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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Under the extension, Mount Sinai South Nassau’s home health agency will now become a part of the two organizations’ existing joint venture. The JV now includes home health, hospital-at-home, SNF-level care at home and palliative care.

What has now been created is the home health agency “Mount Sinai at Home,” which has capabilities across the continuum of care.  

“This new initiative accelerates our strategic goal of delivering a continuum of home-based care to more Mount Sinai patients,” Contessa COO Aaron Stein said in a statement. “Mount Sinai at Home provides a strong offering to patients, providers and health plans. Together, we are truly changing healthcare by rendering care where patients want it the most, their homes.”

The New York-based Mount Sinai Health System has a network of 43,000 employees, 400 outpatient practices and nearly 300 labs. In terms of extending into home-based care, it has historically been an innovator. Contessa and Mount Sinai partnered to launch palliative care services last February.

On its end, the Nashville-based Contessa partners with 12 health systems and 30 health plans, serving patients in nine total states. Amedisys – one of the largest home health providers in the country – acquired Contessa in June of 2021.

Contessa and Mount Sinai originally partnered on hospital-at-home initiatives in 2017. Mount Sinai at Home – formerly Mount Sinai’s South Nassau home health agency – treats 3,000 patients per year.

“Mount Sinai at Home will allow South Nassau to expand our services to patients in the growing areas like hospital at home, home care and home infusion therapy,” Dr. Adhi Sharma, the president of Mount Sinai South Nassau, said in a statement. “We have a long tradition of bringing high quality patient care directly to the home where it can be delivered in more comfortable and familiar surroundings, often at reduced cost. Increasingly, this is what patients want and we are pleased to be on the cutting edge of that trend.”

These kinds of partnerships are what Amedisys has recently been touting about Contessa.

The acquisition was always going to be a near-term drag on financials for Amedisys, but these sorts of deals are transforming what Contessa can do for the company right now, much to the delight of Amedisys leaders.

“What we’ve seen happen now is … some super large urban cities have these large health systems that want to provide the full continuum of care, and they want to leverage capabilities from hospital at home to end-of-life care in the home,” Amedisys CEO Chris Gerard said in June.

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That’s according to a May report from the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). The findings throw further support for facility-based care alternatives, including the types of hospital-at-home models that lean heavily on home health and home care agencies.

“Given the scale and persistence of patient harm in hospitals in the decade since our last report, HHS leadership and agencies must work with urgency to reduce patient harm in hospitals,” stated the report.

As part of their work, OIG investigators examined medical records for a random sample of 770 Medicare patients discharged from acute care hospitals during October 2018 – a period of relative normalcy long before the COVID-19 crisis. The examination included a preliminary review where nurses screened records for possible patient harm, as well as a physician-led review to further assess the severity of adverse health events.

Among their findings, investigators determined that one in four hospitalized Medicare patients experienced harm during their stay.

For nearly 25% of those individuals, the “harm events” resulted in additional costs to Medicare. Additionally, physician-reviewers determined that 43% of the harm events could have been prevented if patients had been provided better care.

A similar OIG effort in 2010 found that 27% of hospitalized Medicare patients experienced harm during stays in October 2008, with nearly half of those events preventable. While the earlier investigation has led to an increase in federal oversight and internal efforts from hospitals to strengthen clinical practices, there are clearly still problems.

“Addressing patient harm and promoting patient safety takes on added urgency in light of the ongoing pandemic and its effects on hospital operations,” the report continued. “Despite substantial action by HHS agencies and success in reducing certain types of events, patient harm remains pervasive, is often preventable, and continues to cost the Medicare program and patients.”

The most common type of harm event was related to medication, such as patients experiencing delirium or other changes in mental status. Other common events included hospital-acquired infections, pressure injuries and problems that arose during procedures.

In October 2018 alone, OIG estimated that medicare spent $520 million on costs associated with patient harm events. Two-thirds of patients received care that was paid under the Medicare Inpatient Prospective Payment System (IPPS).

“We found that 20% of patients covered by IPPS who experienced harm events incurred additional costs to the Medicare program and potentially to the patients themselves as a result,” the report noted.

To combat systemic problems, OIG broadly recommended more checks and balances, with further federal oversight. Yet long-term investment in hospital-at-home models that shift higher-acuity care into the home – or prevent hospitalization in the first place – could also make a major difference.

A 2012 analysis, for example, found that hospital-at-home patients had a 19% lower six-month mortality rate compared to hospitalized patients. A more recent study found that hospital-at-home patients also had a lower risk of long-term care admission, with lower rates of depression and anxiety.

