As part of the study, Dr. Bruce Leff and his study co-authors examined the prevalence, characteristics, predictors, health service use, and mortality outcomes of 2,435,519 homebound Humana Inc. (NYSE: HUM) MA beneficiaries in 2022.

“We thought it would be useful to understand if this population exists in MA, because if it does, then we need to be thinking about how to optimize care for these people, and make sure they get the care that they need, and make this somewhat invisible population visible,” Leff, a professor of medicine and director of the center for transformative geriatric research at Johns Hopkins University School of Medicine, told Home Health Care News.

The researchers found that the prevalence of homebound individuals was 22%.

Additionally, researchers found that homebound status was independently associated with greater health service utilization and mortality.

“One thing that the study demonstrates is that being homebound is a very powerful predictor of poor outcomes, whether it’s emergency department visits, or inpatient admissions into the hospital, or skilled-nursing facility admissions or death,” Leff said.

What’s more, Leff and his colleagues were surprised to find out that homebound status was an independent risk factor.

“Beyond people having certain chronic conditions, beyond people being frail, it was still an independent risk factor for facility-based utilization and death, and that to us, spoke volumes,” he said. “We thought it would be in the mix, but were a little bit surprised by just how powerful a predictor it was. When MA plans are doing in-home wellness assessments, they’re asking a lot of questions, some of which are likely required by CMS, but adding a single question on homebound status might be really valuable.”

Arming MA plans with this knowledge could potentially encourage them to seek stronger partnerships with home-based care providers looking to enter partnerships.

Leff pointed to the study’s findings as an indicator that these types of collaborations are necessary.

“What this study suggests is the need for health systems and MA plans to collaborate with entities that know how to do things in the home, and that might be skilled home health care companies — and we’ve seen MA buying out some of the big players in the space — or it might be home-based primary care practices,” Leff said.

Leff also noted the opportunity to bring together home-based palliative care, hospital at home, skilled nursing facility care at home, home health care and home-based primary care – all as a part of a larger home care ecosystem.

“In the future, we’re going to be doing a whole lot more at home, and the hospital will become a big ER, OR and ICU,” he said.

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The past few years have been a time of transformation for the hospital-at-home model. As it cements its popularity, new players have begun to rise with it.

While hospital at home has long been embraced across the globe — in Australia, Canada and across Europe, for example — the model popped up in the U.S. in the 1990s. That’s when Dr. Bruce Leff conducted a successful pilot trial.

Those trials found the total cost of care was 32% lower than brick-and-mortar hospital care. They also found that the mean length of stay of hospital-at-home programs was one-third shorter.

Home Health Care News explores the model further and profiles a few of the key emerging players in this HHCN+ exclusive report.

The case for hospital at home

Over the years, robust evidence has emerged from numerous studies on the effectiveness of the hospital-at-home model – on cost efficiency, medical outcomes and more.

A 2018 study conducted by researchers at the Icahn School of Medicine at Mount Sinai found that hospital at home achieved shorter average lengths of stay compared to traditional in-patient care, at 3.2 days compared to 5.5 days, respectively.

The same study also found that the model significantly lowered rates of hospital readmissions and emergency department visits.

In 2020, another study published in the Annals of Internal Medicine found that the costs for patients receiving hospital-level care in the home were 38% lower. Researchers also found that these patients were less sedentary and had lower readmission rates within 30 days.

The hospital-at-home model has also shown promising results in the area of cancer care.

Traditionally, cancer care delivery takes place in brick-and-mortar facilities exclusively. This is also slowly beginning to change.

A 2021 study published in the Journal of Clinical Oncology found that an in-home cancer care model led to a 55% reduction in unplanned hospitalizations, with 47% lower costs.

Hospital-at-home roadblocks

Despite the evidence of hospital at home’s effectiveness, two major roadblocks have impeded the model’s widespread adoption.

One of these roadblocks is the cultural norms of health care in the U.S., and hospitals and health systems acting as gatekeepers resistant to change.

“It’s sort of the difference between understanding you need to change, knowing how to change and making the change, because some things are just so hardwired into systems,” Leff previously told HHCN. “Rewiring health care, health care delivery and attitudes — all of that is hard.”

In addition to being a pioneer in the U.S. hospital-at-home space, Leff is a geriatrician, a professor of medicine and director of the Center for transformative geriatric research at Johns Hopkins University School of Medicine.

The other major barrier is the lack of a clear path to reimbursement. This is especially notable because, for potential hospital-at-home operators, setting up shop can be a costly and time-consuming endeavor when an organization doesn’t have the right resources or infrastructure in place, according to a recent report by Chilmark, a Boston-based health care research firm.

The path to reimbursement began to open up in 2020. At the time, the U.S. Centers for Medicare & Medicaid Services (CMS) announced its Acute Hospital Care At Home program.

The CMS waiver program was a COVID-19 relief measure that allowed operators to receive payment for delivering care in the home when hospital capacity was stretched extremely thin.

The waiver has been a major game changer.

Currently, there are at least 125 health systems and 290 hospitals across 37 states approved to work under the CMS waiver. This doesn’t include the many operators that are providing care outside of the CMS waiver, of course.

