Effective Care: California Left Behind as Other States Expand Hospital at Home Programs

Originally published in California Health Law News

[co-author: Tiffany Okeani]

Hospital at Home (“HaH”) programs received renewed interest during the COVID-19 pandemic as a way to relieve hospital capacity issues and allow patients to receive effective care outside of the traditional hospital setting. In the post-pandemic era, Medicare extended the waiver allowing HaH programs, and some states have supported HaH efforts by providing Medicaid funding. Despite decades of research showing that HaH programs are safe and cost effective, California is not allowing its hospitals to offer HaH programs.

1. What is HaH?

In HaH programs, patients receive acute care in their homes. Hospitals provide hospital equipment, monitoring, and a multidisciplinary team of clinicians that monitor and care for the patient, typically with multiple daily visits.¹ Although programs can vary, they tend to offer similar services, and they tend to restrict the program to patients receiving treatment for certain conditions who live within certain geographic areas. They may also restrict the program by payor type.

For example, the University of Chicago Medicine’s HaH program, which the University had not started building until 2023, includes the following:

• Provision of medical equipment, including a tablet to connect the patient to the remote monitoring team;
• Medications, imaging, lab tests delivered at home;
• Daily meals, if needed or requested;
• Twice a day in-person visits by a nurse at the patient’s home;
• Daily telehealth visits with a physician;
• Daily call from a nurse to coordinate care and check in on treatment; and
• Specialty consultations when needed.²

In addition, University of Chicago Medicine’s program is limited to patients who are Medicare beneficiaries receiving treatment for certain conditions (such as chronic obstructive pulmonary disease or an acute infection) and who live within 30 minutes of the Hyde Park campus.³

In addition, patients who need assistance with daily activities must have a caregiver who is staying with them.⁴

Mass General Brigham, which has offered HaH since 2017, offers services comparable to the University of Chicago Medicine in its HaH program and similarly limits the program to patients who live within a 30-minute drive time of a participating Mass General Brigham campus.⁵ Mass General Brigham’s program had 70 beds by October 2024 and claims to be the largest HaH program in the United States.⁶ Further, Mass General Brigham announced in early November 2024 that it will partner with the New England Center and Home for Veterans and Ariadne Labs to offer the HaH program at a homeless shelter for veterans in Boston.⁷

1. HaH Programs Offer Quality Improvements and Can Lower Costs

Research shows that HaH can be safer and more cost-effective than traditional hospital stays and can be particularly good for patients vulnerable to hospital-acquired infections and other problems with hospital care.⁸ Studies have found reductions in inpatient-induced delirium, 30-day readmission rates, mortality, stress in patients and caregivers, and pressure sores resulting from immobilization.⁹ In fact, a Center for Medicare and Medicaid Innovation demonstration showed that HaH programs also lowered Medicare costs.¹⁰ In addition, the study showed that “patient and family care experience is better.”¹¹ Centers for Medicare & Medicaid Services (“CMS”) released a report in September 2024 stating that their analysis showed that acute HAH inpatient episodes had a longer average length of stay (of less than a day) than comparable inpatient episodes but had significantly lower Medicare spending in the 30 days post-discharge.¹² CMS noted that HaH patient selection criteria and differences in clinical complexity “make it difficult to definitively conclude” that the HaH program resulted in lower Medicare spending.¹³ CMS added that interviews with patients, families, and caregivers showed that they had an overall positive experience.¹⁴ Interviews with clinicians showed that they also had a positive experience.¹⁵

Development of HaH in the United States

Although the concept of HaH was first developed in the U.S. by geriatricians in the 1990s, it has never been widely adopted so it still has the feel of a groundbreaking service.¹⁶ HaH programs are more widespread in England, Canada, and Israel and supported by payment policies that reimburse HaH care.¹⁷

