This comment was an anomaly, in terms of its brevity. While most respondents expressed similar sentiments, they chose to utilize more words to do so.

Overall, providers went into detail about the specific challenges they are facing in their market, and why the proposed payment rule would impact access to care.

Below are the comments Home Health Care News thought stood out from providers, as they see their margins decrease year over year.

Some comments have been edited for length and clarity.    

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Within our market, the incidence of home health admissions that include wound care and specifically the types of wounds included within this proposal are increasing. Any decrease to reimbursement for HHAs who are treating these types of wounds would be detrimental to patient care. The cost of supplies continues to increase like everything else in the economy and labor costs to access skilled nurses or therapists who actually have proper wound care treating in these types of cases are also increasing.

In our agency, we recently had to refer a patient who was sent to us to another agency due to the patient’s insurance. The patient developed a pressure wound and the nurse who was sent to treat the patient was not properly trained in wound care. Over the next few weeks, the patient reported that the wound was increasing in severity and he was concerned that the nurse did not seem to know what she was doing. He requested that she get some additional help. The nurse brought her supervisor to observe the wound care provided and ask if it was proper or adequate. The supervisor instructed her that the only thing she could do correctly at that point was call an ambulance for the patient. The patient had developed gangrene in the wound and was transported to a hospital. A few weeks later, the patient’s leg was amputated just below the knee. The result of amputation resulted in significantly higher expense to Medicare than paying for adequate wound care wound cost. Worse, the patient’s quality of life is now irreversibly affected by loss of limb.

I understand the need to try to reduce expenses and cut costs across our federal budget. Home health is a great program that allows for significant improvement in patient outcomes while decreasing hospitalization. I strongly encourage Medicare to consider increasing spending for home health companies to provide quality supplies and hire or train their staff with the necessary certifications and skills needed for advanced care in the home. While the expense for home health may increase, I don’t think it’s a surprise that the rate of hospitalization will decrease and that significantly decreases the overall cost of health care while also improving patient outcomes.

— Primary Home Health LLC

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I am an administrator of a small independent home health care agency in Calumet City, IL. Every year we are fighting for survival and every year CMS is proposing to cut reimbursement and adding more regulations. Unfortunately, it is the same this year. There has got to be a way that you come up with a plan to stop this madness. It is difficult to pay nurses and have enough people in the office to maintain all of the regulatory requirements. Can you please remove some of the regulations so we can get back to the business of taking care of patients? You just extended RCD 5 additional years. You have extended HHVBP. You have added NOAs but didn’t remove any regulatory burdens nor have you given an increase in reimbursement. The hospital systems are dropping home health agencies like flies in Illinois because it appears we are not valuable. Independent home health agencies are closing because they can’t provide care, pay field staff and keep up with the regulatory burdens put upon us by you. We need a break, please!

— Deirdre Hezekiah Onwukwe

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I would like to express my concerns regarding the recently released proposed rule for the CY2025 Home Health Prospective Payment System (HH-PPS). As an occupational therapist and a former home health provider, the proposed changes could significantly impact access to quality occupational therapy services for Medicare beneficiaries. Reducing payment for key occupational therapy services raises alarms about the sustainability of these essential services, which play a crucial role in enhancing the well-being and independence of patients in their home environments. It is required to maintain focus on ensuring that Medicare beneficiaries receive the highest quality of care, and adequate compensation for occupational therapy. I urge CMS to reconsider these proposed payment reductions to ensure that patients continue to receive the necessary occupational therapy services for their recovery and overall health.

— Vera Gallagher

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While we appreciate CMS’ efforts to combat fraud, waste, and abuse, CMS must provide clear guidance to any provider under a PPEO, including the timeline for reviews, the process for any appeals, and the criteria for when sanctions and penalties are imposed.

CMS’ proposed rate reduction does not consider the high costs of inflation, staffing shortages, turnover, and labor stresses that home health providers are facing. Combining those challenges with significant cuts to funding would reduce our patients’ access to life-changing care. This affects the patients who need us the most who may not have the funds and are most vulnerable.

The most vulnerable populations rely on our high-quality care and these cuts will restrict their access to care, particularly in rural and underserved areas.

Changes to the wage index will move some agencies from an urban designation to a rural one, thereby further reducing their reimbursement at a time when rural agencies are facing increased challenges recruiting and retaining employees.

We give excellent care to all who need us and even give charity/indigent care as we can but further cuts to our funding would make it almost prohibited. Our clinicians work very hard and they are not given annual raises, in fact some have not had a raise in almost 3 years. Home health is not an easy job, it is an act of the heart and yet they give everything they have to the patients and community we serve!

— Seaport Scripps Home Health

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My home health agency serves rural Wyoming. With the high cost of supplies, labor, recruitment and overall cost to service a rural area, the proposed Rule will nearly eliminate our ability to continue to service these areas. We are currently facing high inflationary wages And stiff staff competition with the hospital and other health care providers. A 4% reduction in our reimbursement will only exacerbate the issue.

The 5% wage index cap also prevents our rural communities from obtaining a market rate wage that allows us to hire competitively.

The need for home health in rural communities is only becoming more and more necessary. This rule will prevent all home health agencies from being able to have sustainable reimbursement to service rural communities.

CMS needs to consider the overall stress home health agencies are under with the current economic environment. CMS should consider a reimbursement increase of 5%.

— Symbii Home Health and Hospice Wyoming

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Compared to CY 2024, CMS estimates a decrease of 1.7% in Medicare payments to HHAs for CY 2025. Henry Ford Health is concerned that the annual update to the home health payment rate has not kept pace with significant increases in the cost of labor, medical supplies and other resources needed to provide high-quality care to our patients.

