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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While not common in the United States, home-based cancer treatment programs have carved out important roles in health care systems abroad. In their Journal of Clinical Oncology article, for example, authors Nathan Handley and Justin Bekelman point to the success of oncology hospital-at-home (HaH) programs in countries such as France and Italy.

They also highlight the positive outcomes generated by other types of home-based care programs in the U.S. to make their case.

“The building blocks for an oncology HaH are already in place in the United States,” the oncologists wrote. “Management of many specific cancer-related symptoms and complications is feasible in the home setting. Outpatient management of low-risk febrile neutropenia is as safe and effective as inpatient management, at half the cost. Delivery of certain types of treatment in the home environment, such as intravenous fluids and certain types of chemotherapy, is common.”

Creating oncology HaH programs would require navigating past a few roadblocks — such as uncertainty regarding patient selection, operational logistics and reimbursement processes — but the benefits of the program would outweigh those challenges, Handley and Bekelman argue.

Some providers are already testing that theory out. In December, the University of Utah’s Huntsman Cancer Institute launched “Huntsman at Home,” a program designed to provide hospital-level care for cancer patients in the comfort of their own homes in partnership with Community Nursing Services. The goal of the program is very similar to the one outlined in the article.

“Patients could have greater satisfaction with equal or greater quality,” Handley and Bekelman wrote, noting that home-based treatment would lower patients’ risk of hospital-related infections and complications. “Hospitals, by diverting a subset of patients from inpatient units, could reallocate inpatient beds, decreasing the wait time for scheduled hospitalizations and increasing the ability to accept hospital-to-hospital transfers and, by downsizing outpatient infusion centers, could decrease overhead and total costs.”

Meanwhile, payers would save money, as treatment in the home is among one of the least expensive care interventions.

While not specific to cancer treatment, HaH program data supports the authors’ claims.

Take Johns Hopkins, for example, which has been offering HaH for more than 20 years. When compared to in-patient settings, the program has shortened average length of stay by one-third, lowered cost by 30% and improved patient satisfaction.

Still, to be successful, oncology HaH programs would need guidelines to govern which cancer patients can appropriately be seen at home — much like the guidelines that currently exist for general home health patients. Additionally, the Centers for Medicare & Medicaid (CMS) would need to ensure appropriate reimbursement models, methods and codes exist.

Ultimately, the authors hope — and expect — to see the role of acute care hospitals evolve when it comes to cancer patients, as the industry is also pushing for other types of care.

“Rather than being a routine site of care, acute hospitalization should become the exception: a site reserved for expert and intensive care of our sickest patients, with, it is hoped, a rapid transition to home as soon as possible,” Handley and Bekelman wrote.

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