In March 2020, the CMS launched the “Hospital Without Walls” initiative, using waiver authorities under section 1135 of the Social Security Act, which permits the Secretary to waive certain facility standards during declared public health emergencies (“PHEs”).¹⁸ This initiative was a comprehensive effort to maximize resources and combat COVID-19, waiving hospital physical environment and Life Safety Code requirements to allow for the delivery of care beyond hospital walls and an increase in hospital capacity to continue critical non-COVID-19 care.¹⁹

In November 2020, CMS launched the Acute Hospital Care at Home (“AHCaH”) waiver program initiative allowing for fee-for-service Medicare-certified hospitals to treat patients with inpatient status at home by waiving the Condition of Participation (“CoP”) requiring 24-hour and seven-day-per-week onsite nursing.²⁰ Hospitals also had to integrate the program with the physical hospital enough to ensure that a patient could be seamlessly transported and admitted to the physical hospital when needed.²¹ CMS reimbursed AHCaH claims at the same level as inpatient care, including equal payment of the facility fee.²² To participate, a hospital had to apply and be approved by CMS.²³

In December 2022, President Biden signed into law H.R. 2617, the Consolidated Appropriations Act for Fiscal Year 2023, which extended waivers and flexibilities associated with the AHCaH initiative until December 31, 2024.²⁴ HaH proponents have been seeking to make the waiver program permanent.²⁵ As of the beginning of November 2024, the waiver had not been extended.

3. HaH Programs Can Face Lack of Payment, High Upfront Costs, and Patient/Clinician Skepticism

Prior to the November 2020 CMS waiver, there were about 20 HaH programs in the U.S., predominantly in Medicare Advantage and Veterans Affairs settings.²⁶ Lack of payment by traditional Medicare and commercial payors was a significant barrier to establishment of HaH programs.²⁷ Furthermore, implementing a HaH model was challenging for hospitals, considering that building a HaH requires a virtual hospital unit with full supply chains and logistics management to assure highly reliable, high-quality, safe care.²⁸ In addition to the high upfront costs and lack of reimbursement, additional obstacles include generating sufficient patient volume to achieve cost effectiveness, overcoming healthcare professionals’ and patients’ concerns over care quality and safety, securing an adequate supply of skilled professionals, and ensuring reliable telehealth and remote monitoring technologies.²⁹

3. HaH Current Status

Medicare’s AHCaH program has led to growth of HaH programs across many states. As of March 2024, 321 hospitals in 37 states had obtained a waiver.³⁰ Furthermore, in a research letter published in the January 2024 issue of Annals of Internal Medicine, researchers at Mass General Brigham reported positive results from the AHCaH waiver-related HaH programs. The researchers examined outcomes of 5,858 patients from across the U.S. who were cared for under the AHCaH waiver, using Medicare fee-for-service Part A claims filed between July 1, 2022 and June 30, 2023.³¹ They concluded that patients tended to do as well as if they had been in a traditional brick-and-mortar hospital, and they were not likely to suffer a setback requiring a quick return to the ER.³² The researchers found a 0.5% mortality rate and 6.2% escalation rate (returning to the hospital for at least 24 hours).³³ In addition, within 30 days of discharge, 2.6% of patients were admitted to a skilled nursing facility, 3.2% died, and 15.6% were readmitted. The five most common discharge diagnoses were heart failure, respiratory infection (including COVID), sepsis, kidney/urinary tract infections, and cellulitis.³⁴

3. California Prohibits HaH Programs

On May 11, 2023, the Department of Health Care Services (“DHCS”) and California Department of Public Health (“CDPH”) ended their AHCaH program, stating that CDPH does not have statutory authority to license this type of care with the expiration of the state’s PHE.³⁵ The California Legislature’s Assembly Committee on Health noted a number of California laws that make a HaH program challenging to license, including mandated nurse staffing ratios, pharmaceutical service requirements, and fire safety requirements, among others.³⁶

Adventist Health was the only hospital system to be granted a CDPH license to operate an AHCaH pilot in California.³⁷ Although the system provided over 6,000 days of HaH home care to more than 1,100 patients throughout California, Adventist Health closed its last HaH site in March 2022.³⁸ It appears that unless the California Legislature affirmatively allows for HaH programs and provides for the waiver of certain Title 22 hospital requirements, California cannot and will not allow for the development of HaH programs. This result is despite the fact that in the last decade, the number of emergency departments (EDs) and hospital beds have decreased in California while the state’s population and demand for acute care services have increased.³⁹ HaH programs crucially divert eligible patients into a home setting, thereby improving inpatient capacity, access to care for more patients, and the care experience, from which the state of California could greatly benefit.

