“The data suggests that, for the populations that have been studied in multiple different places, it’s a very safe service to be done and with high-quality care, low readmission rates, low escalation rates, low infection rates,” Dr. Adam Groff, co-founder Maribel Health, told Home Health Care News. “The bottom line is people love it, patients love it and it’s a high-quality care experience.”

Maribel Health is a company that helps health systems modernize and deliver advanced home-based care services through technology. This includes services such as, hospital-at-home care, community paramedicine and other high-acute care models.

In 2020, the hospital-at-home model had its breakthrough. Though the model was common internationally, it was considered niche in the U.S. This changed with the introduction of the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care At Home program.

A recent report from CMS found that the program has been largely successful.

Simply put, the CMS waiver created a mechanism for reimbursement for hospital-at-home care. The lack of straightforward reimbursement had been a major roadblock for the model.

Despite the momentum the model has seen in recent years, challenges still exist when it comes to operations and scalability.

Specifically, less than 9% of waiver-approved hospitals accounted for more than 70% of all U.S. admissions, according to data from MedPAC’s June 2024 report to Congress.

“If you add all the admissions together, it’s less than 1/10 of 1% of the Medicare fee-for-service inpatient hospital admissions across all programs,” Ronald Paulus, president and CEO of Maribel Health, told HHCN. “It’s clear that there is an operational challenge that needs to be overcome.”

Additionally, almost two-thirds of hospitals had zero admissions.

Paulus noted that even with these challenges, there have been some examples of success.

“For example, Mass General Brigham in Boston, where our medical director practices, they’ve achieved a census of about 70 from a number of hospitals,” he said. “UMass is not too far away, it has gotten to a census of 20 with just one hospital. Atrium Health has gotten into the upper 40s, low 50s across multiple sites. There are some inklings of success, but the average hospital at home program in the U.S. that had admissions, averaged only two admissions per week, so it’s not achieving what it can.”

For context, among hospital-at-home operators, an average daily census of five is similar to roughly 50 in the hospice space, and around 250 in home health, Groff noted.

“A hospital-at-home program with only five patients doesn’t sound like a lot, but it’s actually a very complex operation,” Groff said. “If you think about what some of these folks are doing — getting to censuses of 50 or plus, that is a very complicated operation. It requires a lot of new knowledge around operations, and then technology to support it.”

In order for hospital-at-home care to continue to see forward movement, there are a number of pillars that Groff and Paulus believe that providers must embrace.

“In some ways it’s simple, in other ways it’s very difficult,” Paulus said. “One is building a high performing team. The second is having a very clear organizational structure. It can’t be a side job. There has to be a clear leader with ongoing P&L responsibility and oversight. Third, there has to be a relentless focus on growth and optimization. You’re reinventing the program at each increment of census. A program of four is totally different from a program of 12, which is totally different from a program of 26, and so forth.”

Another key pillar is having the right tools and analytics that allows providers to orchestrate all of this.

“Those pillars will be very familiar to home health and hospice operators because that’s how they run their businesses,” Groff said. “On the technology and knowledge front, I think this is a challenge for everybody in the home-based care space.”

Currently, hospital-at-home operators are waiting to see if the CMS waiver will continue on. Without an extension, the waiver is set to expire on Dec. 31.

This year, legislation that addresses the model has been introduced. Paulus is optimistic about the future of the model.

“In our divided world, it seems to be something that has support on both sides of the aisle politically,” he said. “It has a neutral score from the CBO, so that’s very helpful, in terms of a programmatic renewal. We know that patients and consumers have reached out to say that they like this, and they want to have this. If we sit back and think about the demographics of the United States, and how it’s aging, in 2050, the entire [country] is going to look like Florida did in 2020. There aren’t enough buildings to care for all of these people.”

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Hospital at Home (HaH) is a sustainable, innovative and next-generation health care model. From the physician’s perspective, it offers person-centered medical care and keeps patients out of the hospital, away from possible complications and on to better outcomes. However, there are still plenty of challenges for providers to work through.

“People love to have inpatient or acute level care in the comfort of their own home,” Dr. Adam Groff, co-founder of Maribel Health, told Home Health Care News. “The data suggests that for populations studied in multiple areas, [HaH] is a safe service with high-quality care, low readmission rates, low escalation rates, low infection rates and, bottom line, patients love it.”

Maribel Health, based in Hanover, New Hampshire, designs, builds and operates advanced clinical care models in the home and community to expand health system capacity and improve patient access.

While it seems like a win for patients and caregivers, the model has seen growing pains.