Much of this cut is attributable to a 4.067 percentage-point decrease that is a result of the behavioral assumption adjustment. CMS’ behavioral assumption adjustments are in direct response to regulatory changes that home health providers are required to follow since implementation of the PDGM on January 1, 2020. These behavioral assumptions are challenging because they are punishing home health providers for decisions brought on by regulatory change. For instance, one reason for lowering payments under the behavioral assumption adjustment was the assertion that there would be an increased volume of “home health periods of care” that would receive a comorbidity adjustment resulting from considering all 24 comorbidities on a claim rather than just five. Specifically, the intent of the PDGM was to rely more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment groups, with 432 possible case-mix adjusted payment groups.

As a result of the effects of these changes – as well as to PDGM calculations, low-utilization payment adjustment (LUPA) threshold and outlier reimbursement – HHAs will experience even deeper cuts than the 1.7%. Henry Ford Home Health Care estimates that the reduction is closer to 2.3%.

— Henry Ford Health

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You continue to cut reimbursement to providers and limit access to services that impact independence, member health, sustainability for providers, and ability for members to remain at home. You cut these services and then blame the providers for poor outcomes. By limiting access to these services, Medicare in the end spends more money to provide services to members in hospitals and skilled nursing facilities. It is time to support members in their home and maintain their health in the first place. It is far less expensive for Medicare to treat people who are healthy enough to recover than to provide services once diseases have progressed and prognosis is far less positive.

— Anonymous

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“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.”

The post Hospital-At-Home Care’s Future Still Hangs In The Balance appeared first on Home Health Care News.

The report found that patients receiving care through the program differed demographically from those at traditional inpatient facilities. Generally, hospital-at-home (HaH) patients were more likely to be white, live in urban areas, and less likely to receive Medicaid or low-income subsidies. These differences may be due to the criteria established by participating hospitals to identify suitable patients for this type of care.

Patients receiving care at home generally experienced fewer catheter-associated urinary tract infections. Mortality rates were also lower. Those with less complex respiratory and infectious conditions had lower 30-day readmission rates than those in traditional inpatient settings. However, readmission rates for patients with more complex respiratory infections were higher for those receiving care at home.

The study found that patients receiving care at home through the initiative resulted in lower Medicare spending during the 30-day post-discharge period. Furthermore, even though at-home patients received the same services as those in traditional hospital settings, they used fewer of the same services. This suggests that hospitals experience lower costs over time when providing care to patients in their homes.

The study also revealed that at-home patients required care slightly longer than those in traditional settings, but the difference was negligible (less than a day).

Feedback collected from patients, caregivers and family members about at-home care was overwhelmingly positive. Patients reported feeling more relaxed, less anxious and less depressed at home, which seemed to facilitate their recovery. Caregivers and family members believed better health outcomes were one of the main benefits of receiving care in a familiar and comfortable environment.

“People who have been in a brick-and-mortar hospital and also cared for in their home report that they sleep better in their beds and that it is less noisy and confusing,” Nancy Foster, vice president for quality and patient safety at the American Hospital Association (AHA), recently told Home Health Care News. “For older folks who sometimes get confused when they’re away from home, this is a way for them not to experience those challenging effects of being hospitalized but still receive hospital-level care.”

Lessons learned

While the feedback received was primarily positive, it also revealed some limitations and opportunities.

One concern was the potential need for additional care, especially for patients with limited mobility. While approved hospitals are expected to provide all nursing care, including help with daily activities, CMS received feedback that, at times, family members took time off to be with their loved ones or hired extra nursing aides.

Another common concern was the program’s effective implementation. Specifically, there was potential for confusion among clinicians and hospital staff regarding the services provided and among patients about what services are covered by Medicare.

Overall, feedback from patients and caregivers aligned with existing evidence on HaH programs; they generally viewed the care provided as safe, effective and a positive experience.

“Clinicians, doctors and nurses who have been involved in the HaH program are enthusiastic about it,” Foster said. “It allows them to have a deeper relationship with their patients, to see more of what their home life is like, and to be able to advise them on how to recover well and then how to stay well from whatever condition brought them into the hospital, even if that hospital was their home.”

The waivers and flexibilities associated with the AHCAH initiative expire Dec. 31, and its future remains unclear.

“By the end of the year, Congress will need to act to extend the Medicare waiver,” Foster said. “We’ve heard considerations of a bill that would extend it for five years, but we don’t know whether that will be passed.”

Foster added that if the bill is not passed, no fee-for-service Medicare or Medicaid patient could be cared for at home.

“Congress is concerned that we can demonstrate high-quality care being delivered, that we are not putting a tremendous burden on family members or other loved ones in the home, and they have expressed concern about whether this would be equitable,” Foster said. “However, we see a dominance of people with more limited means benefiting enormously from the hospital-at-home program.”

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Hospital at Home (HaH) is a sustainable, innovative and next-generation health care model. From the physician’s perspective, it offers person-centered medical care and keeps patients out of the hospital, away from possible complications and on to better outcomes. However, there are still plenty of challenges for providers to work through.

“People love to have inpatient or acute level care in the comfort of their own home,” Dr. Adam Groff, co-founder of Maribel Health, told Home Health Care News. “The data suggests that for populations studied in multiple areas, [HaH] is a safe service with high-quality care, low readmission rates, low escalation rates, low infection rates and, bottom line, patients love it.”

