Inpatient Notes: The Future of Hospital-at-Home Care Soumya Rangarajan, MD, MPP; and Grace Jenq, MD H ospital at home (HAH) has been extensively studied in many countries since the 1970s. Numerous random- ized controlled trials of HAH, including those at Johns Hopkins Hospital and Brigham and Women's Hospital, have shown the safety and efficacy of hospital-level care delivered in the home. These studies show that HAH programs result in similar lengths of stay, quality of care, safety, and patient experiences as typical inpatient hos- pitalizations, while delivering increased patient physical activity, decreased cost, and decreased 30-day readmis- sion rates (1). Hospital at home has become the stand- ard of care in several countries, including the United Kingdom and Australia. In Victoria, Australia, 6% of all hospital bed–days are through HAH, including 58% of patients with deep venous thrombosis and 25% of patients with cellulitis. In 2008 to 2009, the care of 32 462 inpatient episodes was delivered at home, equivalent to the yearly volume of a 500-bed hospital (2). CHALLENGES AND OPPORTUNITIES Why has HAH's expansion in other industrialized nations not been replicated in the United States? Nearly all countries with HAH have a universal single-payer health care system. In these systems, health care expenditures are capped as a percentage of the nation's gross domestic product. Therefore, these systems tend to invest in mobile technologies and remote monitoring that serve more patients at a lower cost (2). The United States has a primarily fee-for-service health care system. Because HAH programs generally use fewer medical services (such as laboratory tests, imaging, and procedures), they often receive smaller payments. Before the pandemic, risk-based payment models through Medicare Advantage were the primary financing mecha- nism for HAH (3). In risk-based models, medical providers are paid a standard fee per patient, and are responsible for providing high-quality medical care within this budget. Much like nationalized health care programs in other coun- tries, this encourages innovation outside of the expensive hospital setting. However, risk-based models lead to higher payment uncertainty, so uptake has been slow. Logistical barriers have also hampered growth of HAH. Many cities at the forefront of HAH are in densely populated urban centers, where hundreds of thousands of patients are easily reached within a 5-mile radius of the hospital. However, many hospitals in the United States have patients traveling hundreds of miles across several states to seek medical care. Some hospitals have creatively overcome these logistical hurdles. The University of Utah Huntsman Cancer Institute's successful oncology HAH program expanded to underserved rural communities through community health workers, local registered nurses, and therapists who understand the unique needs of their populations (4). In addition, medical providers (including emergency department providers, hospitalists, and inpatient specialist consultants) are accustomed to brick-and-mortar acute hospital care. Successful HAH programs require that these providers alter their normal workflow and develop new practice patterns. These types of changes take time, espe- cially if providers are unaware of the capabilities of HAH programs. For example, most physicians are unaware that HAH programs can deliver intravenous medications several times daily; daily laboratory and radiologic evaluations; and in-person assessments by nurses, medical providers, therapists, and so forth. As programs grow, having trainees participate in HAH through their residency curriculum should lead to better understanding of the programs and broader acceptance. THE ACUTE HOSPITAL CARE AT HOME WAIVER The COVID-19 pandemic only exacerbated already unprecedented inpatient and emergency department capacity constraints. Previously, all Medicare-reimbursed hospital care required 24/7 on-site nursing availability. However, in March 2020, the Centers for Medicare & Medicaid Services (CMS) eased regulatory restrictions on where inpatient care could occur, and in November 2020, CMS created the Acute Hospital Care at Home waiver. Under this new rule, a hospital is paid the exact same Medicare diagnosis-related group payment regardless of whether the care is provided in the hospital or the home. Hospitals must apply for the waiver and have regular mor- bidity and mortality–style meetings to show quality, safety, and ongoing quality improvement. In addition, patients must be admitted to HAH from the emergency depart- ment or hospital (that is, the waiver currently does not cover emergency department–avoidance HAH admis- sions directly from an outpatient clinic or the patient's home). The CMS waiver was a turning point for HAH in the United States. Since 2020, a total of 250 hospitals across 112 health systems in 37 states have started HAH pro- grams. However, the future of regulatory reform from the HAH waiver is uncertain beyond 2022, and congres- sional legislation will be necessary to ensure that Medicare will continue to provide similar reimbursement. Bipartisan bills are currently working through the U.S. House of Representatives and U.S. Senate (5). Currently proposed legislation would extend HAH regulations for an additional 2 years and would also expand telehealth reimbursement. THE FUTURE OF HAH Hospital at home is here to stay. Some health sys- tems have enlisted their own home health agencies, infu- sion companies, and more. Private companies have also joined the HAH revolution, delivering logistical assistance and patient monitoring in easy-to-use devices. Permanent changes to CMS regulations and increased dissemination of alternative payment models (that is, risk-based payment) HO2 © 2022 American College of Physicians ANNALS FOR HOSPITALISTS Annals of Internal Medicine Downloaded from https://annals.org by University of Michigan on 12/21/2022.