3 considerations and 8 steps for creating an HaH program
With a roughly two-year goal of being able to deliver acute hospital care to up to 200 patients in their homes, Mass General Brigham in Boston exemplifies a growing trend among U.S. health systems in embracing the strategic potential of a hospital-at-home (HaH) program.a
The prediction that HaH programs would continue to proliferate across our nation’s healthcare system has proven to be on target.b it now seems clear the innovative care model of providing hospital-level care in a patient’s home as a substitute for acute inpatient hospital care is finally getting the attention it deserves from hospital systems. The growing interest in HaH programs since early 2021 has been motivated by five key factors that provide evidence of the benefits HaH programs can deliver:
- Better clinical outcomes for patients who received HaH care compared with similar patients who received care in an acute care hospital, with lower rates of mortality, better patient and family satisfaction, less caregiver stress and better functional outcomes
- Substantial cost savings compared with traditional inpatient care
- improved coverage by payers, spurred by the CMS Acute Hospital Care at Home waiver program, which allows approved HaH Programs to bill traditional inpatient rates for HaH patients
- Emergence of new technologies, particularly remote patient monitoring and associated technology
- An ongoing increase in the numbers of hospitals taking on risk, with growing numbers of lives included in their risk-bearing or risk-sharing programs
When CMS first announced its Acute Hospital Care at Home waiver program on Nov. 25, 2020, six health systems with extensive experience providing hospital care at home were approved to participate. By Jan. 15, 2021, the number of health systems approved for the program had grown to 36, involving 88 hospitals. As of Oct. 26, 2022, CMS noted that there were 114 health systems approved for the CMS waiver program, representing 256 hospitals in 37 states.c
Key considerations in deciding whether to begin an HaH program
Health systems that are considering applying for the CMS waiver to implement their own HaH programs should not go live with a program without first making sure they have thoroughly addressed three key considerations.
1 Identify the primary objectives for the HaH program. Likely objectives include the following:
- Increase hospital capacity. If a hospital is full or nearly full, starting an HaH program may be a cost-effective option to open up hospital beds, thereby increasing capacity without building additional bricks and mortar. The Mayo Clinic, for example, is programing 125 to 150 HaH beds for a new hospital it is building in Florida.
- Reduce the total cost of care. Some health systems have their own provider-sponsored health plan and/or accountable care organization (ACO) with a large enrollment. Because HaH programs have lower costs than comparable hospital stays, adopting a program could reduce an organizations’ total cost of care. Presbyterian Health Care in new Mexico, an early HaH innovator, has reported savings of 19% to 30% compared with traditional inpatient care, with lower average length of stay and fewer lab or diagnostic tests.
- Maintain a competitive market position. In a market where competitors are offering and marketing HaH programs, a health system may need to establish an HaH program to remain competitive and meet consumer interests and demands.
2 Assess the level of leadership interest and commitment for initiating an HaH program. Planning and implementing a successful HaH program are significant undertakings, requiring the involvement of numerous departments and an investment of time and resources. It is imperative to have not only board and senior executive commitment to the program but also strong support for the program among medical staff, including physicians and nurses. Educating key leaders about HaH programs will be critically important.
3 Perform a risk assessment to determine extent to which the organization would be able to financially sustain the HaH program after the current COVID-19 public health emergency (PHE) is lifted. The CMS waiver program allows hospitals to receive payment at inpatient rates for HaH programs, but that provision is tied to the COViD PHe. The PHe is currently set to expire on Jan. 11, 2023, unless it is extended, as has happened every 90 days since the pandemic began. Congress is working on this issue, and a bipartisan proposal was introduced in the House and Senate in March that would extend the waiver program for two years beyond the end of the PHe. It remains to be seen whether Congress will approve this proposal and send it to the President for signature.
Support for HaH programs by State Medicaid programs and commercial payers is another important consideration. Participation in innovative care delivery programs by states and commercial payers varies by entity and locale. Although an HaH program could be started based solely on the CMS waiver for Medicare and possibly Medicare Advantage enrollees, the ability to get to sufficient scale for long-term success will depend on participation by other payers.
8 Steps for preparing to start an HaH program
Once a health system has made at least a tentative decision to implement an HaH program, it will require several months of planning before it can commence the program. Health systems then should anticipate a 12- to 18-month ramp-up period to get to scale. The following are essential planning steps.