Other studies have suggested hospital-at-home patients recover quicker and have a lower risk of outside infection due to a more controlled environment.

New York-based Mount Sinai Health System launched its own hospital-at-home program in 2014 as part of a three-year grant from the Center for Medicare & Medicaid Innovation (CMMI). Since then, the Mount Sinai team has repeatedly observed outcomes that surpass traditional hospital care.

“Outcomes were better and we were able to reduce complications,” Dr. Al Siu, director of Mount Sinai at Home, previously told Home Health Care News. “We were able to show we could do this safely, and that there was another option for patients and their families.”

The hospital-at-home concept isn’t new, but programs have dramatically increased since the start of the pandemic, partly thanks to the temporary Centers for Medicare & Medicaid Services (CMS) “Acute Hospital Care at Home” waiver. As of May 17, 97 systems and 225 hospitals in 35 states had been approved for the waiver, which will end when the public health emergency expires.

The OIG report suggests that policymakers consider a more permanent replacement, ensuring that hospital-at-home programs can continue thriving moving forward. That’s something hospital-at-home stakeholders are certainly pushing for, specifically in the form of the ​​Hospital Inpatient Services Modernization Act.

“There’s a lot of interest and support for the waiver,” Jeremiah McCoy, director of policy and government relations at Moving Health Home, previously told HHCN. “We just need to continue to build on that and make sure that the Hill is hearing what everyone’s saying, not only for what the opportunity has been during the pandemic, but what this means for a future iteration of the acute care home model in Medicare.”

In addition to hospital-at-home models, the OIG report also suggests that policymakers consider further investments in home health and home care.

Home health and home care agencies often enable hospital-at-home programs by being the “eyes and ears” in the home. But home-based care agencies themselves have repeatedly been found to prevent hospitalizations.

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In actuality, hospital-at-home models surfaced in the 1990s. Early adopters included Johns Hopkins University, which pioneered its own concept — and proved that it worked — decades before the current buzz.

In-home hospital care feels new to many in 2021, however, because widespread adoption has been historically thwarted by the lack of a reliable reimbursement mechanism. That was the case until the COVID-19 crisis forced the U.S. Centers for Medicare & Medicaid Services (CMS) to roll out a dedicated waiver last November.

Dr. Bruce Leff, a geriatrician and a health services researcher, began working on a hospital-at-home model the first day he joined Johns Hopkins in 1994. The value of such initiatives was the same then as it is now, Leff told Home Health Care News.

“We found that when older adults got acutely ill, a fair number of them would refuse to go to the hospital because they had previously had bad experiences in the hospital,” he said. “And often as geriatricians, I think we recognized the potential problems with hospital care and the potential dangers and illness that comes from being in the hospital.”

Conditions like pneumonia and heart failure could be treated in the hospital, of course. But Leff and others worried that those patients may end up worse off as a result of their hospital stay.

In part, Johns Hopkins was able to confirm its hypothesis after participating in multiple demonstrations, some on a national scale. After receiving hospital-level care in the home, patients typically had lower rates of mortality, delirium and other adverse health outcomes, while caregivers experienced less stress.

Combined, those benefits additionally tended to lead to lower costs overall.

Armed with these and other findings, hospital-at-home advocates have long advocated for payment support. CMS has paid for the model off and on during demonstrations, but never on a permanent basis.

Even with the new CMS waiver and the strong interest it has generated, permanent fee-for-service payment is still not a sure thing moving forward. As of March 3, 48 health systems and 109 hospitals in 29 states had been approved for the CMS program, which is set to last only for the duration of the public health emergency.

‘A wildly successful demonstration’

Organizations that had prior experience with hospital-at-home models were granted a go-ahead under the waiver program at an expedited pace. A few of those groups had originally worked with Johns Hopkins to launch their models, too.

Leff and Johns Hopkins had worked with Arizona-based Presbysterian Healthcare Services — a not-for-profit health system and insurer — since 2008. Likewise, New York-based Mount Sinai Health System had worked with Johns Hopkins on a CMS demonstration from 2014 to 2017.

“That was a wildly successful demonstration,” Leff said. “But once the demo was over, that payment went away. So Mount Sinai took their hospital-at-home model and then started to develop risk contracts with Medicare Advantage plans in the New York market, thus sustaining their hospital-at-home.”

Mount Sinai, which has a network of eight hospital campuses, now works with the Nashville, Tennessee-based Contessa Health to facilitate its program.