Maribel Health, based in Hanover, New Hampshire, designs, builds and operates advanced clinical care models in the home and community to expand health system capacity and improve patient access.

While it seems like a win for patients and caregivers, the model has seen growing pains.

“One challenge is clarifying the distinction between HaH care and other in-home health care services like home health or skilled nursing facility (SNF) care,” Heather O’Sullivan, president of Mass General Brigham Home Hospital, told HHCN. 

Based in Boston, Mass General Brigham Home Hospital provides comprehensive home-based care, including chronic, urgent and acute care, directly to patients in their homes.

The structure and implementation of HaH care vary depending on the hospital’s needs, capacity and patient population. Some organizations run the program out of the emergency department and admit eligible patients to their homes. In contrast, others rely on community paramedics or specialty clinics to refer patients to the program.

“While the use of paramedics in health care is not new, the pandemic accelerated the scaling of this workforce to support home-based acute care,” O’Sullivan said. “By incorporating paramedics into the HaH model, we address workforce shortages while enabling health care professionals to practice at the full scope of their licensure. This expansion not only meets the complex needs of our patients, but also ensures that we are using our workforce to its optimal potential.”

The HaH model was introduced at Johns Hopkins in 1995 and was used to manage and treat older patients who refused hospital stays or were at higher risk of hospital-acquired infections.

Early trials of the model found the total cost of at-home care was 32% less than traditional hospital care, the length of stay was one-third shorter and the incidence of complications was dramatically lower.

“HaH can reduce hospital overcrowding and provide care that aligns with patient preferences,” O’Sullivan said. “As health care systems increasingly focus on strategic sustainability amidst a rapidly evolving health care ecosystem, scaling HaH presents a unique opportunity to meet growing patient demand while improving clinical outcomes and satisfaction.”

Though the structure of these programs varies, many commonalities exist. They are well-suited for medium-acuity patients needing hospital-level care, but stable enough for safe monitoring from their homes. They are also suitable for patients with conditions requiring defined treatment protocols, such as pneumonia, congestive heart failure, chronic obstructive pulmonary disease (COPD) or diabetes.

“One of the greatest advantages of this model is that it allows clinicians to enter patient’s homes, offering insights into social and environmental factors that may impact health – insights often missed in a traditional hospital setting,” O’Sullivan said. “This holistic view enables more tailored care.”

The Centers for Medicare & Medicaid Services (CMS) launched the Acute Hospital Care at Home waiver during the pandemic, which created a payment system for HaH through Medicare. Now, the model is popular enough that providers are operating within that waiver – which has been extended to the end of 2024 – but also outside of it.

Launching a program

Novant Health New Hanover Regional Medical Center in Wilmington, North Carolina, began enrolling patients in its HaH program in March. The program is in its early stages and is growing.

“To date, the Novant Health New Hanover Regional Medical Center (NH NHRMC) program has cared for approximately 70 acute patients in their home,” Christy Spivey, senior director of nursing, told HHCN. “Patient experience has been overwhelmingly positive, reaching satisfaction scores of 100%.”

According to Spivey, there have been no unexpected returns to the hospital, and readmission rates are either within or better than those of similar hospitalized patients. Based on the number of patients served at home, NH NHRMC has saved almost 300 in-hospital physical bed days, creating the capacity to keep higher acuity patients in those beds.

“Our health care providers have found great satisfaction in meeting the patient’s needs creatively, allowing the patient to heal in their home environment,” Spivey said. “Often, they find that providing health education is better received by the patient when they are at home. They can also include family members in the plan of care and education, which supports the patients. And the ease of access to the patient via technology makes it easy to see patients from wherever the provider is located.”

Spivey went on to say that patients benefit for many of the same reasons.

“First, they can heal in the comfort of their home, with loved ones, and even pets,” she explained. “They can easily reach a [nurse] or physician by touching a button on a screen if they have a question. Specially trained community paramedics and a physical therapist come to their homes to administer care and therapies, where the approach is tailored to their unique needs.”

Core tenets of the Novant Health program support optimal nighttime sleep, medically ordered meals, and optimized mobility, all tailored to the patient’s unique needs. Pharmacists, case managers, and other care team members can also visit the patient virtually to teach and support the patient’s care plan.

According to Spivey, nationally reported outcomes consistently show patients in these programs have higher satisfaction and lower readmission rates than similar patients who receive care inside the hospital.

Overcoming challenges

To be eligible for the Acute Hospital Care at Home program, patients must meet clinical and social criteria established by CMS. The program has 78 approved diagnoses, including pneumonia, COPD and urinary tract infections.

On Sept. 18, the U.S. House Energy & Commerce Committee approved a bill extending necessary flexibilities to benefit telehealth and hospital-at-home providers.

The Telehealth Modernization Act of 2024 would grant two-year extensions to various telehealth flexibilities implemented during the COVID-19 pandemic. These include continued payment for virtually furnished care services, eliminating in-person or geographic requirements for telehealth providers and supporting audio-only telehealth. These flexibilities are set to expire at the end of this year.

The act would also extend the hospital-at-home waiver by an additional five years. Again, for now, the waiver program is expected to expire at year end.

While the HaH model offers numerous benefits, it also comes with challenges. Significant barriers and limitations exist, including payment reimbursement issues, physician and patient resistance, patient safety concerns and implementation hurdles.

“The single biggest challenge is the looming end of the CMS Hospital Care at Home waiver,” Dr. Stephen Dorner, chief clinical and innovation officer for Mass General Brigham Healthcare at Home, told HHCN. “We need congressional action to extend the waiver and maintain federal support for this incredible care delivery model.”

