Bringing Hospital Care Home: Transitional or Transformative?

This is the final post in a four-part ACCCBuzz blog series on the hospital-at-home model. Before reading below, be sure to check out the first, second, and third post in this series.

“The diversity of hospital-at-home programs highlights the commitment to innovation that is often necessary to implement these approaches.” — Hospital at Home Users Group™

Atrium Health and Blessing Health System serve large rural areas in several states. To differing degrees, both health systems are engaging in hospital-at-home models, leveraging technology to improve access to care for acutely ill patients in service areas that include large rural populations. Both are members of the Hospital at Home Users Group.

Atrium Health is also among 19 health systems—including Vanderbilt University Medical Center, UNC Health, WakeMed Health and Hospitals, Sentara Healthcare, and H. Lee Moffitt Cancer Center & Research Institute—that are currently participating in the acute Home Hospital Early Adopter Accelerator Program. This collaboration between CaroNova and Ariadne Labs, which launched in September 2021 “aims to provide the tools and resources needed for [health] systems to succeed in the launch of their home hospital program.”

Blessing Health System was selected from a highly competitive applicant pool to participate with Ariadne Labs in its Rural Home Hospital program. This three-year clinical trial is assessing if these models can provide high-quality care and maintain cost savings. Appalachian Regional Health is the other U.S. health system selected to participate in the trial.

With the COVID-19 pandemic has come increasing health system attention to the hospital-at-home model. With the Centers for Medicare & Medicaid Services (CMS) waiver in place during the COVID-19 Public Health Emergency (PHE), a growing number of institutions have applied for and been granted the CMS Acute Hospital Care at Home program waiver.

In early March 2022, the Hospital Inpatient Services Modernization Act (H.R.7053/S.3792) was introduced by Senators Thomas R. Carper ( D-DE) and Tim Scott (R-SC), and in the House by Representatives Brad Wenstrup (R-OH) and Earl Blumenauer (D-OR). This legislation would extend the CMS Acute Hospital Care at Home waiver flexibilities for two years beyond the end of the COVID-19 PHE. According to Moving Health Home, a coalition advocating for the home as a site for clinical care, extending the waiver would allow time for additional data collection and development of legislation to make the at-home acute care hospital program permanent under Medicare. In the absence of congressional action, the CMS Acute Hospital Care at Home waiver will end when the COVID-19 PHE ends.

For a virtual panel on Advancing Acute Care into the Home, Modern Healthcare tapped Stephanie Murphy, DO, medical director, Atrium Health Hospital at Home, and Irshad Siddiqui, MD, executive vice president and chief of Information Technology and Innovation, Blessing Health System; and Maulik Majmudar, MD, chief medical officer and co-founder, Biofourmis. The session was part of Modern Healthcare’s recent Hospital at Home virtual briefing.

No Better Time

Both health systems had specific drivers accelerating the launch of their acute hospital care at home programs. For Atrium Health, the COVID-19 pandemic was a tipping point. Atrium implemented its program during the pandemic, hoping to support continuous access to quality care despite potential disruptions due to COVID-19 surges. For Blessing Health System, participation in the Rural Home Hospital program was a further catalyst to innovation.

Advancing the Model

For the model to advance, panelists agreed that two changes are essential:

1. Payment by payers
2. A shift in the way that providers look at healthcare.

Dr. Murphy emphasized that to drive innovation “we must speak not just to cost but to quality.” A critical way to accomplish this is to contribute to the growing body of research and literature on the model’s value. Dr. Murphy also added that to be sustainable, these models must align with patients’ needs and values.

The panel then discussed three key questions that institutions should answer when considering integration of an acute care hospital-at-home program:

1. What gaps will the program fill? Look at the needs of your healthcare system and thoroughly understand the gaps you are trying to fill with the at-home care delivery model, Murphy urged. Health systems need to clearly identify the problem they are trying to solve, Dr. Majmudar agreed. Capacity management? Transitioning to value-based care? Participation in a local payer demonstration project? The program should be tailored to the institution, he said.
2. What patients will be eligible for participation? Outside of the COVID-19 pandemic, patient identification is very challenging, Murphy said. In talking to programs around the country, she has found that patient identification is everyone’s Achilles’ heel. A further challenge is integrating the model across multiple sites. What resonates with some care sites or at the system-level may not resonate elsewhere, Dr. Murphy cautioned.
3. How will the model integrate with existing provider workflows? At Atrium Health, its acute hospital-at-home care program was launched with a specific focus on COVID-19 diagnoses. Because of this, the workflow was integrated with emergency department and inpatient physician workflows. Murphy explained that as the pandemic wanes, the health system is working to shift the protocol to non-COVID-19 diagnoses.

In implementing a new care model, Majmudar suggested that institutions start small, with a niche diagnosis to prove the model, and then consider how and where to expand.

As health systems innovate to develop hospital-at-home models, Dr. Murphy emphasized that it is important to remember that healthcare is only a piece of patients’ every-day experience. “As much as we can fit into their life, the better for that patient,” she said.

Closing the Gap or Deepening the Divide?

Asked to speak to how the hospital-at-home model might help decrease disparities in care and improve access for rural populations, Dr. Siddiqui expressed cautious optimism. While the model is “a great opportunity to improve access,” unless it is operationalized correctly, he said, there is risk of worsening inequity.

Rural communities face persistent challenges. Some areas have seen no progress in improving internet broadband access. Their distance from everything, including healthcare services and family members, often means hours of driving. For providers, awareness of the rural population’s uniqueness and differing cultural norms like discomfort with data sharing are important, Siddiqui noted. On the other hand, when care is delayed because people do not want to go to the hospital, the at-home hospital model offers an option for accessing care earlier rather than later, Dr. Siddiqui said. While technology is a double-edged sword in terms of mitigating access disparities in rural settings, “I think there is huge potential to solve the problem as opposed to exacerbating it,” he said.

Evaluation of the patient’s in-home space, as part of hospital-at-home protocol, presents an opportunity to identify and address care barriers, Dr. Murphy noted. In a brick-and-mortar healthcare setting, providers can only ask patients about their living situation. Patients living in less-than-ideal circumstances may not feel comfortable sharing this information, she said. But because hospital at-home models require an evaluation to determine if the home can serve as a site for clinical care, providers gain a better picture of patients’ living conditions, Murphy said. This allows healthcare systems to bridge gaps, so patients can be successful going forward.

Dr. Siddiqui agreed. “Care delivery in a non-clinical setting opens up this whole opportunity for addressing social determinants of health and socio-economic factors. It gives us a lot more to solve, and those are things we want to solve for.”

Among the challenges in advancing the hospital-at-home model are questions about continuity of care and transitional care management, Dr. Siddiqui said. “How do we keep primary care offices involved in the continuum of care?” At Blessing Health System, the model is under the hospitalist service line, because hospital-at-home care is a complex undertaking, involving equipment, meals, and medications, Dr. Siddiqui said. However, to integrate the model, health systems must address new care transition questions, such as: How to hand-off patients when they are discharged? How will the health system address technology that may need to stay with patients? How will data be shared with a primary care provider after transferring care?

On the Horizon

To conclude the session, panelists were asked to share the one hospital-at-home development on the horizon that they are most excited about. For Dr. Murphy, it is “watching this care delivery model flex for all,” rural, urban, suburban populations; seeing how this unfolds and develops over time. Dr. Siddiqui is excited about the opportunity for more data, as more patients receive care through these models, and the capacity to develop algorithms to understand what patients do well on these programs, and how we can inform decisions at the point of care. Lastly, Dr. Majmudar envisions a future where patients presenting to the