These and others have found ways to keep their hospital-at-home programs alive despite a lack of reimbursement because the concept works so well, Leff said. Hospital-at-home has been particularly applicable during the COVID-19 pandemic, as patients have shied away from institutional-based settings and hospital capacity has been of grave concern.

Par for the course

The U.S. continues to be a laggard when it comes to hospital-at-home models. Plenty of countries in Europe have banked on this type of in-home care for years now.

But Leff is hoping that the COVID-19 crisis will be the tipping point that leads to widespread adoption.

“I think it’s just par for the course, in some ways, for health care delivery and innovation, in general,” Leff said. “It usually takes 17 or 18 years for innovation implementation to set in. But there are dozens and dozens of randomized, controlled trials of hospital-at-home. When you put them together … , the results for hospital-at-home are actually quite stunning.

Now that hospital-at-home has piqued the interests of health systems across the country, each has a decision to make: whether to build their own program or license the framework from someone else.

Johns Hopkins enables providers to license out its model, but that decision really should be made on a provider-by-provider basis, experts say.

Illinois-based Quincy Medical Group, for example, did elect to license out the Johns Hopkins model. In its nearly three-year implementation of hospital-at-home, it wanted to lean on the original innovators, QMG Interim CMO Dr. Rick Noble told HHCN in December.

“This way, we won’t have to reinvent the wheel,” Noble said. “We basically purchased their best care protocols that we’re going to implement.”

There is a lot of information on best practices that is publicly available, however. And on top of that, home-based care organizations — especially ones like Contessa Health — are often great partners in helping launch hospital-at-home programs.

Not licensing out also allows organizations to customize their own model, in line with their own operations.

The backwards bicycle

The hospital-at-home model works. So why hasn’t it been widely adopted and supported sooner? Leff likened it to learning how to ride a bicycle backwards.

Although it seems like a straightforward challenge, it’s not a simple learning process. The implementation of hospital-at-home is similar, in the sense that providers have to re-learn how to deliver care completely, which takes a long time.

“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 said. “Rewiring health care, health care delivery and attitudes — all of that is hard.”

It’s why home-based care providers have faced frustration over the years as their care delivery systems proved to be superior to others, but still weren’t widely adopted or recognized.

“It’s not just hospital-at-home, but home-based care delivery, in general,” Leff said. “But I do think that’s starting to change, especially as the value discussions change. And it’s all about leadership leading culture change, and moving things forward. So yeah, it’s been frustrating, sure. But I think persistence has been helpful.”

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Mount Sinai’s network includes eight hospital campuses, in addition to the Icahn School of Medicine at Mount Sinai. On its end, the Nashville, Tennessee-based Contessa helps health systems provide hospital-level care in the home through its Home Recovery Care model.

The new initiative, dubbed “Palliative Care at Home,” will offer care at home for a mix of “seriously ill COVID-19 patients” and others, including individuals with complex chronic conditions who need daily treatment. This includes people living with cancer, end-stage renal disease or congestive heart failure, for example.

For Mount Sinai, offering palliative care services in the home allows the health system to scale a model that moves care into an alternative setting and lowers hospitalization rates.

“For the estimated 2 million Americans living with serious illness, many of whom are confined to the home by their physical limitations, the final frontier of care is in the community,” Niyum Gandhi, executive vice president and CFO of Mount Sinai, said in a statement.

Contessa’s role in the partnership is to operationalize the new program while lending expertise in staffing, Travis Messina, CEO of Contessa, told Home Health Care News. Contessa will additionally spearhead payer negotiations and more.

“We provide all the administrative and operational support and oversight,” Messina said. “We also provide care management functions and select care provision functions.”

Mount Sinai originally launched a pilot version of this program — funded by the West Health Institute — last spring as a response to the public health emergency.

Palliative Care at Home builds on this pilot and two previous home-based care programs: Rehabilitation at Home and Hospital at Home. The latter program was launched in partnership with Contessa in 2017.

“Hospital at Home provides a discrete episode of care, designed as a mechanism to replace hospitalization,” Dr. R. Sean Morrison, chair of the Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai, said in the statement. “Palliative Care at Home provides ongoing care and support day after day, month after month, for seriously ill patients and their families in their own homes, thus avoiding unnecessary and burdensome emergency department visits and hospital admissions.”

Morrison is one of the original architects of Mount Sinai’s palliative care program.

On the home-based care front, Mount Sinai also recently partnered with Boston-based Current Health, a remote patient monitoring platform, to provide cancer care.