Regarding challenges to care delivery itself, Dorner said that all health care providers are working to overcome them.

“The first is culture change,” he said. “This is not how people are used to providing or receiving acute hospital-level care, and it takes a lot of time and effort to educate and facilitate buy-in. Then, once people understand the phenomenal quality benefits associated with HaH care and agree to undertake it, the logistical challenges of delivering that care take hold. Orchestrating the complexities of home-based acute care delivery – staff, supplies, patients, equipment, medications, food – can be daunting. Finally, there is a burgeoning market for solutions to these challenges that is waiting on certainty from federal regulators that the waiver will remain in place before activating.”

Most private payers do not cover hospital-level care in the home. Hospitals have had some success with Medicare Advantage (MA) plans and Veteran Affairs (VA), but health systems with insurance plans have a similar opportunity to cover HaH care.

“It’s important for providers to write and call their senators and representatives to let them know they want their support for the continuation of the Acute Hospital Care at Home Waiver,” Dorner said. “When you look at the traditional health care landscape, the growing demand for access, and the ever-longer wait times for care, it’s clear that the status quo is unsustainable. We need new solutions to deliver better care, and HaH is our greatest promise to realize a better future in care delivery.”

The benefits of HaH for patients

Nancy Foster, vice president for quality and patient safety at the American Hospital Association (AHA), told HHCN that she believes people would be surprised at the costs of HaH programs, and the overall benefits.

“We’ve looked at various studies,” she said. “They are comparable to the brick-and-mortar hospital, partly because we use staff time differently. We have staff traveling to the patient and so forth. We need technologies that you might not have to use in the hospital, but that assist with bi-directional communication. So, there are different costs, but the totals are similar.”

Dr. Ronald Paulus, co-founder of Maribel Health, agreed and provided more background.

“The literature is pretty clear that when your emergency department is congested, there’s significant harm that accrues to patients, including excess mortality,” Paulus told HHCN. “So, anything that improves the throughput of my emergency department and inpatient floors is a good thing from a safety perspective. But it is also good from an economic perspective. If you look at how HaH has been studied, it’s been shown to reduce direct costs by just under 40%. It’s at least 20 times more capital efficient, and when the program is run effectively, it can generate double digit EBIDTA margins.”

Standing up a HaH program requires logistical and technical work, which requires time, staff and budget. Some hospitals have partnered with companies that can provide the technology, manage logistics or provide care coordination to facilitate the implementation of a HaH program.

According to O’Sullivan, to support the growth of this model, organizations must continue to focus on expanding the health care workforce and address gaps in education.

“This includes initiatives like industry and academic partnerships to create new career opportunities for students and the innovative use of a broad professional team in the home hospital model,” she said. “We are working closely with educational institutions to address gaps in standardized curricula, ensuring that the future health care workforce is well-prepared to meet the new and undefined demands of this growing model.”

Before the pandemic, there was skepticism that the quality of care provided at home would be as good as in the hospital. This could be changing. As patients are reluctant to go to the hospital and telehealth capacity is growing, HaH care is becoming a more desirable option for providers and patients.

“Growth can be achieved by demonstrating the success of HaH models, advocating for legislative support and continuing to innovate in care delivery,” O’Sullivan said. “At Mass General Brigham, we’ve reached 70 beds in our Home Hospital program. Our pilot program has evolved into a core service, delivering high-quality, patient-centered care at home. Research has consistently shown that patients and caregivers prefer this model due to its proven outcomes and an overall positive experience for all involved.”

Spivey said that overcoming barriers and limitations is an ongoing internal and external process, and that growth depends on the customer’s voice.

“As more people hear about the program, they ask their physicians if they can be included, which will provide more momentum,” she said. “We provide internal education and presentations to physicians, nurses and other team members. Case managers have worked to integrate screening processes into daily patient rounds. Screening protocols for the team have been honed to support more rapid identification of patients, including optimizing the electronic medical record to create patient lists based on inclusion criteria. Also, including family in the initial discussion about the program is critical. If the patient or family is uncomfortable with care in the home, they can decline participation. For those who consent to participate, it is clear that if they become uncomfortable while receiving care in the home, the team will work with them to address the issue or bring the patient back to the hospital, if necessary.”

Dorner said the most significant opportunities for HaH are better patient care, job satisfaction and value.

“We know that the quality of HaH exceeds traditional brick-and-mortar hospital care for the patients who can safely receive care at home,” he said. “We also know that clinicians who join HaH, either as part of a diversified traditional clinical portfolio or as their full-time job, report increased job satisfaction. Some of these clinicians, who otherwise would have left health care at the end of the pandemic, have found the clinical care of HaH to provide more fulfilling, deeper connections to patients, which is why many of us joined health care in the first place. All in all, there’s better value associated with HaH care, and delivering greater value at a greater scale presents a spectacular opportunity for health care across the United States.”

According to O’Sullivan, there is immense potential for health care system transformation using the HaH model.

“HaH can reduce hospital overcrowding and provide care that aligns with patient preferences. As health care systems increasingly focus on strategic sustainability amidst a rapidly evolving health care ecosystem, scaling HaH presents a unique opportunity to meet growing patient demand while improving clinical outcomes and satisfaction,” she said.

Dorner added that there’s a clear upside to investing in the growth of this care delivery model, given the long-term regulatory and financial certainty that will increase patient awareness of the HaH model’s benefits, as well as the hospital’s willingness to break out of the mold and do something innovative.

