliver hospital-level care in our patients' homes with lower readmission rates, more physical mobility, and a positive patient experience," he said. "During these challenging times, a focus on the home is critical. We are so encouraged that CMS is taking this important step, which will allow hospitals across the country to increase their capacity while delivering the care all patients deserve."
Scaling Up Quickly
If other hospitals and health systems recognize the value of HaH, how long might it take them to develop and implement these programs in the midst of a pandemic?
Atrium Health, a large health system in the Southeast, ramped up a hospital at home initiative last spring for its 10 hospitals in the Charlotte, North Carolina area, in just 2 weeks. However, it had been working on the project for some time before the pandemic struck. Focusing mostly on COVID-19 patients, the initiative reduced the COVID-19 patient load by 20%-25% in Atrium's hospitals.
Medically Home, the HaH infrastructure company, said in a news release that it "enables health systems to establish new hospital-at-home services in as little as 30 days." Medically Home has partnered in this venture with Huron Consulting Group, which has about 200 HaH-trained consultants, and Cardinal Health, a large global medical supplies distributor.
Karjian told Medscape Medical News that he expects private insurers to follow CMS' example, as they often do. "We think this decision will cause not only CMS but private insurers to cover hospital at home after the pandemic, if it becomes the standard of care, because patients have better outcomes when treated at home," he said.
Asked for his view on why CMS specified that patients could be admitted to an HaH only from emergency departments or inpatient settings, Karjian said that CMS wants to make sure that patients have access to brick-and-mortar hospital care if that's what they need. Also, he noted, this model is new to most hospitals, so CMS wants to make sure they start "with all the safety guardrails" in place.
Overall, Karjian said, "This is an exciting development for patients across the country. What CMS has done is terrific in terms of letting patients get the care they want, where they want it, and get the benefit of better outcomes while the nation is going through this capacity crunch for hospital beds."