Over the years, operators such as Contessa Health, DispatchHealth and Mount Sinai have positioned themselves as stalwarts in the hospital-at-home movement.

Still, the CMS waiver program was never meant to be permanent, which means that reimbursement could again become uncertain in the future.

In May, the public health emergency officially came to an end, taking with it many of the flexibilities that kept providers afloat during the height of the pandemic. However, the Acute Hospital Care At Home waiver has been extended until 2024.

Aside from cultural and reimbursement barriers, there are other challenges as well.

For one, providers need to have a consistent amount of patients admitted at any given time for their programs to remain sustainable.

Plus, internet and cellular connectivity remains an issue in some remote areas, the Chilmark report noted.

It’s sort of the difference between understanding you need to change, knowing how to change and making the change, because some things are just so hardwired into systems.

Dr. Bruce Leff of Johns Hopkins

The market’s big players

In recent years, companies that have been able to help partners implement or improve their hospital-at-home programs have become beneficiaries of the movement.

One of these companies is Inbound Health — an enablement platform that helps health systems and health plans develop high-acuity at-home care programs, including hospital at home.

“We bring all of the enablement capabilities that health systems need to launch and scale these programs,” Inbound Health CEO Dave Kerwar told HHCN. “That’s the care model, which we’ve now scaled to 6,000 different patients across 350 disease states. It’s a custom developed technology, an analytics platform. A proprietary platform we built specifically for the hospital-at-home and SNF-at-home care models.”

Originally under the Allina Health umbrella, Inbound Health spun off and became a separate entity last year.

For Inbound Health, being a high-acuity care enabler also means bringing supply chain, labor and logistics partners – as well as a machine learning analytics platform and an operations unit – to the table.

The company also helps its partners navigate reimbursement.

“We’ve created contracts with commercial and Medicare Advantage payers, and we have a replicable process we go through to be able to ensure that our health system customers get on contract so that they can be reimbursed for hospital-at-home care episodes,” Kerwar said.

When Inbound Health got started, the company had an average daily census of between five to 10 patients.

“We’ve quintupled that over the last three years,” Kerwar said. “Our average daily census is in the low 50s. We achieved this by creating a care model that was very deeply integrated into the clinical and operating workflow of the health systems we serve.”

More recently, Inbound Health expanded its services to include post-surgical care for general surgery, including orthopedics, bariatrics and hernia. This was a move to address hospitals and health systems’ capacity constraints.

In Kerwar’s view, the biggest question that remains is what the future of reimbursement looks like.

“We fully expect, given the excitement regulators have about this care model, that this will become a permanent payment model under the CMS benefit structure,” he said. “What we don’t know is exactly what it will look like, in terms of rates and requirements.”

Hospital-at-home unicorns

Biofourmis made waves when it surpassed what’s known in the startup world as unicorn status — a valuation at over $1 billion — last year when it raised a $300 million funding round.

The recent evolution of the company has been drastic, according to Kuldeep Singh Rajput, the CEO and founder of Biofourmis.

“We have truly evolved the company into a technology-enabled care delivery company,” he told HHCN. “Our focus is around how we deliver virtual care using a command center. How do we coordinate and deliver enhanced services — phlebotomy, DEM, infusion — all delivered into the patient’s home?”

Biofourmis was founded in Singapore back in 2015. The company’s U.S. offices are headquartered out of Boston.

As a company, Biofourmis has two main verticals. There’s Biofourmis Care, which is focused on care delivery across the continuum — managing post-acute and complex chronic care patients. The company leverages software and data science, along with clinical care teams, to deliver care virtually in the home.

The other segment of the company is focused on the pharmaceutical sector.

In its first year as a company, Biofourmis had seven health system partnerships under its belt. Today, that count is at roughly 60.

Rajput believes that Biofourmis’ value-add is helping its partners streamline their clinical workflows and reduce the fragmentation of point-of-care solutions.

“One of the biggest pain points for health systems is that with all of these digital tools and technologies, there’s a lot of fragmentation in the marketplace,” he said. “Hospital systems are certainly frustrated because of all these point-of-care solutions. They want to work with a partner that enables configuration of different care pathways, configuration of care continuum and acuity on a single platform.”

Infrastructure is still needed

Current Health has also gained strong momentum over the years as more health systems made moves to provide hospital at home, eventually catching the eye of Best Buy (NYSE: BBY). The electronics retail giant purchased the company in 2021.

“Current Health had our best commercial year ever after the acquisition,” Current Health CEO and co-founder Chris McGhee told HHCN. “Best Buy, through Geek Squad, has an entirely unique capability in the market to cross that final mile and go across the threshold into the patient’s home and support that individual with the technology, ensuring that the nurse or the doctor isn’t becoming IT support.”

Based in Boston, Current Health offers a platform equipped with remote care management, telehealth and patient engagement tools to help health care providers conduct at-home care, including hospital-at-home care.

Currently, the company holds upwards of a quarter of the U.S. hospital market, according to McGhee. 

The extra layer of support that Best Buy and Geek Squad offer the company has helped more patients receive care under hospital-at-home programs.