“Increasingly, we will see improvements to equipment becoming more modular, portable and interconnected,” he said. “We’ll see software solutions to care orchestration to make moving equipment and services across a broader geography seamless. Eventually, this will be the primary method of caring for many conditions that require hospitalization today, and society will greatly benefit from it.”

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Dr. Pippa Shulman, the chief medical officer at Medically Home, believes the home will eventually become the lynchpin of the U.S. health care system.

“What you’re going to see is a full shift to the idea of hospitals, as a place where you seek ICU care, surgical care and emergency care for trauma, but that everything else can be delivered in the home,” she recently told Home Health Care News.

At Medically Home, Shulman and her colleagues have worked to drive the hospital-at-home movement forward by helping a number of health care organizations enter the space and scale.

Shulman discussed this during an interview with HHCN, which took place during the FUTURE conference last week. During the discussion, Shulman also touched on why it’s important to embrace technology that is actually helping clinicians solve problems, and her predictions around the future of the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home waiver.

HHCN: Can you talk about how you’ve seen hospital-at-home establish itself as a notable care delivery model in broader health care, and what this has meant for patients?

Shulman: What people don’t realize is hospital at home has actually been a care delivery model in this country for more than 20 years, just generally on a small scale, and usually in health systems that have integrated payer networks, or that are like the VA. There had been a lot of slowly growing interest, really brewing in 2017, 2018. Right around that time, CMMI put out a demonstration grant opportunity that Mount Sinai and the Marshfield Clinic took advantage of.

About that time was also when I was establishing a program in Massachusetts. We all know what happened just a few years later, which was the Covid pandemic. With the sudden need for capacity in space, home hospital was ready. That was really the turning point.

The second turning point was when CMS issued the waiver allowing for reimbursement. That was such a missing piece to this story, and then you had a rush into the space from all sorts of interested parties, which was wonderful. It allowed for small systems and big systems to get involved where they might not have, and it allowed for Medicare reimbursement, which had really not been a part of the play until that point. Now, you have 10 states where Medicaid is reimbursing for home hospital. The outcomes are terrific. The data keeps coming in really strong. The pandemic was such a terrible moment for our health care system, but that moment allowed for this incredible time of innovation.

In your view, how has Medically Home moved the needle forward in the larger hospital-at-home movement?

I came to this as a primary care provider, but I also was doing home-based medical care. I ran a home-based primary care, home-based post-acute care, a SNF program, and worked for an organization where my goal was to keep my patients out of the hospital.

When we were looking to set up a home hospital program, we needed help with logistics and technology. Technology is a bit of a commodity. You can get that from anywhere, but how do I get oxygen in the middle of the night to my patient’s bedside? How do I get blood drawn when I need it, and get it transported? Home nurses are a wonderful resource, but many of them only travel with the supplies they need that day, and often can’t respond to an emergency situation despite the fact that many of them want to, and so you have to retool an entire system.

That’s really the idea of Medically Home. How can we support logistics and the coordination of care, so that a physician in the hospital doesn’t have to worry about whether the care is going to get there?. It is really allowing for the extension of that hospital’s brand, so to speak, right into the home. That’s the power of the model, and the missing link for so many that want to scale and build, particularly for smaller or mid-sized health systems.

Partnerships are crucial to the company, as Medically Home helps companies scale their hospital-at-home programs. What should companies that want to move into this space be looking for in a partner?

We partnered with a number of wonderful national partners in the home health care space. I think it is, first of all, really looking beyond traditional home care.

We are not talking about the home health episode in an OASIS form anymore. I know a lot of people are saying that, but I think that’s really No. 1. It is thinking about your workforce in a different way. How do I need to upskill my workforce? How do I need to potentially add new competencies to my workforce, and be able to respond to dynamic needs of a home hospital program? The home hospital program may start out taking care of older patients with acute exacerbation of chronic disease, but they’re going to quickly morph into wanting to take care of post-surgical patients, younger patients and cancer patients.

Can you adapt with them to be able to provide those services? Can you develop cooperative education agreements? Can you help source supplies? Can you take care of more than one need? Maybe you came in with skills around nursing, but are there skills that you can add to your wheelhouse that maybe you didn’t have before. It’s still about problem solving, and coming up with new solutions.

What are some clinical challenges you believe that hospital-at-home should be focused on?

One clinical challenge I think about a lot is — as people are getting more and more interested in care that comes into home, there’s a lot of money and focus on technology, sensors, remote patient monitoring. We need to make sure that if we’re going to put something in a patient’s home, that we are getting clinically actionable, accurate data from it, and that it’s safe to use.

I worry about the proliferation of technology that’s of little use. I want to make sure that we’re developing technology that is actually solving a problem we have, and that is able to replace and add to the home hospital environment, not just solve a doctor’s anxiety.

Similarly, I think about things like point-of-care testing. If we really want to expand the services we can provide in the home, we need to make sure that we can get testing and results as close to the patient as possible, to reduce the time from assessment to diagnosis to treatment.

We already know we can get plain film X-ray and ultrasound. They’re already working on things like CT in trucks, but [I’m hoping to see] different kinds of technology to be able to do more imaging, to do more point-of-care testing, so that we could detect infection sooner.

In 2023, Medically Home moved into ED in the Home. Are there some other ways Medically Home would like to collaborate with providers to shift care in the home? Things the company isn’t doing right now? How is Medically Home moving towards this?

We really think about all elements of care that could be decentralized into the home.

The idea of ED in the Home is just, a patient has an emergent need, can we respond to it? Let’s take a step back.