“One challenge is clarifying the distinction between HaH care and other in-home health care services like home health or skilled nursing facility (SNF) care,” Heather O’Sullivan, president of Mass General Brigham Home Hospital, told HHCN. 

Based in Boston, Mass General Brigham Home Hospital provides comprehensive home-based care, including chronic, urgent and acute care, directly to patients in their homes.

The structure and implementation of HaH care vary depending on the hospital’s needs, capacity and patient population. Some organizations run the program out of the emergency department and admit eligible patients to their homes. In contrast, others rely on community paramedics or specialty clinics to refer patients to the program.

“While the use of paramedics in health care is not new, the pandemic accelerated the scaling of this workforce to support home-based acute care,” O’Sullivan said. “By incorporating paramedics into the HaH model, we address workforce shortages while enabling health care professionals to practice at the full scope of their licensure. This expansion not only meets the complex needs of our patients, but also ensures that we are using our workforce to its optimal potential.”

The HaH model was introduced at Johns Hopkins in 1995 and was used to manage and treat older patients who refused hospital stays or were at higher risk of hospital-acquired infections.

Early trials of the model found the total cost of at-home care was 32% less than traditional hospital care, the length of stay was one-third shorter and the incidence of complications was dramatically lower.

“HaH can reduce hospital overcrowding and provide care that aligns with patient preferences,” O’Sullivan said. “As health care systems increasingly focus on strategic sustainability amidst a rapidly evolving health care ecosystem, scaling HaH presents a unique opportunity to meet growing patient demand while improving clinical outcomes and satisfaction.”

Though the structure of these programs varies, many commonalities exist. They are well-suited for medium-acuity patients needing hospital-level care, but stable enough for safe monitoring from their homes. They are also suitable for patients with conditions requiring defined treatment protocols, such as pneumonia, congestive heart failure, chronic obstructive pulmonary disease (COPD) or diabetes.

“One of the greatest advantages of this model is that it allows clinicians to enter patient’s homes, offering insights into social and environmental factors that may impact health – insights often missed in a traditional hospital setting,” O’Sullivan said. “This holistic view enables more tailored care.”

The Centers for Medicare & Medicaid Services (CMS) launched the Acute Hospital Care at Home waiver during the pandemic, which created a payment system for HaH through Medicare. Now, the model is popular enough that providers are operating within that waiver – which has been extended to the end of 2024 – but also outside of it.

Launching a program

Novant Health New Hanover Regional Medical Center in Wilmington, North Carolina, began enrolling patients in its HaH program in March. The program is in its early stages and is growing.

“To date, the Novant Health New Hanover Regional Medical Center (NH NHRMC) program has cared for approximately 70 acute patients in their home,” Christy Spivey, senior director of nursing, told HHCN. “Patient experience has been overwhelmingly positive, reaching satisfaction scores of 100%.”

According to Spivey, there have been no unexpected returns to the hospital, and readmission rates are either within or better than those of similar hospitalized patients. Based on the number of patients served at home, NH NHRMC has saved almost 300 in-hospital physical bed days, creating the capacity to keep higher acuity patients in those beds.

“Our health care providers have found great satisfaction in meeting the patient’s needs creatively, allowing the patient to heal in their home environment,” Spivey said. “Often, they find that providing health education is better received by the patient when they are at home. They can also include family members in the plan of care and education, which supports the patients. And the ease of access to the patient via technology makes it easy to see patients from wherever the provider is located.”

Spivey went on to say that patients benefit for many of the same reasons.

“First, they can heal in the comfort of their home, with loved ones, and even pets,” she explained. “They can easily reach a [nurse] or physician by touching a button on a screen if they have a question. Specially trained community paramedics and a physical therapist come to their homes to administer care and therapies, where the approach is tailored to their unique needs.”

Core tenets of the Novant Health program support optimal nighttime sleep, medically ordered meals, and optimized mobility, all tailored to the patient’s unique needs. Pharmacists, case managers, and other care team members can also visit the patient virtually to teach and support the patient’s care plan.

According to Spivey, nationally reported outcomes consistently show patients in these programs have higher satisfaction and lower readmission rates than similar patients who receive care inside the hospital.

Overcoming challenges

To be eligible for the Acute Hospital Care at Home program, patients must meet clinical and social criteria established by CMS. The program has 78 approved diagnoses, including pneumonia, COPD and urinary tract infections.

On Sept. 18, the U.S. House Energy & Commerce Committee approved a bill extending necessary flexibilities to benefit telehealth and hospital-at-home providers.