Looking ahead, McGhee believes the infrastructure around hospital at home will need to continue to grow in order for the model to continue progressing. 

“We as a society have spent trillions of dollars building up the infrastructure around the hospital, ​​making it possible within the electronic health record for us to admit a patient to the hospital with one click,” he said. “That is not the case today within the hospital-at-home market. We – as enablers, technology companies, hospitals, health systems and other partners in the space – have to collectively build up that infrastructure and make it easier to enroll and manage patients in these programs.”

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The report highlights BPC’s recommendations for the U.S. Centers for Medicare & Medicaid Services (CMS) on how to improve home health services for Medicare fee-for-service beneficiaries.

“Given the clear changing trends in our health care delivery system today and the increasing demand for home-based care, there are opportunities to address the current Medicare home health program, which we think does create some inequities and barriers to those who need care in their home,” Bill Hoagland, senior vice president at BPC, said during a panel discussion on the new report on Thursday. 

BPC is a Washington, D.C.-based think tank that is focused on presenting policy solutions in a number of key areas, including health care. 

In 2019, Medicare spent almost $18 billion on home health services and served about 3 million fee-for-service beneficiaries.

Still, the Medicare home health benefit does not sufficiently address the needs of beneficiaries with multiple comorbidities or complex conditions. This is largely due to the fraud and abuse guardrails, according to the report.

“A history of fraud and abuse in the home health sector has been a key driver of policymaking decisions,” BPC wrote in the report. “The Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare payment policy, has regularly highlighted program integrity issues related to home health services. In response, Congress and the U.S. Department of Health and Human Services (HHS) have worked to curb overutilization of home health services, uncovering multimillion-dollar fraud schemes in the process.”

While the increased oversight helped to decrease inappropriate care, an uptick in audits and medical necessity denials also made it more difficult for Medicare beneficiaries with complex needs to receive care services, according to the report.

The updates that have been made to payment policies also play a role in limiting access to care. Specifically, CMS changed the home health payment methodology to move away from therapy-based thresholds.

“[Therapy-based thresholds] were really a major contributor to a lot of that fraud and abuse we saw in the former system,” Ruth Katz, senior vice president of public policy and advocacy at LeadingAge, said during the discussion. “You used to have agencies avoiding patients who didn’t need therapy visits, working hard to find reasons for more therapy visits, so they could bump up their payments. CMS also reduced the length of episodes by half, from 60 to 30 days, and reduced payment for subsequent home health periods. That meant people who needed more support for longer periods of time could be left high and dry.”

Katz also noted that the end of Requests for Anticipated Payment (RAPs) has also been tough on providers, especially not-for-profit agencies that are operating on thin or non-existent margins. These providers may be hesitant about taking on patients that have complex care needs, she said. 

The report also found that the structure of the home health benefit has contributed to racial and ethnic disparities.

“Black Medicare beneficiaries and Hispanic Medicare beneficiaries more often experience [start of care] delays than their white counterparts,” Chanee Fabius, assistant professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, said. “We need to examine the reasons behind either refusal or denial, and what sort of information is communicated from hospitals and nursing homes to home health agencies.”

Being unable to access home health services places Medicare beneficiaries in untenable positions, according to Gretchen Jacobson, vice president of Medicare at the Commonwealth Fund.

“For most beneficiaries, the assistance from home health aides is often needed to make skilled care at home a real option,” she said during the panel discussion. “Without coverage of home health aides, beneficiaries either pay out of pocket for that care, which many beneficiaries cannot afford to do, or rely on unpaid caregivers – like spouses or their children – which many beneficiaries don’t have. Or, they are forced to receive care at a nursing home or other institution.”

BPC recommends that CMS streamline coverage and eligibility determinations and adjust quality and payment incentives.

Additionally, the organization recommends that CMS improve beneficiary and caregiver experience and optimize service availability, including establishing staffing standards.

“Standards can always be helpful, particularly if they’re flexible and recognize a variety of different scenarios and situations that they can help normalize and communicate with the expectation of service delivery for home health agencies,” Anne Tumlinson, CEO of ATI Advisory, said.

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Many of the provisions that have allowed health systems and home-based care players to treat patients in their homes during the COVID-19 crisis are tied to the public health emergency (PHE). The worry is that when the PHE expires in December, progress will be lost.

The founding members of the coalition were Medically Home, the Mayo Clinic and Kaiser Permanente, the latter two of which invested $100 million in Medically Home – a hospital-at-home enabler – earlier this year.

Additional member organizations of the coalition include Adventist Health, ChristianaCare, Geisinger Health, Integris, Johns Hopkins Medicine, Michigan Medicine, Novant Health, ProMedica, Sharp Rees-Stealy Medical Group, UNC Health and UnityPoint Health.

Johns Hopkins is widely seen as the pioneer of the original hospital-at-home model in the U.S.

“Over the course of the last year and a half, multiple systems have gotten 1,000 or more patients enrolled in these programs,” Dr. Stephen Parodi, the executive vice president of The Permanente Federation, told Home Health Care News. “We know that the waivers are tied to the PHE, whether it gets extended or not. But once that PHE expires, many of these programs are going to be facing a regulatory cliff.”