The need for flexible, responsive care delivery models has never been more apparent. The COVID-19 pandemic highlighted the vulnerability of the U.S. healthcare system, a system that tethers nearly all care delivery to physical facilities such as hospitals, skilled nursing facilities, and assisted living facilities, among others. HaH programs have demonstrated feasibility, efficacy, and effectiveness; and, if given the choice, many patients would select an HaH program.⁴⁰ As the American population ages and telemedicine and remote monitoring advances, California can rise to the occasion by re-implementing its HaH program to further the health of its vulnerable patients and match increasing demands for acute services.

¹ Department of Health and Human Services Administration for Strategic Preparedness and Response (“HHS ASPR”), Technical Resources, Assistance Center, and Information Exchange (TRACIE), Acute Care Delivery at Home (April 2021), https://files.asprtracie.hhs.gov/documents/aspr-tracie-acute-care-deliveryat-home-tip-sheet-.pdf.

² Emily Ayshford, Hospital at Home: New Program Brings the Hospital to Patients’ Homes, Univ. of Chicago Medicine, Feb. 6, 2024, https://www.uchicagomedicine.org/forefront/patient-carearticles/2024/february/hospital-athome.

³Id.

⁴Id.

⁵Mass General Brigham, “Home Hospital,” https://www.massgeneralbrigham.org/en/patient-care/services-andspecialties/healthcare-athome/home-hospital#accordiond62a140507-item-b9d2b29251.

⁶ Giles Bruce, How Mass General Brigham Built the Largest ‘Hospital at Home,’ BECKERS HEALTH IT (Oct. 30, 2024), https://www.beckershospitalreview.com/telehealth/how-mass-generalbrigham-built-the-largest-hospital-athome.html; American Hospital Association, Providers Betting Big on Future of Hospitals at Home, April 9, 2024, https://www.aha.org/ahacenter-health-innovation-marketscan/2024-04-09-providers-bettingbig-future-hospital-home.

⁷Giles Bruce, Mass General Brigham 1st to Expand ‘Hospital at Home’ Outside the Home, BECKERS HEALTH IT (Nov. 7, 2024), https://www.beckershospitalreview.com/digital-health/mass-generalbrigham-lst-to-expand-hospital-athome-outside-the-home.html?origin-BHRE&utm_source-BHRE&utm_medium-email&utm_content-newsletter&oly_encid=3536E1785601I5X.

⁸S. Klein Hospital at Home Programs Improve Outcomes, Lower Costs But Face Resistance From Providers, Payers, The Commonwealth Fund, citing to B. Leff, L. Burton, S. L. Mader et al., “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients,” Annals of Internal Medicine, Dec. 2005 143(11):798-808

⁹HHS ASPR, supra note 1.

¹⁰Bruce Leff & Arnold Milstein, What We Learned From The Acute Hospital Care At Home Waiver—And What We Still Don’t Know, HEALTH AFFAIRS FOREFRONT (June 27, 2022), https://www.healthaffairs.org/content/forefront/we- learned-acute-hospital-care-home-waiver-and-we-still-don-t-know.

¹¹Id.

¹²Centers for Medicare & Medicaid Services (“CMS”), Report on the Study of the Acute Hospital Care at Home Initiative (Sept. 2024), https://www.cms.gov/newsroom/fact-sheets/fact-sheet-report-studyacute-hospital-care-home-initiative.

¹³ Id.

¹⁴ Id.