The Telehealth Modernization Act of 2024 would grant two-year extensions to various telehealth flexibilities implemented during the COVID-19 pandemic. These include continued payment for virtually furnished care services, eliminating in-person or geographic requirements for telehealth providers and supporting audio-only telehealth. These flexibilities are set to expire at the end of this year.

The act would also extend the hospital-at-home waiver by an additional five years. Again, for now, the waiver program is expected to expire at year end.

While the HaH model offers numerous benefits, it also comes with challenges. Significant barriers and limitations exist, including payment reimbursement issues, physician and patient resistance, patient safety concerns and implementation hurdles.

“The single biggest challenge is the looming end of the CMS Hospital Care at Home waiver,” Dr. Stephen Dorner, chief clinical and innovation officer for Mass General Brigham Healthcare at Home, told HHCN. “We need congressional action to extend the waiver and maintain federal support for this incredible care delivery model.”

Regarding challenges to care delivery itself, Dorner said that all health care providers are working to overcome them.

“The first is culture change,” he said. “This is not how people are used to providing or receiving acute hospital-level care, and it takes a lot of time and effort to educate and facilitate buy-in. Then, once people understand the phenomenal quality benefits associated with HaH care and agree to undertake it, the logistical challenges of delivering that care take hold. Orchestrating the complexities of home-based acute care delivery – staff, supplies, patients, equipment, medications, food – can be daunting. Finally, there is a burgeoning market for solutions to these challenges that is waiting on certainty from federal regulators that the waiver will remain in place before activating.”

Most private payers do not cover hospital-level care in the home. Hospitals have had some success with Medicare Advantage (MA) plans and Veteran Affairs (VA), but health systems with insurance plans have a similar opportunity to cover HaH care.

“It’s important for providers to write and call their senators and representatives to let them know they want their support for the continuation of the Acute Hospital Care at Home Waiver,” Dorner said. “When you look at the traditional health care landscape, the growing demand for access, and the ever-longer wait times for care, it’s clear that the status quo is unsustainable. We need new solutions to deliver better care, and HaH is our greatest promise to realize a better future in care delivery.”

The benefits of HaH for patients

Nancy Foster, vice president for quality and patient safety at the American Hospital Association (AHA), told HHCN that she believes people would be surprised at the costs of HaH programs, and the overall benefits.

“We’ve looked at various studies,” she said. “They are comparable to the brick-and-mortar hospital, partly because we use staff time differently. We have staff traveling to the patient and so forth. We need technologies that you might not have to use in the hospital, but that assist with bi-directional communication. So, there are different costs, but the totals are similar.”

Dr. Ronald Paulus, co-founder of Maribel Health, agreed and provided more background.

“The literature is pretty clear that when your emergency department is congested, there’s significant harm that accrues to patients, including excess mortality,” Paulus told HHCN. “So, anything that improves the throughput of my emergency department and inpatient floors is a good thing from a safety perspective. But it is also good from an economic perspective. If you look at how HaH has been studied, it’s been shown to reduce direct costs by just under 40%. It’s at least 20 times more capital efficient, and when the program is run effectively, it can generate double digit EBIDTA margins.”

Standing up a HaH program requires logistical and technical work, which requires time, staff and budget. Some hospitals have partnered with companies that can provide the technology, manage logistics or provide care coordination to facilitate the implementation of a HaH program.

According to O’Sullivan, to support the growth of this model, organizations must continue to focus on expanding the health care workforce and address gaps in education.

“This includes initiatives like industry and academic partnerships to create new career opportunities for students and the innovative use of a broad professional team in the home hospital model,” she said. “We are working closely with educational institutions to address gaps in standardized curricula, ensuring that the future health care workforce is well-prepared to meet the new and undefined demands of this growing model.”

Before the pandemic, there was skepticism that the quality of care provided at home would be as good as in the hospital. This could be changing. As patients are reluctant to go to the hospital and telehealth capacity is growing, HaH care is becoming a more desirable option for providers and patients.

“Growth can be achieved by demonstrating the success of HaH models, advocating for legislative support and continuing to innovate in care delivery,” O’Sullivan said. “At Mass General Brigham, we’ve reached 70 beds in our Home Hospital program. Our pilot program has evolved into a core service, delivering high-quality, patient-centered care at home. Research has consistently shown that patients and caregivers prefer this model due to its proven outcomes and an overall positive experience for all involved.”

Spivey said that overcoming barriers and limitations is an ongoing internal and external process, and that growth depends on the customer’s voice.