The Oakland, California-based health care giant Kaiser Permanente is both a provider and health plan. The organization – which The Permanente Federation is a part of – currently serves 12.2 million members from over 600 locations in eight states and the District of Columbia.

The health system has cared for hospital-at-home patients through the Centers for Medicare & Medicaid Services’ (CMS) “Acute Hospital Care at Home” waiver and another advanced care model over the last year and a half.

The coalition – which is similar to the Moving Health Home coalition, albeit with different home-based care goals – wants to set more permanent pathways for hospital-at-home care moving forward. Specifically, it would like to see The CMS Innovation Center test acute-care-at-home delivery models.

“We collectively think that it’s important that these programs are allowed to continue while we develop the appropriate guardrails and a measurement strategy for being able to put together a demonstration project,” Parodi said. “Then, we’d be able to show the value of these programs from a quality, safety, satisfaction, equity and also financial perspective.”

There are currently 77 health systems and 177 hospitals in 33 states approved for Acute Hospital Care at Home, according to CMS. The waiver has allowed health systems to open up space for COVID-19 patients in hospitals and also be properly reimbursed for hospital-level care at home during the pandemic.

While insiders are confident some sort of extension of the waiver will come to fruition, some health systems see problems with the waiver that need to be addressed before anything becomes official.

The coalition’s goal is to not only advocate for more hospital-level care at home, but also to point lawmakers in the right direction when developing a demonstration.

“By proving we can provide high-quality acute care outside of a hospital building, we have turned on its head the notion of where patients with serious or complex conditions can be cared for,” Michael Maniaci, the physician leader for advanced care at home at Mayo Clinic, said in a press release. “By further developing a nurturing policy landscape, we can advance the well-being of patients by catalyzing innovative, collaborative, knowledge-driven models to redefine the standard of high-acuity care that meets each person’s unique needs.”

More than anything, this has to do with the patients and the new type of care they’ve been exposed to during this unique period, Parodi said.

“We’ve seen significant uptake,” he said. “Patients are able to recover faster, and they’re able to get additional services beyond the hospitalization in a more seamless fashion, without the transition that you would have from a brick-and-mortar hospital to another venue of care.”

If patients need to transition from acute-level care to post-acute, for instance, that can all be done in the home. And it can be done without patients having to lay in a hospital bed for days while their health deteriorates, only to be moved again to another setting.

Kaiser Permanente’s patients, on average, have rated its hospital-at-home programs at 4.9 out of 5, a number “you just can’t match” elsewhere, Parodi said.

A demonstration, or a more future-facing version of the waiver, would allow for more specific measurements and baselines of success for hospital-at-home participants, the coalition believes.

It would also allow for other providers, such as home care and home health organizations, to get involved.

“I do think home-based organizations stand to benefit,” Parodi said. “Even with the existing programs, there’s sort of the advanced care part, which is the classic, hospital-level care. But then the patient progresses, and some of them get better enough that they can be discharged from the program altogether. But some patients still need additional help. They may need classic home health services or other services that, if they don’t get them, they may end up back in the hospital. … So we welcome the expertise of a classic home health agency to be able to inform on what that seamless transition looks like.”

Hospital-at-home has advanced “light years” during the pandemic, Parodi said.

Many of the involved health systems were already putting together focus groups prior to COVID-19 to start – or advance – these types of programs, but the actual experience has been invaluable.

A halt to the flexibilities that have been offered to providers during the pandemic, however, could be damaging, which is why the coalition was created now.

“This model will finally allow underserved patients safe and cost-effective access to care that is long overdue,” Rami Karjian, the CEO of Medically Home, said in the press release. “We look forward to working with Congress to expand access to this safe and effective model of care delivery.”

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The creation of CMS’s wavier — a COVID-19 relief measure — has created a path forward for hospitals already working in the in-home care space, as well as those looking to enter for the first time. Despite widespread interest, some hospitals are still gun shy, focused more on their brick-and-mortar operations than the hospital-at-home concept.

Although it has been around for a while, the hospital-at-home model seems tailor-made for the current time.

Generally, hospital-at-home programs attempt to provide acute, hospital-level care in the home as an alternative to hospital admission, which can be costly. To do so, programs try to identify eligible patients whose medical conditions can be cared for in the home setting through coordinated nursing and clinician visits, plus necessary testing and treatment.

The hospital-at-home model falls in line with the growing preference for home-based care and the move away from institutional settings.

Furthermore, the COVID-19 emergency has emphasized the importance of decentralizing the way that care is delivered.

In some shape or form, the hospital-at-home model has existed for more than 20 years, though in that time reimbursement remained a major roadblock that limited the widespread adoption of the model. Even now, there is no permanent mechanism in fee-for-service Medicare to pay for these services.

Dr. Bruce Leff, a professor at the Johns Hopkins University School of Medicine, believes that CMS’s wavier is a good first step when it comes to addressing hospital-at-home reimbursement.

“I think CMS wanted to develop something that was relatively simple, relatively understandable, relatively uncomplicated in terms of what the payment would look like,” Leff told Home Health Care News. “What they chose to do is basically create a process where hospitals that could attest to being able to provide hospital-at-home services … would be able to get paid a standard hospital DRG payment in a fee-for-service context.”