If we have the ability to deploy a person or a resource to the home 24 hours a day on-demand, how can we connect that with all sorts of other care systems that already exist?

Think about the novel program you could develop for cancer patients – and we’ve done a lot of studies and trials of cancer patients and supporting them through their cancer journey. If we had cancer patients be able to say, ‘Hey, I’m not feeling well today,’ knowing that they don’t have to go to the hospital, but that we could come to their house and deliver treatment for their symptoms right then, imagine how that would change that cancer patient’s journey. We’ve done studies that show that it does change their journey.

I really think about these ways that we can use the ability to deploy our services, and deploy a clinician, to the home on-demand, with longitudinal care, with chronic disease management programs, again, targeted at the right patients. The patients want help when they have a problem, and if we know how to address it at that moment, and avoid them going to the facility in the hospital, you’ve really broken that cycle of facility-based care altogether.

Do you have a prediction for the next five years for the home-based care space at large?

My prediction is before the end of the year, we are going to pass the waiver that’s going to allow an extension for home hospital care, which I’m very excited about, that’ll give us a nice, long runway. What that will allow us to do is collect more data, and lay out a path to permanent payment. That will open a door for us to be able to prove out acute care-at-home on a much larger scale, and move into obs care, cancer care — some of these other care models I’ve been talking about. 

What you’re going to see is a full shift to the idea of hospitals as a place where you seek ICU care, surgical care and emergency care for trauma, but that everything else can be delivered in the home.

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“[Graham Barnes’] track record of growing and nurturing health care companies gives us deep confidence in his ability to elevate Medically Home and build on the strong market position that has been achieved to date,” Maneesh Goyal, chairman of the board of directors for Medically Home, and COO of the Mayo Clinic Platform at the Mayo Clinic, said in a press statement. “We would also like to extend our heartfelt gratitude to Rami Karjian for his dedication and leadership bringing Medically Home to where it is today.”

Boston-based Medically Home partners with organizations to help them deliver hospital-at-home services, as well as emergency department services in the home. The company coordinates in-home visits, sets up the proper technology and equipment, and pulls together all of the necessary resources.

In April, Boston Medical Center rolled out a new hospital-at-home program. The health system launched this in collaboration with Medically Home.

Later that month, BrightStar Care also announced that they would provide primary in-home clinician and transport services with Medically Home.

As part of the leadership transition, former CEO Rami Karjian will remain at Medically Home in a new advisory role, along with co-founders Raphael Rakowski and Andy Lipman.

“Both Medically Home and the overall movement to decentralize care are at an inflection point,” Karjian said in the press statement. “Medically Home’s platform has already successfully cared for more than 40,000 patients and we expect the market to accelerate with new opportunities in the future as Graham takes the helm. We are proud of all that has been done establishing this new model of patient care delivery and believe we have set a new standard in patient care that will endure. We welcome the next chapter for Medically Home under Graham’s proven leadership.”

Barnes has been the CEO of multiple companies, including HealthWyse, HealthyCircles and and Concerro Inc. He has served in multiple advisory roles over the last few years as well.

“I am honored to be appointed to lead Medically Home and advance its innovative model of care,” Barnes said in the statement. “Medically Home has built a safe and robust clinical, logistics, and operational model that underpins acute care at home and post-acute care at home for more than 20 organizations. There is tremendous potential to continue partnering with leading healthcare organizations to provide patients and the clinicians who serve them with our scalable care model.”

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Ultimately, the goal is to reduce unnecessary emergency room visits or hospitalizations. The urgent care service line will be added to Lifespark COMPLETE, Lifespark’s value-based population health business.

The Minnesota-based company provides home health, home care, hospice, primary care and senior living, among other services. Those services are offered to a wide range of patients. Within Lifespark COMPLETE, however, all of those services are available to members.

In COMPLETE, Lifespark has taken global risk. It is responsible for patient outcomes, full stop. And, while many home-based care companies want to take on more risk, it comes with a lot of responsibility.

That’s why in-home urgent care was added, according to Lifespark CEO Joel Theisen. It was one of the last situations where the company felt like it needed to fill a gap for its patients.

“We’re taking full, upside-downside risk,” Theisen said. “And we’re building brick, by brick, by brick. We felt this was important. With what we saw in our data, we needed it. We always wanted to do it.”

The mobile and urgent response team is made up of nurses and paramedics. They can deliver care in the home to prevent a hospitalization, but also can coordinate a visit to the hospital if that is what the patient needs. In the latter situation – where a patient does need to go to the hospital – Lifespark’s team is able to brief the inpatient facility on the specifics of a patient to ensure interoperability.

Lifespark will also be coordinating telehealth visits with doctors as part of the in-home urgent care offering.

“When someone goes into the hospital [unnecessarily], the experience is horrible,” Theisen said. “The costs are horrible. It’s like a bomb going off. And that’s where delirium sets in. That’s where all this fear and angst sets in. As we were strategizing, we knew we had the proactive, the predictive and the prescriptive pieces down, but we needed the acute reactive. We needed the urgent response, because when we do miss, we have to stay connected – because we know the member better than anyone else.”

Lifespark will also ensure a safe and seamless transition back to the home after a hospital visit, if it’s needed.

Dexter Braff, the founder and president of the M&A firm The Braff Group, told HHCN last year that the best way for a home-based care company to go at risk would be to build a home-based care continuum from the start.

In essence, that is what Lifespark has been trying to do.

