Medicare’s Acute Hospital Care at Home (AHCAH) waiver program rolled out in 2020, providing reimbursement for the care model that gained popularity in response to Covid and strains to inpatient capacity. The addition of payment led many health systems to explore the model, though there has been continued discussion around the HAH model’s viability, with challenges around census, staffing, and model scalability. And, while not a permanent fix, reimbursement for the HAH model was extended through September via the CR just passed by Congress.
In this context, THMA recently interviewed the Mayo Clinic Health System, Mass Brigham General, and Mount Sinai Health System to discover how they successfully implemented and scaled their Hospital-at-Home programs. Here are our findings.
Six Commonalities
1. Many programs are expanding beyond care outlined in the waiver: Some of the most successful programs in this space are continuing to grow their average daily censuses by reaching new patient populations, often at higher levels of acuity or need (e.g., post-surgical care at home, SNF at home, palliative care at home, oncology-at-home).
Broad trends are pushing the industry in this direction: while the number of seniors with chronic diseases is projected to double this decade, inpatient hospital and SNF closures have reduced capacity to care for these patients in traditional settings.
Systems are targeting higher acuity patients within their H@H programs. While most programs initially focus on patients with simpler conditions (e.g. UTIs or cellulitis) with shorter average LOS, private payers that reimburse for H@H are concerned that a focus on low-acuity patients undercuts the value proposition and potential for savings.
“As we’ve matured, we certainly see higher acuity patients coming into the home. The expectation that we’ll be taking care of complex patients in the home has really gone up.” - Denise Keefe, SVP of the Continuing Health Division at Advocate Health
2. Many systems see strategic value even in absence of reimbursement: Systems typically reach a financial breakeven point at around 30 patients, but most programs are still well below this figure. Indirect benefits justify these programs’ costs to some system leaders.
Capacity and arbitrage: Many systems with strong H@H programs face problems with a lack of sufficient capacity in their inpatient facilities. In addition, some systems also face strict limits on their ability to build additional inpatient beds (factors include capital constraints, rising construction costs, and CON laws). Moving eligible patients home frees inpatient up beds for higher acuity patients.
Quality and cost: Payers are interested in H@H care’s potential for higher quality care (e.g., lower readmissions) and cost savings. Several program leaders say they’ve negotiated for reimbursement parity with inpatient care and would prefer to reinvest savings back into the program.
Patient satisfaction: Systems want to give patients options, and many patients express a preference for home care when offered. A 2024 survey found that 47% of U.S. adults expressed a preference for home hospital care.
“We want to go from acceptable to preferable… When we can get to the point where it’s smooth and sleek like Amazon, and the patient can get what they need instantaneously with an app on their phone, then we’ve won the game, that’s really what we’re aiming for.” - Dr. Michael Maniaci, medical director for Mayo Clinic’s Care Anyplace division
3. There’s greater urgency to work with private payers: Uncertainty about the fate of the federal waiver program has driven urgency among many systems to establish or expand home hospital contracts with commercial and MA payers. In addition to the higher-acuity service lines mentioned above, some systems are also catering to lower acuity patients that need less monitoring than required by Medicare in the waiver.
4. More systems are looking at partnerships for scale, collaborating with other providers and vendors to drive faster growth, especially with respect to technology and software platforms that often fall outside of their core competencies.
Some home hospital programs have sought to jumpstart their connections with payers by leveraging their partners’ existing relationships.
Some health systems without their own substantial H@H programs are also considering partnerships with other health systems that have scaled-up programs in their market or adjacent markets. This could allow them to leverage these capabilities (and get capacity relief) without investing in their own infrastructure.
5. Staffing remains a key limit on growth, even for scaled programs: Industry-wide shortages of clinical staff (including nurses) and high turnover make it more difficult to build out home hospital programs as they start to achieve greater scale. This challenge is compounded by the fact that home hospital staff need additional training to operate effectively in this relatively novel care setting.
There’s growing interest in the industry to enable paramedics to provide in-home support in lieu of an APP or nurse—a model that 18 states currently allow.
“Our top three challenges are staffing, staffing, and staffing… it takes time, you need to hire the right people, and you need to make sure they’re trained properly in this relatively new and growing model of care.” - Dr. Ania Wajnberg, president of Mount Sinai at Home
6. Local market conditions can limit or expand a program’s growth potential: Even if your system’s program is doing everything right, local factors can put a hard limit on scale and cost-effectiveness. And conversely, some markets are a natural fit for Hospital-at-Home expansion.
Density: Home hospital programs in dense urban markets benefit from reduced travel times for staff (who are traveling from the participating hospital and between multiple patient homes).
Facility construction: Real estate is also typically more expensive in these markets, adding to the challenges of building out inpatient capacity. CON laws are also a limiting factor in some states.
Hospital type: A study published in JAMA last year found that uptake of the Medicare AHCAH waiver was concentrated among large urban teaching hospitals.
In addition to their dense geography, these systems often have greater resources that they can invest in the program during early stages.
Policy environment: Some states have more complex regulations for home health and home hospital care that add to the compliance burden for systems.
Only 12 state Medicaid programs offer reimbursement for home hospital care.
Learn how:
The Mayo Clinic implemented and improved its Advanced Care at Home program by broadening eligibility, increasing care offerings, and implementing new AI and advanced data analytics technology.
Mass Brigham General built MGB Healthcare at Home (the largest hospital-at-home programs in the country) and increased its care offerings (adding general medicine, post-operative capabilities, etc.) and expanded its footprint to reach underserved communities.
Mount Sinai has transformed its home hospital program since 2014 to offer more services, increase its remote monitoring technology, and quadruple its size.
Read the full report here.