World-renowned Johns Hopkins has been exploring the hospital-at-home model since the early 1990s. Johns Hopkins doesn’t currently operate a program, but the organization is generally considered to be a pioneer in the space.

As of March 16, 109 hospitals in 29 states have been approved for the CMS waiver. Just a handful of participants were approved when the initiative was first announced.

CMS’s wavier resolves what many health care experts believe was one of the biggest challenges surrounding the model, but some hospital leaders are likely wondering how long this will last.

“If CMS doesn’t create a method to either make the current waiver permanent or come up with a new form of payment that goes beyond the public health emergency, the current payment will expire,” Leff said. “There may be some systems that are saying, ‘I don’t know if I want to make changes in our health care delivery when it’s possible that the payment will only last for the duration of the public health emergency.’”

Indeed, setting up and maintaining a successful hospital-at-home program is no easy task. Moving into this space requires an organization to have a strong clinical staff and operational support in place.

“Having high-acuity care in the home is such a transformation for the hospital systems,” Rami Karijan, Medically Home’s CEO, told HHCN. “It’s not for the faint of heart.”

Offsetting some of the more daunting aspects of setting up a hospital-at-home program has created space for companies like Medically Home, which has raised tens of millions of dollars since launching.

Boston-based Medically Home has built a model that allows organizations to provide acute services in the home. To do so, Medically Home helps its partners coordinate in-home clinician visits, in addition to any necessary technology, equipment or other supplies.

“There are 18 different services patients receive in the hospital today that need to be configured to go into the home 24/7, within an hour’s notice, with great levels of care and quality,” Karijan said. “Getting that ecosystem — we call it acute rapid response — set up within a city or state is really hard work. It’s not a side project.”

Another reason some hospitals might be holding off when it comes to hospital-at-home programs is the overall culture of health care. Leff, however, believes that this will eventually change.

“My own sense is that in the future, what we call the hospital now is going to end up being a big emergency room, operating room and intensive care unit,” he said. “I think everything else will ultimately end up getting pushed out to the home and community. I don’t know if that’s 10, 20, or 30 years from now, but I think everything will start to move in that direction. But you do see powerful forces that always want to bring things back to what they were.”

It’s hard to know what CMS’s next move will be, but officials will probably factor hospitals’ performance under the wavier into any decision-making about the future.

“I think that CMS will be trying to evaluate the experience of the waiver,” Leff said. “I think they’re thinking about a lot of the future issues and how to take advantage of the changes that came in the wake of the pandemic.”

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As part of the study — led by Brigham and Women’s Hospital and Partners HealthCare System — researchers conducted a randomized controlled trial that included 43 hospital-at-home patients and 48 patients receiving traditional hospital care between June 2017 and January 2018.

Overall, researchers found that only 7% of hospital-at-home patients were readmitted within 30-days. On the other hand, 23% of patients receiving traditional hospital care were readmitted within 30-days.

Aside from lower rates of readmission, hospital-at-home patients were also less sedentary and spent less of the day lying down.

“Perhaps patients who receive acute care at home are less likely to develop ‘posthospital

syndrome’ because they sleep better; eat better; walk more; and become less deconditioned, malnourished, and sedated,” the researcher wrote in the study. “Discharge planning may also be more effective at home because it occurs where patients and caregivers will be carrying out postdischarge tasks and can be tailored to the home environment.”

Furthermore, researchers also found that, compared to traditional patients, hospital-at-home patients had fewer laboratory orders, imaging studies and consultations.

Additionally, hospital at home was 38% less costly than traditional hospital care.

Researchers noted that the patients who took part in the study had a variety of conditions and that the study only examines a small sample size.

In-home care has long been recognized for its ability to curb costs and lower hospital readmission rates. With that in mind, many health systems and organizations launched hospital-at-home programs in 2019.

Despite how underutilized hospital-at-home programs are in the U.S., mainly due to tricky reimbursement barriers, studies have consistently touted the benefits of the model.

For instance, other studies have found that hospital-at-home care achieves shorter average lengths of stay compared to traditional in-patient care, at 3.2 days compared to 5.5 days. Hospital-at-home models have also been found to have lower rates of emergency department visits, according to researchers at the Icahn School of Medicine at Mount Sinai.

“[Studies have shown that] at six months after treatment, 50 people treated in hospital at home, one more [patient] is alive than they would have been if they had all been treated in the hospital,” Dr. Bruce Leff, a professor of medicine at the Johns Hopkins University School of Medicine, said while speaking at the 2019 Home Health Care News Summit in October. “You think about the drugs that now command six-figure prices, [some] don’t come anywhere close to that.”

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Generally, hospital-at-home programs attempt to provide acute, hospital-level care in the home as an alternative to hospital admission, which can be costly. To do so, programs try to identify eligible patients whose medical conditions can be cared for in the home setting through coordinated nursing and clinician visits, plus necessary testing and treatment.

Even though hospital at home isn’t as prominent domestically as it is abroad, the past decade has seen organizations such as Highmark Health, DispatchHealth and others adopt the model.

