Congress should extend a waiver of hospital care at home

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HHospitals can be places of healing and, at times, of suffering, especially for older people with complex medical conditions. For duly selected patients requiring hospital care, hospital care at home offers the advantages of hospital care in the comfort and safety of the home and facilitates a better understanding of the medical and social context of patients.

Hospital-at-home programs across the country expanded after the Centers for Medicare and Medicaid Services began paying for these services in November 2020 to address pressures hospitals have faced during the pandemic.

Since launching in August 2021, our UMass Memorial Health home hospital team has cared for nearly 300 acutely ill patients who would otherwise have spent days in the traditional hospital. Reflecting the results of randomized controlled clinical trials, our hospital-at-home program has demonstrated excellent results in quality, safety and patient satisfaction.

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Still, hospital-at-home programs across the United States are at significant risk of contraction unless Congress acts to extend the waiver for acute hospital care at home.

Here’s an example of how the program works: Late in the afternoon, our hospital home team at UMass Memorial Health assessed a patient we’ll call Joe. He presented to the emergency room with a serious kidney infection requiring hospitalization for close monitoring, specialist consultation and intravenous antibiotics. Joe’s case has been complicated by the fact that, at 62, he has diabetes, kidney disease and had a kidney transplant several years ago. After his evaluation in our emergency department, it was clear that Joe needed ongoing hospital care. Our home hospital nurses and doctors reviewed his medical records, performed a home safety review to understand and mitigate the risks, and determined that Joe was a good candidate for home hospital care. After hearing about our Home Hospital Program as an alternative to traditional hospital care, Joe chose to be admitted to our Home Hospital Program.

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Joe was transported to his home by ambulance, met at his home by a hospital nurse and introduced to his hospital doctor via telehealth. Upon admission, Joe was connected to his hospital home care team via remote vital signs monitoring devices that monitor his heart rate, oxygen level, blood pressure, temperature and weight and transmit information via a tablet that allows responses 24/7 from nurses. doctors with rapid response at home by clinicians within minutes if needed. These connections between Joe and his care team were facilitated by the wireless technology we brought into the house. This technology does not require the patient to have Internet service, which is important because 22 million seniors across the country do not have broadband Internet access at home.

With the Home Hospitalization program, Joe and patients like him have access to the same services offered in a traditional hospital, but in a familiar environment without the associated risks of hospitalization for the elderly – confusion, falls and infections. In addition to 24/7 monitoring and care, doctors see him every morning via video, and nurses visit him at home at least twice a day.

Another benefit of hospital care at home is that by caring for Joe in his home, our team was able to identify and overcome barriers to health, including difficulties in adhering to a complex medication regimen, declining memory and the limits of financial resources.

As Joe’s kidney infection improved, we were able to coordinate a simpler treatment regimen, develop a plan for closer family support, and connect Joe with community resources.

The tragedy is that Joe, and other medically complex and socioeconomically disadvantaged patients who are on Medicare or traditional Medicare, will soon lose access to the option of hospital care. at home unless Congress acts to expand the CMS Acute Hospital Care at Home waiver before the end of the federal public health emergency.

Hospitalization at home is not new. In fact, hospital home care has been studied and delivered to patients in the United States for almost 25 years. For appropriate patients, hospital home care reduces mortality by 20-30%, readmissions by 20-30%, and the need for patients to be transferred to rehabilitation facilities after hospital stay by 80 at 90%, with associated improvements in total over 30 days. costs. Patient satisfaction with hospital home care, on the other hand, is higher compared to traditional hospital care.

Before the emergence of Covid-19, hospital-at-home programs were generally small. Traditional Medicare — the largest health insurer in the United States — did not pay for hospital care at home. As a result, hospital-at-home programs were more likely to be instituted in health care systems with global budgets, such as the Veterans Health Administration, or those with resources to invest in home-hospital development before certainty. payments. Poorer safety net health systems, which typically serve more patients on Medicare and Medicaid and whose patients could have benefited from this program, have often been unable to invest in these programs due to lack of reimbursement. administration costs for this type of coverage by insurers such as Medicare.

The Covid-19 pandemic has dramatically accelerated the growth of hospital-at-home programs in the United States, from less than 50 before the pandemic to more than 200 today. In November 2020, amid an increase in hospitalizations across the country, CMS announced the Hospital Acute Care at Home Relief Program to help expand hospital capacity. For hospitals that have applied for and been approved for this waiver program, CMS has waived certain conditions for participation in traditional Medicare and Medicaid, allowing hospitals to provide and be paid to provide in-home hospital care while holding accountable for quality and safety reports.

Health systems have embraced hospital-based home care for their patients. The more than 200 CMS-approved hospital-at-home programs across the country provide safe and effective care with reporting mandates in place to ensure that the same highly favorable outcomes seen in previously published clinical trials of care are maintained. home hospitals. Patients covered by traditional Medicare or Medicaid are now routinely offered the choice of receiving the same care they would have received in the traditional hospital in the comfort of their own home, an option that did not exist before the CMS waiver.

Any patient with an eligible condition – severe Covid pneumonia, bacterial pneumonia, exacerbation of heart failure, exacerbation of lung disease, skin and soft tissue infections, etc. – who requires hospital care should have access to hospital care at home. Unfortunately, uncertainty about payment for hospital home services now threatens to slow the growth of this safe and effective model of care. Many healthcare systems cannot afford to take the risk of implementing new hospital-at-home programs knowing that payment for these services could disappear within just a few months when the federal public health emergency takes hold. end.

In our hospital-at-home program, 32% of patients receive traditional Medicare, 25% of patients receive Medicaid, and 18% of patients receive both Medicare and Medicaid, representing some of the most complex populations on medical and socio-economically disadvantaged people we serve. When the federal public health emergency expires, the Acute Hospital Care Waiver Program will also disappear, and our patients who receive traditional Medicare, Medicaid, or both will lose access to hospital care at home. , creating a major equity challenge in the distribution of this safe and effective model of care for our health system with a safety net.

The bipartisan Inpatient Services Modernization Act, introduced in the Senate and House of Representatives earlier this month, gives hope for the future of hospital-at-home programs. By extending the CMS waiver for acute hospital care at home, this legislation will help ensure that all patients – regardless of race, ethnicity or socio-economic status – continue to have access to safe hospital care. and effective at home.

Constantinos Michaelidis is a hospitalist and medical director of the UMass Memorial Health Hospital at Home program. Candra Szymanski is a registered nurse and associate vice president of the UMass Memorial Health Hospital at Home program.

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