Hospital stays are hard. What if you could get care at home?
The pandemic pushed Medicare to start paying for “hospital-at-home” care for the first time, launching the largest test ever of home-based hospital care.
David Mercurio’s problems in the hospital started right away.
“The first two nights when I was there, about 3 in the morning, two patients outside in the hallway were yelling and screaming and throwing things,” Mercurio said.
In November 2020, the 70-year-old construction business owner landed at UMass Memorial Medical Center in Worcester, Massachusetts, after he woke up at home with a raging fever and little control of his body.
Doctors identified the problem as a rare tick-borne illness. In the hospital, doctors and nurses constantly came in and out of Mercurio’s room — standard procedure given his condition, but it left him sleep-deprived and cranky. And data show people over 65 can become delirious or pick up new infections in the hospital.
After a week, his doctors said he could finish his hospitalization at home.
The concept of “hospital at home” has been around for decades. The idea is that hospital-level care can be provided to patients with conditions like pneumonia, heart issues and skin infections in their own homes through a mixture of home visits from medical staff and telehealth. Dozens of randomized controlled trials have found lower mortality rates, readmission rates and costs for hospital-at-home patients.
But before the COVID-19 pandemic, only about two dozen programs existed in the U.S., in large part because Medicare, which provides health insurance to 65 million mostly older Americans, refused to pay for it. The U.S. Centers for Medicare and Medicaid Services funded a few small pilots, but federal health officials withheld widespread payment over concerns about patient safety and fraud.
As the pandemic overwhelmed hospitals, CMS began to see replicating hospital care at a patient’s home as a way to provide much-needed capacity. In a matter of weeks in November 2020, CMS put together a special waiver that allowed hospitals to apply to offer hospital-at-home and receive the same payment they would for an inpatient stay.
“We and colleagues had been working on this for a long time, and then, bam, because of the pandemic, it moved through very, very quickly,” said Bruce Leff, a geriatrician at Johns Hopkins and a leading hospital-at-home researcher.
Like building a ‘new wing’ of the hospital
As of March 20, 277 hospitals have received approval from CMS to operate hospital-at-home programs, although researchers like Leff estimate only about half have started treating patients due to the challenges of setting up a program.
Indiana currently has six approved hospital-at-home programs, according to CMS. Kentucky has one at Appalachian Regional Healthcare
UMass Memorial Medical Center set aside $2 million in February 2021 to launch a hospital-at-home program, said Constantinos Michaelidis, the program’s medical director. The hospital had to hire new staff, find vendors to provide things like X-rays, meals and internet in patients’ homes, as well as create new workflows and contingencies.
“If a nurse is walking between room A and room B in the middle of the winter, that nurse is not thinking to him or herself, ‘Oh, gosh, I need a four-wheel drive vehicle,’ whereas we do think about that. We do make those investments,” he said.
Some hospitals outsource much of this work to a handful of companies that specialize in building and running hospital at home programs. With their help, hospitals have built programs in as little as four or five weeks, according to Leff. UMass did it themselves, and after six months, they admitted their first patient in August 2021.
Michaelidis said they started with just a few patients to make sure they could deliver quality care, but by the time David Mercurio was admitted in November 2022, UMass had treated nearly 750 patients at home.
Bringing the hospital home
David Mercurio was thrilled at the chance to finish his hospitalization at home.
“This is the way I looked at it: They're going to give me the same treatment they're going to do in the hospital. And I trusted them in the hospital, so why wouldn't I trust them at home?” he said.
His wife Melanie was skeptical. She knew David would be more comfortable at home, but would he be safe?
“He was still pretty weak at the time,” she said. “I'm thinking to myself, are they doing this because he's whining so much about wanting to go home and they're just trying to pacify him and say, OK?”
David’s doctors and Melanie’s daughter – who worked at the hospital – convinced her, and the evening of David’s eighth night, Melanie drove lead-car in a caravan headed for home. Behind her was a car with two nurses, and bringing up the rear was David in an ambulance.
When they got home, the nurses took David’s vitals while he sat in his gray recliner with his Pomeranian, Kiwi Belle, by his side.
“It was fantastic,” David said.
Instead of big, beeping bedside machines, the nurses slipped a small white band on David’s arm to allow his UMass clinical team to constantly monitor things like his skin temperature, heart rate and oxygen level from the hospital. The wooden table next to his chair became a command center of sorts, filled with medications and a tablet that David could use for telehealth or emergencies.
For the next eight days, nurses came to the house twice a day, and during at least one of those daily visits, Michaelidis or another doctor would join via video. When Melanie worried that David had a blood clot, the hospital sent someone out to do an ultrasound as David sat in his recliner.
“They came for ultrasound, EKG, IVs,” David said. “Whatever they needed [to do], they did right in my home.”
