These days, when people with Medicare get to the hospital, they’re increasingly asked: Would you prefer using our hospital at home program?
That can be an enticing option if you need acute care for any of 60 conditions like COPD, pneumonia, congestive heart failure and urinary tract infections but not for things requiring a brick-and-mortar medical center like surgery or an MRI.
In 2019, people with Medicare had over 800,000 hospitalizations that could have qualified for hospital at home, according to the actuarial and consulting firm Milliman.
The disruptions of hospital stays
“There’s lots of evidence that, on average, patients are more comfortable in the home,” says Pamela Pelizzari, principal and senior healthcare consultant at Milliman. “If you’ve ever been in the hospital, it’s disruptive. It’s not restful. You’re getting disturbed constantly for lots of things. There’s an infection risk that it makes sense to try and avoid.”
With hospital at home, “we try to make sure that patients get to sleep at night at their usual sleeping hours, not wake them at weird times of day and organize the care so it allows for good rest,” says Dr. Pippa Shulman, chief medical officer at Medically Home.
Data on the quality and usefulness of hospital at home is fairly sparse. But a few studies have shown that compared to brick-and-mortar hospital stays, the in-home service lowers mortality rates, fall risks and the onset of delirium while helping patients avoid infections some get in hospitals.
What patients and caregivers say about hospital at home
Studies have also found high satisfaction rates from hospital-at-home patients and their caregivers. For people with Medicare, the out-of-pocket cost for hospital at home is generally the same as for receiving similar care in a hospital.
Increasingly, says Rami Karjian, the founder and CEO of Medically Home, hospital at home is “becoming the default standard to provide care for eligible patients, as opposed to an exception.”
Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, calls hospital at home “a very effective, efficient way to care for patients.”
How hospital at home works
Hospital at home typically lasts for four or five days and can be declined by patients who prefer hospital stays. It has three components: daily in-person visits from doctors, nurses and paramedics; daily virtual visits from physicians and nurses at the hospital at home’s “command center” and Bluetooth-enabled remote monitoring from tablets and phones given to patients plus the personal emergency response devices they wear.
Advances in technology have made hospital at home much easier to provide, says Michael Dowling, co-author of The Aging Revolution and president and CEO of Northwell Health.
“Our tech kit takes about 15 minutes to set up,” says Medically Home’s Shulman.
Medical care provided by hospital at home can include IV antibiotics and infusions, EKGs, blood pressure monitoring, x-rays, and respiratory or oxygen therapy.
Typically, to qualify for hospital at home, people with Medicare need to first go to the hospital for an interview. If they’re selected as candidates, they then decide whether to enroll or to stay in the hospital.
Medicare and hospital at home
Hospital at home has been offered in the United States, England, Australia and Israel for decades, but Medicare typically didn’t cover it until the pandemic.
In 2020, however, when people without the virus wanted to stay out of hospitals and hospitals needed space for those requiring treatment for it, the Centers for Medicare and Medicaid Services (CMS) began allowing reimbursement for Traditional Medicare and private insurers’ Medicare Advantage plans.
Subsequently, hospital at home took off. In 2021, 186 hospitals offered it. Currently, about 320 hospitals in 37 states do, from Johns Hopkins in Baltimore to Mount Sinai in New York City to Sanford Health in Sioux Falls, S.D. to Presbyterian Healthcare Services in New Mexico.
In 2022, Medicare’s hospital-at-home waiver was extended by two years.
“There’s no greater patient-centered care than care delivered in an individual’s home setting where they’re often most comfortable with their own sleeping accommodations and clothing, in addition to having easy access to their loved ones and their pets, who are often important elements in the return to health,” says Heather O’Sullivan, president of Mass General Brigham Hospital’s Healthcare at Home and a geriatric nurse practitioner.
Hospital at home fans and critics
Today, hospital at home has its fans—and its critics.
Lisa Rother, an Oklahoma City nurse, recalls the experience of one older man who had hospital at home from Medically Home, where she’s senior director of strategic marketing operations.
“He had been in hospitals multiple times for an infection of his bones and was losing his fingers gradually,” she says. “He wouldn’t stay in the brick-and-mortar hospitals because he felt very uncomfortable there. So, we hospitalized him within his home, helping him complete his full medical treatment and antibiotics and keep his hand.”
Rother says after the patient’s third or fourth day in the program, “he loved our nurses, he loved our physicians and completely changed his attitude.”
After all, she asked, “What better outcome can you have than being able to keep your limb rather than having an amputation?”
The American Hospital Association and American Medical Association are huge proponents of hospital at home.