For Contessa, a hospital-at-home veteran, this partnership with Mount Sinai allows the organization to enter the palliative care space.

“Palliative care was always on our roadmap,” Messina told HHCN. “A significant portion of the patients we treat in hospital-at-home or SNF-at-home are eligible for palliative services, but we were focusing on that highest-acuity episodic encounter first and foremost.”

Generally, SNF-at-home models work to shift skilled nursing facility (SNF) patients into home-based care.

Looking ahead, Messina believes the industry will continue to form partnerships similar to its own with Mount Sinai.

About two-thirds of all palliative programs in the U.S. provide in-home palliative care. In most instances, hospices and hospitals oversee those programs.

“This is just another example of health systems realizing the increased consumer preference to receive more care in the home,” he said. “Obviously, there are a lot of hospital-based palliative care programs. This is a testament to the fact that more health systems are focused on providing services outside of the four walls of their hospital.”

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The New York-city based health system launched Mount Sinai at Home in 2014 as part of its offerings, with the help of a three-year CMS Innovation Center grant.

During the COVID-19 crisis, the program has been more relevant than ever, as the health system has worked to free up beds in its eight hospitals by treating patients at home.

Now, Mount Sinai has paired with Boston-based Current Health — a remote patient monitoring platform — to help keep an eye on cancer patients at their homes.

“Sinai prides itself on being an innovator and leading the field,” Dr. Cardinale Smith, the chief quality officer for cancer services for Mount Sinai, told Home Health Care News. “And this is no different. And I think it’s because we were already in this area that when the pandemic happened, we were able to pivot much more quickly.”

At the onset of the public health emergency, Mount Sinai’s long-touted dedication to home-based care allowed them to simply accelerate.

Current Health’s platform monitors patients throughout the day, enabling physicians and nurses to provide enhanced virtual care for high-risk patients at home. Cancer patients who are undergoing chemotherapy are at an increased risk for infection because they’re immunocompromised.

That’s why it’s far safer for oncology patients to receive care wherever they live.

Mount Sinai was able to pay for Current Health’s services through a large grant provided by the CARES Act. Broadly, governmental grants have helped home-based care companies across the country adopt innovative technologies over the last year.

“Patients with cancer are often immunocompromised. In general, we would like to keep them out of hospitals, if we can,” Dr. Smith said. “And in particular during this pandemic, where they are at higher risk, we want to minimize exposure. Being able to really treat them in place is important to make sure that we maintain their health and safety for as long as we possibly can.”

Christopher McCann, the CEO and co-founder of Current Health, said that patients are noticeably more interested in home-based care options of late. The company established a relationship with Mount Sinai specifically because of its innovative approach to care.

Current Health — a company that began growing its model in the U.K. before crossing the Atlantic — has grown by 3,000% since the beginning of 2020. It now has 400% more customers than it did before last year, which is evidence to back up McCann’s home-based care observations.

Its platform combines health monitoring, data and AI-powered analytics to help health care providers realize when they need to take action with a patient. Current Health has also partnered with the Mayo Clinic and the Biomedical Advanced Research and Development Authority, which is part of the Assistant Secretary for Preparedness and Response within the U.S. Department of Health and Human Services (HHS).

“Two or three years ago, everyone believed that the home was the future and that there would be this kind of unbundling of the hospital with more health care services delivered at home.,” McCann told HHCN. “But it was celebrating a future vision. No one was really sure how fast that would happen. This year, every single health system that I speak to — and I speak to 10 health systems per day — is prioritizing moving health care into the home.”

The U.S. has been a laggard among developed countries when it comes to delivering cancer care at home. But that is beginning to change.

Earlier this month, CVS Health (NYSE: CVS) announced that it had partnered with the Cancer Treatment Centers of America (CTCA) to begin providing chemotherapy services in the home.

Delivering cancer care at home has a wide variety of benefits, some of which were mentioned above. But especially during the pandemic — when disadvantaged populations have often gotten the short end of the stick — it is helping expand access to appropriate care.

Individuals who are socioeconomically disadvantaged are less likely to try video visits during the pandemic and more likely to travel to brick-and-mortar locations for care. Current Health’s

platform helps keep them in their home with regular check-ins from physicians and nurses.

“We have many patients who are socioeconomically disadvantaged,” Dr. Smith said. “And particularly, that burden falls to our black and hispanic patients.”