Since the beginning, world-renowned Johns Hopkins — headquartered in Baltimore — has emerged as a pioneer in the space. Though Johns Hopkins doesn’t currently have an operational hospital-at-home program, the health system has been exploring the model since the early 1990s.

“I started working on hospital-at-home back in 1994,” Dr. Bruce Leff, a professor of medicine at the Johns Hopkins University School of Medicine, told Home Health Care News. “We did all of the development of the theory of the model, the background of the model, literature to support the model and we did the work to develop patient selection criteria.”

Additionally, Dr. Leff and the Johns Hopkins team spearheaded the work of figuring out what patients wanted from a hospital-at-home model, as well as clinical pilots.

As someone that has been at the forefront of the hospital-at-home model for the past 25 years, Leff has seen major progress in recent years.

“The amount of interest over the last year or two, especially in the last six to nine months, has been incredible,” he said. “I get anywhere between half a dozen and a dozen unsolicited emails or calls from health care leaders around the country wanting to learn more about hospital at home — and whether it is something their organization should be thinking about.”

Overall, interest in the model has been “exploding” from payers, health systems, “blue-chip” health industry leaders, physician groups, tech entrepreneurs, medical device companies and home health providers, according to Leff.

“Part of the reason why there has been a lot of interest lately is hospital capacity issues, the high cost of care and people not wanting to build new hospitals,” he said.

Health systems taking notice

Currently, Johns Hopkins coordinates research on hospital at home and has helped a number of health systems implement programs by providing advice and technical assistance.

In the midst of this up-and-coming era for hospital-at-home, additional companies have started to make their mark as well. Contessa, for example, helps its health system partners implement hospital-at-home programs while proving the model can be profitable.

Founded in 2015, Nashville, Tennessee-based Contessa calls its model “Home Recovery Care.” Again, Contessa’s hospital-at-home model is designed to provide hospital-degree care in the home at a more efficient cost.

Today, Contessa has partnerships with Marshfield Clinic Health System, CommonSpirit, Mount Sinai, Ascension Saint Thomas and Prisma Health. The company landed many of those relationships within the past year.

“Based on the interest that we have received, it’s pretty clear that health systems have taken notice,” Dr. Mark Montoney, chief medical officer at Contessa, told HHCN. “This is a model of care that is not only of interest to them, but they recognize this as a growing trend.”

One of Contessa’s most recent partners is Highmark Health, the Pittsburgh-based parent company of Highmark Inc., Allegheny Health Network and HM Health Solutions. The company is the second-largest integrated health care delivery and financing network in the United States based on revenue.

The companies teamed up on a joint venture in November. The JV gives select Highmark Inc. commercial health plan members access to hospital-level care in their homes, including telemedicine, in-home care and care management oversight.

“Right now is a good time to enter into the hospital-at-home model,” Monique Reese, senior vice president of home- and community-based services at Highmark, told HHCN. “Reducing any kind of unnecessary hospital readmissions and hospital-acquired infections became really important to us.”

Additionally, the appeal of value-based care over volume-based care attracted Highmark to this venture, according to Reese. In other words, Highmark was looking for the opportunity to move into more value-based models, the organization is currently utilizing a risk-based model.

Round peg, square hole

Despite the hospital-at-home model making major inroads, some major roadblocks to widespread implementation still exist.

Reimbursement barriers loom largest on this list of roadblocks, as there is no mechanism in fee-for-service Medicare to pay for the hospital-at-home model.

In the case of Contessa, Medicare Advantage (MA) has become one answer to reimbursement barriers in fee-for-service Medicare.

“We focused pretty extensively on the Medicare Advantage health plans because we knew that they had the decision as to whether or not we are reimbursed for a program,” Travis Messina, co-founder and CEO of Contessa, said at the HHCN Summit in September. “If you pick markets where there is high density in relation to MA enrollment, you could treat a credible number of patients, which could support a scalable model.”

Aside from reimbursement challenges, the general culture of health care presents a major roadblock, according to Leff.

“Hospital-at-home is still a bit of a round peg trying to get into a square hole,” he said. “A lot of health systems want to do things differently, but they don’t know how to do it. This is because things get hardwired in systems, bureaucracies are created, people get protective over their jobs, and it becomes difficult.”

But hospital at home’s sudden upward swing in 2019 is unmistakable. Joining the ranks of Contessa this year was Denver-based DispatchHealth, which launched its own hospital-at-home program as part of the startup’s continued evolution.

Founded in 2013, DispatchHealth works alongside in-home nursing care providers, offering mobile high-acuity services and urgent care in 18 markets across the U.S. In December, the company launched a hospital-at-home program to offer advanced care in the home for patients in the Denver market.

“Over the years we’ve looked at opportunities to be able to provide even more value for our payer partners, provider partners and patients,” Kevin Riddleberger, co-founder and chief strategy officer at DispatchHealth, told HHCN. “We saw an opportunity where, if we wrapped more advanced level of care around these patients, we could continue to treat them in the home, versus having to send them to the emergency department and ultimately admitted to the hospital.”