But a 2023 report from the Emergency Care Research Institute said there hasn’t been enough reliable data on hospital-at-home outcomes. “No systematic evidence exists that H@H services to the acutely ill yield better patient care or lower costs compared to the current hospital-based system,” it said.
The nurses who oppose hospital at home
National Nurses United, the nation’s largest union and professional association of registered nurses, strongly opposes hospital at home.
The group calls it “Home All Alone” and “a grave threat to patient care and safety” that can “deprive people of professional, 24/7 nursing care.”
“Devices being deployed in patients’ homes can malfunction and give erroneous readings,” says Michelle Mahon, assistant director of nursing practices at National Nurses United. “There are also user curves. Imagine you’re very sick, running a high fever, can barely see straight and now you’re supposed to enter your own vital signs into an app or tool that maybe you can’t even see properly?”
Hospital-at-home providers and proponents reject those fears.
“We assume the patient and caregiver have no ability or knowledge” regarding the hospital-at-home tech devices, says Shulman.
Some critics, like National Nurses United, also worry about what could happen to hospital-at-home patients with medical emergencies.
“In the hospital, we are able to respond to a patient’s change of condition and recognize it before it becomes a crisis,” says Mahon. “Often, those changes are detected by skilled nurses before the data shows there’s a problem, especially in elderly people. There might be subtle changes in the way they talk or in their cognition, glassy eyes or in the smell of their breath. We can respond within seconds.”
Shulman’s response, from Medically Home: “We do a lot of readings with the virtual technology. If the teams get readings that don’t make sense, we have protocols for repeating them. If that’s not working, we deploy someone to the house to figure out what’s going on and intervene early so we’re not running into emergencies.”
Doctors are most apt to select patients for the hospital at home programs who are unlikely to have a sudden emergency “that would warrant an immediate crush of health care personnel descending,” says Foster.
Hospital-at-home programs often keep in contact with their patients for a month after their experience ends.
“We are making sure that our care plan works and you transition back to your primary care physician or specialist,” says Mark Prather, cofounder and executive chairman of the Dispatch Health hospital-at-home operator.
The Medicare rules for hospital at home
Each hospital at home program has its own technology and care system. But they all must adhere to these CMS rules for people on Medicare:
- At least one daily clinician visit, which can be remote after the initial in-person history and physical exam in the hospital or emergency department
- At least two in-person daily visits; if both are by a paramedic or “mobile integrated health practitioner,” there must also be a daily remote visit from a registered nurse
- An on-demand remote audio connection with someone from the hospital-at-home team who can immediately connect to an RN or physician
- Emergency response to a patient’s home within 30 minutes if needed
Questions to ask before signing up
If you’re considering getting hospital at home or are given the option, Northwell Health’s Dowling recommends asking: What kind of home-care capabilities does the organization have? How much hospital-at-home has it done? Are the nurses trained for the types of things that may need to be done?
Medically Home’s Karjian adds: “I’d ask, ‘If this was your dad, what would you recommend for them?’”
O’Sullivan, of Mass General Brigham, suggests finding out who’d be coming into your home and their credentials.
The American Hospital Association’s Foster thinks you should also inquire about how often the team members will come, how you’ll know what to do if there’s an emergency and how often you might need help from someone living in your home.
Hospital at home generally isn’t a good idea if you live alone. That’s because there may be times when you’ll need in-person assistance and the hospital-at-home crew won’t be with you.
What will happen after 2024?
Medicare’s hospital-at-home reimbursement rules will come to an end for people with Traditional Medicare January 1, 2025 (not for those with Medicare Advantage plans) unless Congress and the Biden administration extend the waiver.
The problem if Medicare stops allowing hospital at home, says Foster, is that “many hospitals are very, very full and often short of staff, which could provide some challenges for inpatient care.”
National Nurses United wants the Medicare waiver to end in 2024. But proponents like the American Hospital Association, the American Medical Association, the American Academy of Home Care Medicine and the American Telemedicine Association want to see an extension for at least five years.
“Congress has been talking a lot about how long to extend [the waiver], which I think is a good sign,” says Rachel Jenkins, the American Hospital Association’s senior associate director of federal relations.
The future for hospitals and hospital at home
If CMS does continue allowing Medicare reimbursement for hospital at home after 2024, experts said, that won’t mean the end of in-person hospital stays—though hospitals gradually may wind up becoming primarily for patients needing surgery or ICUs.
“I don’t think we’re going to be taking out your gall bladder in your living room,” says Prather. “But in 10 years, we will be admitting all the classic medical admissions that are just better at home.”
“Hospitals are one cog in the wheel, not the central cog as they were years ago,” says Dowling. “The other cogs are home care, post-acute care, ambulatory care and physical therapy care. We’ve got to maximize all of those opportunities and be creative about it.”
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