“As more people hear about the program, they ask their physicians if they can be included, which will provide more momentum,” she said. “We provide internal education and presentations to physicians, nurses and other team members. Case managers have worked to integrate screening processes into daily patient rounds. Screening protocols for the team have been honed to support more rapid identification of patients, including optimizing the electronic medical record to create patient lists based on inclusion criteria. Also, including family in the initial discussion about the program is critical. If the patient or family is uncomfortable with care in the home, they can decline participation. For those who consent to participate, it is clear that if they become uncomfortable while receiving care in the home, the team will work with them to address the issue or bring the patient back to the hospital, if necessary.”

Dorner said the most significant opportunities for HaH are better patient care, job satisfaction and value.

“We know that the quality of HaH exceeds traditional brick-and-mortar hospital care for the patients who can safely receive care at home,” he said. “We also know that clinicians who join HaH, either as part of a diversified traditional clinical portfolio or as their full-time job, report increased job satisfaction. Some of these clinicians, who otherwise would have left health care at the end of the pandemic, have found the clinical care of HaH to provide more fulfilling, deeper connections to patients, which is why many of us joined health care in the first place. All in all, there’s better value associated with HaH care, and delivering greater value at a greater scale presents a spectacular opportunity for health care across the United States.”

According to O’Sullivan, there is immense potential for health care system transformation using the HaH model.

“HaH can reduce hospital overcrowding and provide care that aligns with patient preferences. As health care systems increasingly focus on strategic sustainability amidst a rapidly evolving health care ecosystem, scaling HaH presents a unique opportunity to meet growing patient demand while improving clinical outcomes and satisfaction,” she said.

Dorner added that there’s a clear upside to investing in the growth of this care delivery model, given the long-term regulatory and financial certainty that will increase patient awareness of the HaH model’s benefits, as well as the hospital’s willingness to break out of the mold and do something innovative.

“Increasingly, we will see improvements to equipment becoming more modular, portable and interconnected,” he said. “We’ll see software solutions to care orchestration to make moving equipment and services across a broader geography seamless. Eventually, this will be the primary method of caring for many conditions that require hospitalization today, and society will greatly benefit from it.”

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The big idea behind Maribel Health is that patients want to receive care in their homes, but hospitals and health systems don’t always have the tools to make this happen, according to Dr. Adam Groff, co-founder of the company.

“Maribel Health is all about bringing subject matter experts, professional services and technology to help connect the hospitals, physicians, clinics, and home health care operators together,” he told Home Health Care News. “We can do this through a variety of ways, different kinds of clinical programs, but where we started is in the acute-care-at-home space.”

This includes services such as, hospital at home, community paramedicine, and other high-acute care models that extend past the capabilities of just hospital at home.

In order to accomplish this, Maribel Health has assembled a team of experienced health care clinicians, operators and technologists that understand the health care system from multiple angles.

Currently, the company has founding anchor partnerships with Mercy Health System and Bayada Home Health Care.

“With Mercy, we are building what will be an over 200-bed hospital-at-home program across several of their hospitals,” Groff said. “Bayada has a number of deep joint ventures with health systems, and we’re bringing additional advanced clinical capabilities into those deals, so that the home health and hospice operation can more completely serve the needs of their JV partners.”

Bayada CEO David Baiada calls the partnership a clear opportunity to think “actively and innovatively” about how to move more care into the home.

“Every hospital that we work with, whether it’s in a strategic relationship, or in a joint venture partnership, is wrestling with this challenge of moving higher-acuity care into the home for lots of different reasons,” he told HHCN. “We feel like part of our responsibility, as a good partner, is to bring next generation thinking to those relationships, and Maribel Health is a great example of this.” 

As far as reimbursement, Maribel Health works with partners that have contracts with payers in place.

On its end, completing a $25 million funding round will allow Maribel Health to attract talent and grow out the company’s team. It will also allow further development of its technology platform.

“It allows us to bring in more really experienced and talented people who understand the intersection between health systems and home- and community-based operators, and we can enable advanced care in the home through our technology,” Groff said.

For the moment, Maribel Health’s main goal is to help its partners see success.

“The other partners that we’ll announce in the near future all share the vision that we do,” Groff said. “The vision that home- and community-based care of the future will have much more advanced clinical capabilities and technology.”

Looking further ahead, Maribel Health’s goal is to identify and develop relationships with those additional partners.

“Organizations, whether they’re hospitals, clinics, or home health care operators, are all facing some of the same constraints, which is lots of demand, but lack of capacity,” Groff said. “At the same time, you have huge advances with things like artificial intelligence and robotics. We see an inevitable push to give patients more tools and services that allow them to stay at home and in the community.”

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