“Who’s going to say, ‘I’m going to build my organization specifically to go at risk with payers. I’m not worried about the silos that are artificially created by Medicare, Medicaid, or hospitals,’” Braff said. “You’d do home health, hospice infusion therapy, home medical care, physician housecalls, build that organization and have some capacity in a very, very tight footprint. Then go to the payers and say, ‘I’ll take care of all that, and I’m going to charge you X number of dollars per member, per month.’”

Right now, Lifespark COMPLETE is a Minnesota operation, though Lifespark does do work outside of the state. The COMPLETE census is generally around 3,000 or more.

In the future, Theisen wants the operation to grow – by number and by geography.

“Our plan is to take this nationally,” Theisen said. “But for now, we’re going to do everything we can to keep learning, through the data and through listening to our customer base on how to make it better. It’s going to be slow, it’s going to be iterative. But it is definitely not just a flash in the pan.”

As part of the in-home urgent care launch, Peter Carlson has also joined Lifespark as the VP of acute response services.

Carlson previously served as the chief of paramedicine for Medically Home, as well as the community paramedic coordinator (and operations manager) for Mayo Clinic.

“We have a big commitment here, and I hope the nation follows,” Theisen said. “I hope people really feel that they can actually take the risks, and actually get in the game in a more meaningful way to serve seniors.”

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The efforts to unionize first started in February. On May 16, 80 of the health system’s home-at-hospital nurses voted to join the Massachusetts Nurse Association (MNA). That same month, the National Labor Relations Board certified the union to be representatives for the nurses. 

Currently, the union is collectively working on what issues to bring to contract negotiations.

Bridget Ellis, a registered nurse at Mass General Brigham’s home hospital program, said that one of the factors that led these nurses to unionize was feeling like clinicians should have greater input.

“With new policies rolling out and new procedures being formed, we felt that our input, being in the field, was extremely important to be able to maintain patient and nurse safety,” she told Home Health Care News.

Ellis hopes that hospital-at-home nurse unions become more common as more programs continue to launch across the country.

“I see this as a sort of health care of the future, and I don’t think it’s going anywhere, anytime soon … so if the nurses and these programs get ahead of it, and they unionize at a time that is really pressing, I think it’s going to benefit the program overall,” she said.

As of June, there are more than 331 hospitals and 136 health systems across 37 states delivering hospital-at-home care through the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home waiver. Health systems are also delivering that level of care outside of the waiver program, through other payment mechanisms.

Mass General Brigham is one of the big players in the hospital-at-home space. The health system originally rolled out its hospital-at-home program in 2016, which predates the CMS waiver.

Over the next couple of years, Mass General Brigham is looking to expand the hospital-at-home program from 50 to 200 patients. This also somewhat contributed to the decision to form a union.

“There is a way to expand to 200 patients in a safe way, but when our opinions and experiences aren’t being taken into consideration, the number seems very scary, going to 200 patients,” Ellis said. “We thought if we can give our input and talk about our experiences — what’s working, what’s not working — it is a manageable thing to do. You need to hear from the people who are doing the job and who are seeing the patients.”

Mass General Brigham expressed dissatisfaction with the result of the vote to unionize.

“While we are disappointed with the outcome, we recognize that this election is part of a continuing national trend among health care providers seeking collective bargaining through union representation,” a Mass General Brigham spokesperson told HHCN in an email. “As an organization dedicated to providing safe, high-quality care to our community, we recognize the importance of working collaboratively with our nurses, physicians, and other health care providers to address the needs of our patients and community. We remain focused on that critical mission.”

Hospital at home isn’t the only way that Mass General Brigham is serving patients in the community.

Home health care, palliative care and other home-based care services are also part of Mass General Brigham’s service offerings.

In addition to the health system’s nurses, clinicians at Mass General Brigham’s home care segment are also in the process of voting on whether to unionize.

Karen Estey, a speech language pathologist at Mass General Brigham Home Care, said that things like changing productivity expectations and wages, among other factors, contributed to the decision to vote on unionization.

About a year ago, clinicians at Mass General Brigham Home Care were informed that the health system would be rolling out some changes. These policy changes were not uniform across the agency, and not equitable, according to Estey.

“As a speech pathologist, we have a very large territory,” she told HHCN. “Some of the speech pathologists were told that we needed to be seeing 25 to 27 patients a week, just like OT and PT, who have a smaller territory, and the nurses as well. It was not something that was going to be feasible for us. I was told 20 patients, another therapist was told 24 patients, and they work fewer hours than me. The messaging just wasn’t the same. They tend to try to keep us in silos without us really being aware of what’s going on.”

Clinicians at Mass General Brigham Home Care are also seeing more higher-acuity patients, which is more challenging to manage.

“I love working in someone’s home because it’s treating them where they’re most comfortable,” Estey said. “We’re able to do really functional tasks, so there’s some real benefits to being able to see someone in their home environment. There’s also been a real push to keep people out of hospitals. We have more and more patients coming home quickly out of hospitals, and sometimes opting to skip the rehabilitation portion, like a rehab hospital or a skilled-nursing facility stay. Our patients have become more acutely ill, and we’re now tasked with trying to keep them home, and keep them safe. That is incredibly hard to do when you’re being asked to see more people.”

Earlier this month, clinicians at Mass General Brigham Home Care received ballots, which will be counted at the end of June. This segment of the health system has over 400 clinicians.

Mass General Brigham Home Care have received support from their colleagues on the hospital-at-home side of the health system.

Estey thinks it’s likely that the vote to unionize will pass.

“There’s just such strong support,” she said. “Typically, I know it can take like a year or so to unionize. We started working on this on Valentine’s Day.”