1 Select the HaH leadership team. HaH programs require dedicated leadership teams, composed of an executive sponsor, one or more physician leaders and nurse leaders and potentially others representing key services. Because planning for an HaH program requires significant time and effort, it is critical to ensure the effort is well-resourced.
2 If required, find a partner. An HaH program requires sophisticated logistics operations. imagine needing to provide all services that are routinely delivered to patients in a hospital — including physician care, nursing, ancillaries, food, drugs, therapies and the associated it and technology — in a patient’s home virtually on demand.
Careful planning and execution are required to allow for coordinated delivery of these services to the home so that they are available when needed. Few health systems have the full capability to launch all these services and the requisite technology platform without the help of a partner organization. For this reason, many health systems look to companies such as Medically Home, Amedisys and Contessa Health to help them plan and implement their HaH programs.
One of the very first steps in developing such a program, therefore, is to determine whether a partner is needed, because it will be important for the partner to work with the health system’s HaH leadership team in planning and developing the program.
3 Develop workflows. Just as there are numerous workflows in place for inpatient stays, workflows need to be developed for all aspects of the HaH program. A workflow is needed for each service that will be delivered in the home, as well as for services provided virtually.
4 Develop a command center plan. An essential component of any HaH program is a command center staffed 24/7 by at least two clinicians at all times, so that multiple emergent/ urgent issues can be promptly handled.
5 Develop a redundant communication plan. Being able to maintain constant communication between the patient and command center is of mission-critical importance. it therefore is imperative to have backup systems in place to ensure communication can be maintained in the event of a power failure or technology issue.
6 Determine HaH admission criteria. Not all patients are appropriate for an HaH program. Admission criteria need to account for the following factors:
- Patient’s clinical condition and needs
- Acceptability of the home environment for accommodating the in-home care
- Insurance coverage
- The distance to the patient’s home from the nearest participating hospital
Interestingly, program advocates report that a full-time at-home caregiver is not an essential admissions criterion. As with inpatient admissions, an HaH program can use clinical criteria such as Change Healthcare’s interQual Solution to screen patients for appropriateness.
7 Develop an IT plan. The HaH program should use the health system’s electronic health record and, possibly, other health system it applications. The health system should expect to make some modifications to existing platforms, such as adding HaH as a delivery site, creating order sets, developing interfaces with contracted vendors and building needed management and quality reporting.
8 Develop a marketing plan. It is important to have a good patient acquisition plan for the HaH program. Under the current CMS waiver program, HaH patients need to be admitted either from the ED or an inpatient unit. Therefore, education of the ED staff, hospitalists and selected specialists about HaH is important.
Organizations should consider having an HaH advanced practice nurse imbedded in the ED to screen patients and perform the required history and physical. Given that patient satisfaction tends to be high with HaH programs, using patient testimonials also is an effective way to promote a program.
The amount of careful planning required for an HaH program cannot be overstated. An HaH program must care for patients as if they were in an inpatient bed. the same considerations about quality and safety exist, so the same care that goes into delivering inpatient care should be replicated for the HaH program. Success depends on ensuring both patients and referring physicians trust that the HaH program meets or exceeds the same quality and safety standards and metrics as apply to inpatient care. One should anticipate a 12–18-month ramp-up period to get to scale.
The future of HaH
Although the future of HaH is partially dependent on continuation of the CMS waiver program, current experience suggests it likely that some form of reasonable payment will be available for Medicare and Medicare enrollees. So far, published studies indicate that quality and safety are at least equal to what they are for inpatients, costs are lower and patient satisfaction is higher.
With 256 hospitals currently having an approved HaH program, there will likely be pressure on Congress to extend the CMS waiver in some form. Meanwhile, commercial insurers are showing interest in supporting HaH programs. A number of health systems have already developed contracts with commercial payers to cover their programs.
It also is likely that the range of clinical conditions covered by HaH programs will continue to grow, to the point that as many as 20% to 25% of hospital inpatients might eventually be eligible for HaH care. Moreover, although many programs today are focused mostly on Medicare patients, the potential pool of eligible patients will expand as more commercial insurers and State Medicaid programs decide to include HaH as a covered benefit. Advances in remote patient monitoring technology may also help expand the pool of eligible patients.