DispatchHealth’s hospital-at-home program is still relatively new, but expansion plans are already being discussed, according to Riddleberger.

“In the grand scheme of things the hospital-at-home market is small,” Riddleberger told HHCN. “No one has been able to scale it and that’s where we have a tremendous opportunity, having 18 markets across the country. I’m very bullish, moving forward.”

The post Payer, Health System Interest in Hospital-at-Home Models ‘Has Been Exploding’ appeared first on Home Health Care News.

Among the latest is thanks to LHC Group Inc. (Nasdaq: LHCG), which teamed up with South Louisiana Community College (SLCC) to form a new home health lab that will expose college nursing students to the field. The lab — first announced at the end of August — will begin in spring 2020.

In terms of partners, there’s perhaps none better than the Lafayette, Louisiana-based LHC Group to launch a home health lab. The company has both a robust history and scale, as its 32,000 employees currently deliver home health, hospice, personal care and facility-based services to patients throughout 36 states.

SLCC is a community college that serves more than 15,000 students annually and operates campuses in Abbeville, Crowley, Franklin, Houma, Lafayette, Morgan City, New Iberia, Opelousas, St. Martinville and Ville Platte in Louisiana.

As part of the partnership, SLCC has set up a lab that recreates the home, including a living room, bedroom and bathroom. The lab is on SLCC’s campus in Lafayette and will allow nursing students to immerse themselves in the home setting as part of their training.

The lab utilizes donated items such as beds, tables, chairs, walkers, nursing bags and clinical and personal items to set a stage for prospective home health workers. Additionally, LHC Group has provided medical equipment such as vital sign monitors and scales.

LHC Group’s role in the partnership came from a sense of duty the organization felt toward taking an active role in developing and supporting future talent within the industry, something that company leaders hope to see emulated elsewhere.

“We feel it’s important for industry leaders to continue supporting efforts to educate future nurses,” Angie Begnaud, chief clinical officer at LHC Group, told Home Health Care News. “That’s an opportunity that we saw in working with SLCC. It was a collaboration on a need that we find not only here in Louisiana but across the nation.”

LHC Group and SLCC collaborated on the development of the home health lab class, with leaders from the home health giant using their considerable industry expertise to weigh in. SLCC plans to integrate in-home health care classes into its existing RN and LPN program curriculums.

The home health lab class will teach students the history of home health nursing, patient care and holistic care, covering the unique challenges a nurse may encounter working in the home.

“They will be autonomous in the home,” Graci’Ana Breaux, RN-BC, skills lab and simulation coordinator at SLCC, told HHCN. “They have to be able to critically think, have clinical reasoning in order to know whether to call 911 or a physician, whether to send a patient to the hospital. Those are the types of questions a nurse would encounter in a patient’s home.”

For now, the class is only opened to SLCC nursing students, but the school is considering extending the course in the future, according to Breaux.

“We have talked about other collaborative endeavors, such as training home CNA’s and home health nurses in our off-months during the summer,” she said.

In some ways, the class falls in line with recent industry talk about elevating the home into a destination for nurses, who tend to prefer the hospital setting.

Another organization that has taken up this cause is Johns Hopkins, which created an opportunity for experienced nurses to re-imagine their careers by creating a Cross-Continuum Nurse Fellowship program, the first of its kind in Maryland.

The program trains nurses on becoming an expert on care in the home and then allows them to rotate between the home and an acute-care setting.

“Most of the education that nurses are getting is centered around acute-care,” Mary Gibbons Myers, president and CEO of Johns Hopkins Home Care Group and president of Home & Community-Based Services for Johns Hopkins Health System said, previously told HHCN. “We need to work with our academic scholars and try and change the curriculum to focus on the home and community — because that is where a patient is 99% of the time.”

On the home care side of things, an attempt to combat the industry’s record-high turnover rates which climbed to 82% last year, according to Home Care Pulse, has led to the creation of caregiver training programs as well.

In April, Catholic Health teamed up with the Cleveland Clinic, Ascension Michigan and the Ralph C. Wilson Jr. Foundation to create the Transformational Healthcare Readiness through Innovative Vocational Education (THRIVE) program.

The program will allow people who have earned a high school diploma or equivalent to train and become a caregiver.

The THRIVE program will be piloted across three states — Cleveland Clinic in northeast Ohio, Catholic Health in western New York and Ascension Michigan in southeast Michigan — over the next three.

Another program based out of the Stamford, Connecticut-based Building One Community’s Center for Immigrant Opportunity is also doing something similar.

The home health aide program places local immigrants in a six-month cohort that completes both an English language component and skills training course focused on home health care. The most recent cohort had 20 graduates.

“The home health aide program was started in 2016 after we [launched] a survey that asked, ‘What kinds of skills do workers need to learn and grow,’” Ivonne Zucco, the workforce development director at B1C, previously told HHCN. “[We] determined that workers wanted something that offered them a career path. We also found out that the surrounding area needed a lot of home care.”

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It’s also another example of how complex and comprehensive in-home care is becoming.