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That’s according to a new survey from Vivalink, a digital healthcare solutions company that offers remote patient monitoring (RPM).

“Hospital at home is a very fast growing and a very high interest market segment, and we’re paying a lot of attention to that market,” Vivalink CEO Jiang Li told Home Health Care News.

The survey responses come from over 1,000 U.S.-based individuals who are 40 years and older.

One of the survey’s key findings is that 84% of respondents are interested in participating in hospital-at-home-related monitoring, rather than being monitored in the hospital, so that they can return to their home in a more timely manner.

Survey respondents’ overwhelming desire to receive care in their home wasn’t surprising, according to Li.

“Human beings really like the comfort of their home, and if they can get health care in a friendly and familiar environment — it’s much less stressful,” he said.

Indeed, the survey also found that 77% of respondents said they would trust a recommendation from a health care professional that directed them to utilize hospital-at-home-related monitoring.

Plus, among the respondents who tried hospital at home, 84% said that the experience with their program was positive.

Survey respondents also reported an easy user experience with devices that were part of their care plan. Specifically, 49% of respondents said that RPM devices are easy to use.

On the flip side, the 16% of respondents who were not likely to participate in hospital-at-home programs named issues with devices as a big reason for this.

Still, Li pointed out that user experience with devices is very dependent on the company the hospital-at-home program decides to partner with.

“If you step back and look at all the devices available on the market, I’ll say the device to device variation, in terms of the patient experience, varies a lot,” he said. “It really depends on the [care] service provider, and what kind of device they choose to give to a patient, that in turn will significantly impact the patient experience.”

The survey also found that the awareness of hospital at home was generally lower among older adults. In fact, only 42% of respondents aged 70 and older had heard of hospital-at-home programs, compared to 77% of respondents in their 40s.

Older adults were also less likely to participate in hospital-at-home programs. Only 11% of respondents said they had previously participated, while 66% of respondents in their 40s had been part of these programs.

People who live urban areas were also more likely to participate in hospital-at-home programs than their counterparts living in rural communities.

However, respondents living in urban areas were less likely to prefer completely remote primary care than those living in rural communities.

Factors such as the number of hospitalizations a person had also played a role in willingness to partake in hospital-at-home programs. Respondents that had three hospitalizations or more over the past 12 months were more interested in hospital-at-home programs than those who had two hospitalizations or less.

Li hopes that the type of data highlighted in this survey will move the needle in terms of pushing the extension of the Acute Hospital Care at Home waiver forward. 

“There’s a lot of data and evidence already exists supporting the case for extension, this is another data point for them to consider,” he said.

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Plano, Texas-based Resilient is a technology company that enables health care organizations to deliver higher-acuity care in the home.

Meanwhile, Tyler, Texas-based Choice Health at Home is a home health, hospice, palliative care, rehabilitation and home care services provider. It operates locations across Arizona, Colorado, Kansas, Louisiana, Nevada, Oklahoma and Texas.

The collaboration between the two companies kicked off because of another one of Resilient’s partnerships, Jackleen Samuel, CEO of Resilient, told Home Health Care News.

“We were introduced through [Community Hospital Consulting],” she said. “We were introduced because we’re providing the hospital-at-home programs for the hospital and Choice Health at Home has been their preferred provider for home health. It made sense for us to work together.”

In 2023, Resilient joined forces with Community Hospital Consulting – a Community Hospital Corporation organization – on a joint venture partnership.

On its end, Choice Health at Home has a relationship with Community Hospital Consulting that spans almost 20 years.

Even prior to this introduction, through Community Hospital Consulting, leaders at Choice Health at Home had been aware of Resilient’s work.

“Jackleen and Resilient did a lot of good work during the pandemic with the initial initiative from CMS, so we’ve watched that from afar … and we were excited to have the opportunity to work with Resilient,” Choice Health at Home CEO David Jackson told HHCN.

Through the partnership, Choice Health at Home will have access to Resilient’s comprehensive tech stack.

“We’re developing, managing and operating these hospital-level programs into the community, and when we do that, we introduce different technologies to be able to execute on higher-acuity care in the home,” Samuel said. “Some of those technologies are the actual operations and management tied to that, but others are like our 12-lead ECG device that we have a partnership with and have integrated into our program. It’s also remote patient monitoring, 24/7, continuous monitoring, and then being able to utilize those to build on the high-acute programs that we’re developing for the hospitals.”

Samuel also pointed to Choice Health at Home’s experience serving communities as being a key component of this collaboration.

“It’s one thing to program develop and whiteboard what it might look like to reinvent the delivery of health care, it’s a whole other thing to actually deliver that care,” she said. “As we’ve become pioneers or experts in the space of program development for hospitals to enter the community, working with somebody like Choice Health at Home that has a 20-year relationship in these communities and delivering this care, and knowing the clinical aspects of delivering that care, is the one of the best partnerships that we could have thought of.”

Both Samuel and Jackson noted that the partnership between Choice Health at Home and Resilient aims to bridge the gap between home health care and hospital at home.

“This is a new initiative, it’s the frontier of what’s happening,” Jackson said. “The current technologies that home health utilizes are not built for hospital at home, so we hope that a lot of the work that we do with Resilient will help bridge that gap to make hospital at home and home health accessible to more patients.”

Looking ahead, Samuel believes that this type of partnership will become more common among organizations delivering hospital-level care in the home.

“I think hospital at home becomes a marriage between hospitals, technology and providers in the home, and I don’t think it’ll be successful unless home health agencies are involved,” she said.

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