Another likely development is the development of HaH episodes of care that cover both the acute and restorative segments of care. rather than having patients go to a rehabilitation center or skilled nursing facility, some HaH patients will be able to receive the needed post-acute care in their home using the same team of caregivers to enhance the continuity of care. A 30-day bundle covering both acute and post-acute segments is a clear option.
The future of HaH is bright because patient and physician acceptance has been positive and more payers are providing coverage for HaH care. While the pace of HaH growth depends somewhat on whether CMS extends its waiver program, the approach is here to stay because its benefits remain clear and compelling.
a. Bartlett, J., “Mass General Brigham plans massive expansion of hospital-at-home program,” The Boston Globe, July 11, 2022.
b. Jacobs, M.O., and Eggbeer, B., ” Have hospital-at-home programs finally come of age?” Financial Sustainability Report, January 2021
c. CMS.gov, “Approved facilities/systems for acute hospital care at home,” Acute Hospitals Care at home Resources, page last updated Sept. 30, 2022.
Case study: Integris Health’s experience in starting an HaH program
Integris Health, the largest nonprofit health system in Oklahoma, operating multiple hospitals and ambulatory facilities throughout the state, embarked on a hospital-at-home (HaH) program on Jan. 31,2022.
Integris Health had been considering starting a program prior to COVID-19 as part of its strategy to improve accessibility and provide a virtual continuum of care, said Lisa Rother, system director of the health system’s HaH program.
Its flagship hospital was operating at capacity, and the influx of COVID patients made it necessary to quickly initiate the HaH program, she said. Rother noted that the CMS waiver program provided adequate payment, which had previously been a barrier to starting an HaH program.
Integris Health decided that an experienced HaH partner was needed to support a quick launch. After evaluating several options, the health system selected Boston-based Medically Home as its partner. A planning team was established in partnership with Medically Home, and the detailed planning took five months of intensive work. Workflows were developed replicating the inpatient workflows, and the logistics for the program were carefully planned.
Rother underscored the importance not only of getting the right staff, supplies, equipment and technology to the patient’s home when needed, but also of establishing the extensive coordination required to minimize the number of daily visits to the patient’s home to make sure they patient could get their needed rest.
Technology was planned with multiple redundancies so that communication between the command center and patient could be maintained 24/7 without fail, incorporating both internet and cellular communications with battery backup in the event of power failure. Integris Health’s EHR, EPIC, was modified to allow for a seamless flow of bidirectional information.
With the help of Medically Home, vendor agreements were developed for services, such as transportation and mobile imaging, that Integris Health did not directly provide. In some cases, multiple vendors were contracted for the same service to ensure services would always be immediately available.
With about six months of experience, Rother said that patient satisfaction appears to be high (they are still awaiting formal patient satisfaction results), and there have been no hospital-acquired infections. Readmissions are 30% to 50% lower than for traditional hospital inpatients.
Integris Health’s HaH patient capacity is 15 with an average daily census at 10, but as demand continues to increase, capacity will be expanded to 20. Rother anticipated that census will have grown to more than 20 by the end of the 2022. Productive discussions are underway with several commercial payers to include payment for HaH.
To be eligible for HaH care, patients must be admitted for inpatient hospital care, reside within 30 miles of an Integris Health hospital, possess the clinical and social stability to receive hospital level care in the home and have an approved payer source.
An unexpected benefit has been in the area of employee retention. Rother noted that Integris Health’s HaH program provides a practice environment for clinicians that is less physically taxing than working on an inpatient floor.
Regarding lessons learned for other health systems pursing an HaH strategy, Rother offered the following suggestions:
- Consider a technology partner experienced with HaH care.
- Provide dedicated leadership to lead the change effort and optimize the program.
- Engage your clinical leadership, including physicians, to design, implement and optimize your program.
- Develop creative patient transport solutions.
- Develop tools and provide resources to support patient acquisition.
”Hospital-at-Home is an increasingly important component of Integris Health’s continuum of care,” Rother said. “Over this next year, we plan to expand our geographic range and clinical scope of telehealth paired with in-home services to improve the patients’ experience and access to care while driving down the total cost.”