Even with a proven track record for clinical effectiveness and cost savings, the hospital-at-home model’s future hangs in the balance.
“The data suggests that, for the populations that have been studied in multiple different places, it’s a very safe service to be done and with high-quality care, low readmission rates, low escalation rates, low infection rates,” Dr. Adam Groff, co-founder Maribel Health, told Home Health Care News. “The bottom line is people love it, patients love it and it’s a high-quality care experience.”
Maribel Health is a company that helps health systems modernize and deliver advanced home-based care services through technology. This includes services such as, hospital-at-home care, community paramedicine and other high-acute care models.
In 2020, the hospital-at-home model had its breakthrough. Though the model was common internationally, it was considered niche in the U.S. This changed with the introduction of the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care At Home program.
A recent report from CMS found that the program has been largely successful.
Simply put, the CMS waiver created a mechanism for reimbursement for hospital-at-home care. The lack of straightforward reimbursement had been a major roadblock for the model.
Despite the momentum the model has seen in recent years, challenges still exist when it comes to operations and scalability.
Specifically, less than 9% of waiver-approved hospitals accounted for more than 70% of all U.S. admissions, according to data from MedPAC’s June 2024 report to Congress.
“If you add all the admissions together, it’s less than 1/10 of 1% of the Medicare fee-for-service inpatient hospital admissions across all programs,” Ronald Paulus, president and CEO of Maribel Health, told HHCN. “It’s clear that there is an operational challenge that needs to be overcome.”
Additionally, almost two-thirds of hospitals had zero admissions.
Paulus noted that even with these challenges, there have been some examples of success.
“For example, Mass General Brigham in Boston, where our medical director practices, they’ve achieved a census of about 70 from a number of hospitals,” he said. “UMass is not too far away, it has gotten to a census of 20 with just one hospital. Atrium Health has gotten into the upper 40s, low 50s across multiple sites. There are some inklings of success, but the average hospital at home program in the U.S. that had admissions, averaged only two admissions per week, so it’s not achieving what it can.”
For context, among hospital-at-home operators, an average daily census of five is similar to roughly 50 in the hospice space, and around 250 in home health, Groff noted.
“A hospital-at-home program with only five patients doesn’t sound like a lot, but it’s actually a very complex operation,” Groff said. “If you think about what some of these folks are doing — getting to censuses of 50 or plus, that is a very complicated operation. It requires a lot of new knowledge around operations, and then technology to support it.”
In order for hospital-at-home care to continue to see forward movement, there are a number of pillars that Groff and Paulus believe that providers must embrace.
“In some ways it’s simple, in other ways it’s very difficult,” Paulus said. “One is building a high performing team. The second is having a very clear organizational structure. It can’t be a side job. There has to be a clear leader with ongoing P&L responsibility and oversight. Third, there has to be a relentless focus on growth and optimization. You’re reinventing the program at each increment of census. A program of four is totally different from a program of 12, which is totally different from a program of 26, and so forth.”
Another key pillar is having the right tools and analytics that allows providers to orchestrate all of this.
“Those pillars will be very familiar to home health and hospice operators because that’s how they run their businesses,” Groff said. “On the technology and knowledge front, I think this is a challenge for everybody in the home-based care space.”
Currently, hospital-at-home operators are waiting to see if the CMS waiver will continue on. Without an extension, the waiver is set to expire on Dec. 31.
This year, legislation that addresses the model has been introduced. Paulus is optimistic about the future of the model.
“In our divided world, it seems to be something that has support on both sides of the aisle politically,” he said. “It has a neutral score from the CBO, so that’s very helpful, in terms of a programmatic renewal. We know that patients and consumers have reached out to say that they like this, and they want to have this. If we sit back and think about the demographics of the United States, and how it’s aging, in 2050, the entire [country] is going to look like Florida did in 2020. There aren’t enough buildings to care for all of these people.”
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