“We don’t have enough data to say for sure yet, but we think this will help,” she added. “One of the reasons why we picked this platform specifically is because they do provide a tablet in the home to the patient, as well as a hub to enhance WiFi and give some broadband data access to those who don’t have it.”

Rising tides

Hospitals are realizing that they need to move further into the home — and sooner rather than later. To do so, they’ll need help, likely from home health and home care agencies, as well as tech vendors such as Current Health.

But there’s no longer an excuse to not be increasing at-home services for patients.

“I do think that the thing this pandemic has shown us is that we have technology to do this, and we should use it,” Dr. Smith said. “We’ve learned that these things are possible. … And just from a bigger perspective, these are [innovative] conversations that have to happen concurrently to be able to change the landscape of care delivery.”

Mount Sinai did one video visit in January 2020. In March, they did 3,500.

Still, remote patient monitoring for cancer care in the home is in its infancy. Additionally, patients are often unaware of the home-based offerings available to them.

“The place where these devices have been used primarily is in the primary care setting, usually for high blood pressure management,” Dr. Smith said. “Patients are much less aware of these types of offerings. We have a pretty robust hospital-at-home system, and so this is also an adjunct to that, and [another step] to really being able to treat patients in place in their home.”

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In a Wednesday announcement, CMS unveiled new, comprehensive flexibilities that allow hospitals to provide their services “in locations beyond their existing walls.” To secure those flexibilities, hospitals must apply for a special waiver via an online portal, with experienced hospital-at-home organizations eligible for “an expedited process.”

So far, seven hospital systems have received waivers, including Mount Sinai Health System in New York City, one of the earliest adopters of the hospital-at-home model. In 2018, a team of Mount Sinai researchers led by Dr. Albert Siu found that its hospital-at-home program resulted in shorter lengths of stay, fewer ER visits and stronger clinical outcomes compared to traditional in-patient care.

Despite those and other promising findings, the hospital-at-home idea has been slow to catch on in the U.S. due to reimbursement challenges, at least compared to countries where it’s much more common — Australia, Israel, Spain and elsewhere.

CMS’s new hospital-at-home strategy will likely change that, according to Siu.

“While we were collecting this critical evidence base, we started to work closely with CMS and provide input on the model and how it could be leveraged more broadly and more strategically,” said Siu, who serves as chair emeritus of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. “We were able to bring hospital-level services into the homes of our patients throughout New York City, but the one obstacle we faced was, how do we pay for this? To facilitate widespread adoption, we needed a mechanism of reimbursement that would capture a larger portion of the Medicare population.”

In part, CMS is backing the hospital-at-home model due to the coronavirus pandemic, which has stretched hospitals dangerously thin. As of Sunday, a record 93,238 patients were hospitalized due to the virus, according to the COVID Tracking Project.

Mount Sinai admitted its 1,000th hospital-at-home patient during the peak of the public health emergency.

In addition to Mount Sinai, the other hospital systems with waivers include Massachusetts General, the Huntsman Cancer Institute, UnityPoint Health, Presbyterian Healthcare Services and Brigham Health Home. Mercy Hospital St. Louis was approved for a waiver on Monday, a CMS spokesperson told Home Health Care News.

More will join that list in days to come, as many have already been working with private hospital-at-home operators — DispatchHealth, Medically Home and Contessa among them — prior to new CMS flexibilities.

The Mayo Clinic, Highmark Health and Ascension Saint Thomas are just a few examples, as is North Memorial, which partnered with Minnesota-based Lifesprk to launch a hospital-at-home program in July.

Rami Karjian — co-founder and CEO of the Boston-based Medically Home — told HHCN this is a “transformational moment” for high-complexity patients everywhere.

“By decoupling high-acuity patient care from hospital buildings, CMS is enabling hospitals to care for patients in their homes with a model that has been widely shown to deliver better clinical results, higher patient satisfaction and lower costs,” Karjian said in an email.

‘It’s very exciting’

DispatchHealth — the on-demand in-home care provider based in Denver — launched its own hospital-at-home service line in November 2019.

Similar to other models, it has achieved incredible results thus far. Data released by DispatchHealth in October, for example, found that its Advanced Care program saved an average of $6,200 per individual by keeping them away from the traditional hospital setting.

Additionally, hardly any of the high-acuity patients DispatchHealth treat in the home end up back in a brick-and-mortar hospital, according to Dr. Mark Prather, the company’s CEO. In fact, DispatchHealth’s hospital-at-home offering has been “one of the better things” Prather “has ever been involved with as a clinician,” he noted. 