Critics worry about patient safety and hospital closures
David’s experience luckily was relatively smooth, but sometimes patients deteriorate and need to get back to a hospital. CMS requires programs to be able to get them there within 30 minutes, which some critics say is too long.
“We are talking about response needed in seconds, not minutes,” said Michelle Mahon, the assistant director of nursing practice for National Nurses United, the largest nurses union in the country, which fiercely opposes hospital at home.
For Mahon, the 30-minute rule starkly illustrates the inherent danger. Remote monitoring, she said, can miss subtle cues that someone is at risk — things a nurse in a hospital would catch.
“We are with them all the time so we can see changes from day to day, in the glossiness of their eyes or in the smell of their breath. These are the kinds of signals that are alert to us,” she said.
Mahon dismisses the dozens of studies on hospital at home’s effectiveness as too small and sees the practice as an unsafe money grab by hospitals looking to cut labor costs and close physical hospitals. Some hospitals do see the program as a way to save money, but they reject the idea that they’re putting profits over patient care.
Nathan Starr, who runs the hospital-at-home program at Intermountain Healthcare in Utah, said his health system is spending 30 to 40 percent less on hospital-at-home patients without any dip in outcomes. He said much of those savings come from reduced nighttime nursing ratios.
“Typically in a hospital, one nurse will take care of five to six patients 24 hours a day. At home, what we've definitely found is patients sleep, and so our nighttime nursing ratios can be very minimal,” he said.
While many hospital-at-home programs rely heavily on nurses to lead in-home care teams, CMS also allows hospitals to use “community paramedics,” who have less training and are less expensive than nurses.
Another concern critics raise is the potential burden on family members, who are often the ones constantly checking on their loved one. There are no regulations around what hospitals can or should ask of family caregivers.
Melanie Mercurio said having David home did put extra pressure on her. She helped him up and down the stairs, gave him his medications and even collected his urine.
But she said she felt supported. When she had questions, she used the tablet to call the 24/7 help line and got immediate answers from doctors or nurses.
Unanswered questions remain
Despite concerns raised by the nurses union and others, hospital-at-home continues to gain momentum.
Medicare payment was set to expire along with the federal COVID public health emergency, but in December, Congress voted to extend the program through at least 2024. Thousands of patients have been treated in hospital-at-home programs nationwide since November 2020, and reports from individual hospitals and preliminary data on the first 11 months of the CMS waiver suggest patients continue to fare as well or better than their inpatient counterparts.
But disagreements and unanswered questions remain, including which patients are best suited for hospital-at-home and how it should all be paid for.
Pretty much everyone agrees that patients who require surgery or intensive care need to be in a physical hospital, along with any patient who prefers to be in one — hospital-at-home is voluntary. Some practitioners think any patient who needs continuous monitoring of their vitals — a standard part of many hospital-at-home programs — should also be in a hospital. Others are comfortable treating patients with cancer or recent organ transplants at home.
“I do think a lot of what goes on now in hospitals can be done in the home,” Leff of Johns Hopkins said. “Everything? No. But I think hospitals of the future become big ICUs, big ERs and operating rooms.”
A randomized controlled trial is underway to test the feasibility of hospital at home in rural areas that are more spread out and may have less reliable internet access.
Experts say more research is also needed to understand the impact of hospital-at-home on racial and economic health disparities. People in public and other low-income housing have received hospital care at home, and some studies show it can be even more beneficial for people on Medicaid — the public health insurance program for low-income and disabled Americans — than Medicare. Many supporters say allowing clinicians into people’s homes helps them better identify and address social determinants of health like food insecurity.
Policymakers and supporters believe paying for hospital-at-home at the same level as an inpatient stay was necessary to convince hospitals to make the initial investments. But there’s now significant interest, including from hospitals, in figuring out a more appropriate long-term payment model.
“It feels like you need to take a look at what are the resources, what do the patients look like who are getting care in hospital-at-home to make sure payments are fair and adequate and not creating incentives to give patients care at home that they may not be clinically appropriate for,” said Amy Bassano, a former CMS official who’s now the managing director for Medicare at the health care consulting firm Health Management Associates.
Bassano thinks more patient safety and outcome data is needed before further expanding hospital-at-home, but she believes some amount is here to stay.
“I think this is something that will be very hard to just say, nope, never doing it again,” she said. “[I think] this will continue to be an option available for hospitals and patients.”
This story comes from the health policy podcast Tradeoffs, a partner of Side Effects Public Media. Dan Gorenstein is Tradeoffs’ executive editor, and Ryan Levi is a reporter/producer for the show, which ran this story on March 23.
Tradeoffs coverage of issues facing older Americans is supported in part by The SCAN Foundation — advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence.
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