New Hospital-at-Home Waiver Program Is ‘Another Step Forward’ for Home-Based Care

The Centers for Medicare & Medicaid Services (CMS) last week took extraordinary steps toward increasing the U.S. health care system’s capacity by shifting more acute care into the home.

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.”