Since its first pilot a decade ago, the CAPABLE program has expanded to more than two dozen different sites across 14 states, according to Sarah Szanton, the Johns Hopkins School of Nursing professor who developed the program, building on colleague Laura Gitlin’s work from the 2000s. The maturation of accountable care organizations (ACOs) and the evolution of Medicare Advantage (MA) is helping to drive that expansion.

“The world is moving in this direction,” Szanton told Home Health Care News. “CAPABLE fits really nicely into this stream of innovation.”

CAPABLE, which stands for “Community Aging in place — Advancing Better Living for Elders,” is an evidence-based, four-month, interdisciplinary program designed to increase seniors’ mobility, functional ability and overall capacity to age in place by addressing multiple aspects of their health and well-being.

If a participating senior is having trouble with safe bathing, for example, the three-pronged CAPABLE team works to tackle barriers that could include a slippery tub, muscle weakness and structural inadequacies. An OT works with the senior on safe ways to enter the tub; a nurse looks at underlying issues, such as pain, that could affect balance; and then a handyman makes structural improvements, such as installing grab bars or repairing damaged flooring.

“It’s all wrapped around what that person says he or she wants to be able to do,” Szanton said.

While the program’s premise of solving for both physical and environmental problems may seem simple, its results have been eye-popping: For every $1 spent on CAPABLE, the program sees combined savings of nearly $10 to Medicare and Medicaid, in part due to a decrease in hospitalizations and nursing home placements, research from Szanton and others has found.

Among low-income older adults who participate in CAPABLE, the majority have seen functional and mobility improvements, with the average improvement being a roughly 50% reduction in their degree of disability.

About 1,000 individuals have gone through the CAPABLE program in total, according to Szanton.

“Our pilot results were astoundingly effective, so we got major funding from the National Institutes of Health (NIH) and from the Centers for Medicare & Medicaid Services (CMS) in 2012,” she said. “We then ran trials that finished in 2015 and 2017, which also highlighted some impressive results.”

Provider opportunity

CAPABLE was developed out of the Johns Hopkins School of Nursing, but it’s sometimes administered locally by at-home care organizations and their partners. The Visiting Nurses Association of Colorado helps manage the program in Denver, with Habitat for Humanity providing support from the handyman angle.

“That’s one of our flagship programs,” Szanton said.

Meanwhile, Habitat for Humanity likewise spearheads the program in the Twin Cities’ metro area with Allina Health.

Moving forward, additional opportunities for home health and home care providers may arise due to expanded MA flexibilities. CMS announced in 2018 that certain in-home services and supports would be allowed as supplemental benefits in 2019, then doubled down on that move this year for the 2020 plan year.

Those expanded flexibilities include home modification.

Outside of the CAPABLE model, some home care providers have made handyman and home-mod services core components of their business mix. Newton, Massachusetts-based HouseWorks LLC — which employs about 350 caregivers and more than a dozen handymen — is one such provider.

The private-pay home care company started out as a home modification company about 20 years ago. Today, HouseWorks’s home modification arm makes up about 10% of the company’s revenue, CEO Andrea Cohen previously told HHCN.

“What we’re seeing lately is an increase in the number of home care clients who really want home adaptation and are asking for it,” she said.

CAPABLE in 2019

In December 2018, CAPABLE was awarded a $3 million grant courtesy of the Rita & Alex Hillman Foundation to support the program in its nationwide expansion and training efforts. The additional funding also helped the program hire a director of strategic partnerships plus a director of implementation and evaluation, according to Szanton.

But that’s not the most exciting recent update for CAPABLE.

In June, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted unanimously to recommend that CMS test CAPABLE on a bigger scale “to inform payment model development.” The CAPABLE team first submitted a PTAC application last summer.

Broadly, PTAC was set up to make comments and recommendations to the U.S. Department of Health and Human Services (HHS) on proposals for new payment models. The HHS secretary is then required by law to review PTAC’s comments and recommendations on proposals and post a detailed response on CMS’s website.

There are many more hurdles to clear before CAPABLE has the chance to be reimbursed by Medicare, but getting PTAC’s support is an important first step, according to Szanton.

“[It doesn’t mean] any physician or nurse practitioner can write a prescription anywhere in the country at any time [for CAPABLE],” she said. “But more so it’s recommending CMS to study it further and at a larger scale. … Then what CMS does it up to CMS.”

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Home Health Care News is hosting its third annual HHCN Summit on Wednesday, September 18 in downtown Chicago at Convene. Buy your ticket for the conference that will bring together over 300 professionals in home health, private duty, hospice and palliative care for a full day of exclusive, dynamic content and networking. The full agenda for the event will be released on May 15.

For information on sponsorship opportunities for the 2019 HHCN Summit, click here. To submit your details for speaking opportunities, click here.

Confirmed Speakers Include

Paul Kusserow, President and CEO, Amedisys
April Anthony,CEO of Home Health and Hospice, Encompass Health
Keith Myers, Chairman and CEO, LHC Group
Dr. Bruce Leff, Director, The Center for Transformative Geriatric Research at Johns Hopkins University
Jeff Bevis, CEO, FirstLight Home Care
Jennifer Sheets, President and CEO, Interim Healthcare
Brian Petranick, President and CEO, Right at Home

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