¹⁵ Id.

¹⁶Bruce Leff et al., The Acute Hospital Care at Home Waiver and the Future of Hospital at Home in the US, HEALTH AFFAIRS FOREFRONT (May 3, 2024), https://www.healthaffairs.org/content/forefront/acute-hospital-carehome-waiver-and-future-hospital-home-us; Leff & Milstein, supra note
¹⁷ Sarah Klein, “Hospital at Home” Programs Improve Outcomes, Lower Costs But Face Resistance From Providers, Payers, THE COMMONWEALTH FUND, https://www.commonwealthfund.org/publications/newsletterarticle/hospital-home-programs-improve-outcomes-lower-costs-faceresistance

¹⁸CMS, Acute Hospital Care at Home Data Release Fact Sheet (Jan. 16, 2024), https://www.cms.gov/newsroom/fact-sheets/acute-hospital-care-home-data-release-fact-sheet.

¹⁹ Id.

²⁰Center to Advance Palliative Care, Acute Hospital Care At Home Program Frequently Asked Questions, https://www.capc.org/documents/download/882/.

²¹ Id.

²²Eileen Applebaum & Rosemary Batt, The New Hospital at Home Movement: Opportunity or Threat for Patient Care?, CENTER FOR ECONOMIC AND POLICY RESEARCH (Jan. 24, 2023), https://cepr.net/report/the-new-hospital-at-home-movementopportunity-or-threat-for-patientcare/#:—:text-Critics%20argue%20that%20hospitals%2C%20home%2Ohe alth%20agencies%2C%20and,emergency°/020medical%20service%20%28EMS%29%20employees%20to%2Oreplace%20RNs.

²³CMS, Acute Hospital Care at Home, https://qualitynet.cms.gov/acute-hospital-care-at-home.

²⁴Id.

²⁵Eric Wicklund, Congress Eyes Expansion of Hospital at Home Care Model, HEALTHLEADERS (Feb. 9, 2024),

https://www.healthleadersmedia.com/innovation/congress-eyesexpansion-hospital-home-caremodel#:-:text-The%20Acute%20Hospital%20at%20Home,Subscribe

²⁶ Leff et al., supra note 16.

²⁷ Leff & Milstein, supra note 10.

²⁸Id

²⁹Pamela Pelizzari et al, Hospital at Home: Should Payment Models Focus on the Hospital or the Home?, MILLIMAN REPORT (May 2022), https://www.milliman.com/-/media/milliman/pdfs/2022-articles/5-24-22-hospital-at-home-millimanwhite-paper.ashx.

³⁰ Leff et al., supra note 16

³¹ David M. Levine et al., Acute Hospital Care at Home in the United States: The Early National Experience, ANNALS OF INTERNAL MED (Jan. 9, 2024); D. Thompson, Getting Hospital-Level Care at Home is Safe, Effective: Study, US NEWS & WORLD REPORT (Jan. 9, 2024).

³²Id.

³³ Id.

³⁴Id.

³⁵California Department of Health Care Services, The Acute Hospital Care at Home Program, https://www.dhcs.ca.gov/Pages/Acute-Hospital-Care-at-Home-Program.aspx. See also California Legislature, Assembly Committee on Health, Hospital at Home: Considerations for Future Implementation, https://ahea.assembly.ca.gov/sites/ahea.assembly.ca.gov/files/Background%20papoer.pdf.

³⁶ California Legislature, Assembly Committee on Health, supra note 35.

³⁷ Id.

³⁸Id.

³⁹Elizabeth Fernandez, Why Wait Times in the Emergency Room Are So Long in California, UCSF.EDU (June 22, 2023), https://www.ucsf.edu/news/2023/06/425661/why-wait-timesemergency-room-are-so-longcalifornia.

40Jay A. Pandit et al., The hospital at home in the USA: current status and future prospects, NPJ DIGIT MED. 7, 48 (2024), https://doi.org/10.1038/s41746-024-01040-9.