Last week’s news from CMS now adds further fuel to the fire.

“It’s very exciting,” Prather told HHCN. “A lot of us have been disciples of home-based care for many years. I think this is another step forward in opening the aperture for care delivery in the home.”

Under CMS’s new flexibilities, developed in tandem with The Hospital at Home Users Group, participating hospitals will need to provide in-person physician evaluation before starting care in the home. On top of that, a registered nurse is required to perform evaluations on each patient — in person or remotely — daily.

While CMS officials mostly touted last week’s move as an effort to boost capacity as hospitals navigate through worsening COVID-19 surges, hospital-at-home programs will likewise help keep complex populations out of acute settings in the first place.

That’s been a focus of DispatchHealth’s model, Prather said.

“Many of the patients we care for are high-medical needs, high-social needs patients,” he said. “They may not have COVID, but they could have a congestive heart failure exacerbation. By keeping them in the home, we are limiting their exposure to COVID.”

Applying for a waiver

Experienced hospitals participating in the hospital-at-home waiver program will be required to submit monitoring data on a monthly basis, according to CMS. Those without experience will be required to submit data on a weekly basis.

While experienced hospitals will be placed into a fast-track waiver process, those new to the hospital-at-home concept will have to go through a “more detailed waiver request” that “emphasizes internal processes that prove capability of treating acute hospital care at home patients with the same level of care as traditional in-patients.”

If a hospital system has multiple hospitals providing acute hospital care at home, each facility will need to request a waiver.

“However, if the services are run by the same group within a health system, CMS understands that each request could appear very similar,” agency officials clarified.

A hospital-at-home program does not have to be physically administered within a hospital, but a hospital must accept responsibility for the program in order to satisfy the Conditions of Participations.

Moreover, the program must be integrated within a hospital to a “sufficient degree” to ensure that rapid escalation of care is seamless.

As hospital-at-home programs become more common, Prather stressed it will be important to develop additional standards to ensure high-quality care.

The CEO said he has high expectations for DispatchHealth’s program, even after the pandemic subsides.

“There are already significant tailwinds to home care delivery,” Prather said. “It’s, frankly, what consumers want, regardless of the pandemic. We’re very encouraged by the movement at CMS, and I do think that it will continue to open doors.”

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And that may mean more business for home health providers moving forward.

“There’s a growing awareness that the traditional design of emergency-department care isn’t well suited to frail, older adults,” Kevin J. Biese, an emergency medicine physician who heads the new Geriatric ED Accreditation Board of the American College of Emergency Physicians, told The Wall Street Journal, which reported on the ER design trend Sunday.

ERs designed for older adult patients and their families — or “geriatric emergency departments” — are popping up in hospitals across the country, including at La Jolla, California-based UC San Diego Health, according to WSJ.

ERs for older adults have similarly launched at New York-based Mount Sinai Health System and Paterson, New Jersey-based St. Joseph’s University Medical Center. Silver Spring, Maryland-based Holy Cross Hospital and up to five Aurora Health Care hospitals in eastern Wisconsin are also among the group.

Traditionally, ERs have been designed to provide care for patients suffering from ailments ranging from head trauma to severe bleeding — but not necessarily older adults with complex medical conditions

Geriatric emergency departments address the specific needs that elderly patients have when it comes to hospital care, such as special attention paid to injuries from falls, and complications that arise from conditions like diabetes and heart failure.

These departments also serve as a response to the rise in the percentage of ER visits for patients over the age of 65, which saw an increase of more than 27% from 2005 to 2015 despite an uptick in home health care services.

As part of their efforts to cater to older adults and prevent subsequent ER trips, the staff at geriatric emergency departments regularly recommend home health care services, according to WSJ.

About 23.7% of patients discharged to home health services following an ER stay make their way back to the hospital, previous research suggests. About 33% of patients who experience an in-patient hospital stay after an ER visit, in contrast, end up back in the hospital.

Additionally, patients who receive home health care in-home immediately after going to the ER see total 90-day health care costs of $13,012, compared to $20,325 for patients who were treated in the hospital, according to the research.

Currently, geriatric emergency departments can earn Geriatric Emergency Department Accreditation (GEDA) based on their policies, practices and features.

So far, more than 50 departments are GEDA accredited and over 100 across the nation are in the process of getting accredited.

This growing number of hospitals seeking accreditation suggests positive implications for home health care providers who could see a boom in business as ER patients are being sent home sooner — and as geriatric emergency department staff prescribe home health care services.

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