Inside the top 8 hospital-at-home programs

Once patients get a taste of being cared for at home, will they ever want to go back to the hospital?

"Would you give up Amazon tomorrow and just go back to department stores?" Michael Maniaci, MD, physician lead for Rochester, Minn.-based Mayo Clinic's hospital-at-home program, told Becker's. "The genie's out of the box."

Hospital-at-home care has grown exponentially in recent years, enabled by technological advances and regulatory changes, allowing acute-care patients to be treated in the comfort of their homes alongside pets and loved ones.

But which health systems are leading the way in this care model? And what will it take for it to reach its full potential?

Becker's reached out to leaders of the largest hospital-at-home programs around the country to find out. Here is where they rank by average daily census, according to health systems that agreed to provide data for this story:

1. Atrium Health (Charlotte, N.C.): 45-50 patients per day

When COVID-19 hit, Atrium Health looked for solutions for overcapacity. The 40-hospital system already had robust programs for community paramedicine and home medical equipment, so it was quickly able to set up a new "hospital" — in people's homes. In early 2021, the program hit a peak census of 131.

Atrium intends to get back to those big numbers soon, with plans for an average daily census of 50 patients by the end of 2023, 100 in 2024 and 200 in 2025 — the equivalent of a medium-sized hospital. The program has served roughly 8,000 patients, saving about 30,000 inpatient bed days.

"It's had a significant impact on capacity — that is still our primary business case for doing this program," said Colleen Hole, BSN, administrator of Atrium's hospital-at-home program. "But as a clinician, I believe the highest value is to our patients who experience healthcare differently and better in their own environment."

Post-pandemic, the program largely treats infections such as cellulitis and pyelonephritis, and patients with exacerbated chronic conditions, such as heart failure, COPD and diabetes. Nationally, the most common diagnoses have been respiratory infections and inflammation (8.7%), heart failure and shock (5%), and sepsis (3.1%), CMS researchers found.

"As the population of baby boomers, of which I am one, gets into their senior years, we're carrying more chronic conditions," Ms. Hole said. "So we've got to figure out a different way to manage acute-care patients short of building more brick and mortar, which no one can really afford."

Readmission rates are lower than the in-hospital population, while patient satisfaction scores are upward of 10 points higher, Ms. Hole said. "It really shifts the power, frankly, from us healthcare people to the patient and the family," she said. "And that power shift is part of the secret sauce."

Two major challenges for the program include how to identify more eligible patients, which Ms. Hole said could be a job for artificial intelligence and EHR-based algorithms, and reimbursement, as some commercial payers and state Medicaid programs don't cover home hospital, and the CMS waiver for reimbursement is set to expire at the end of 2024.

2. Mass General Brigham (Somerville, Mass.): 25-33 patients per day

Started in 2016 at Boston's Massachusetts General Hospital and Brigham & Women's Hospital, the program recently expanded to an additional three hospitals. It has the capacity for 40 beds, hoping to one day reach 10% of inpatient capacity.

Stephen Dorner, MD, chief clinical and innovation officer of Mass General Brigham Healthcare at Home, listed all the various "decreases" so far: costs, readmission rates, mortality, post-acute facility utilization, testing use, immobility.

"Then on the experience front, patients love it, caregivers love it, and our staff and clinicians love it," he said. "For many of our clinicians who have been practicing for years, they say their home-based care encounters are among the most satisfying that they've ever delivered."

Research has found that home-based hospital care costs about a third less than inpatient treatment, he said, all without having to build new facilities. The more than 11,000 patients treated under the waiver found they had low mortality rates and few complications, according to a CMS study.

"The value proposition is there for systems," Dr. Dorner said. "The bigger gap and investment that's required up front is the know-how to do it."

He said there's interest in expanding the program to post-operative recovery, post-delivery recovery for new mothers, and behavioral health.

Dr. Dorner said the ultimate goal is to provide a "home-based complement of the entire care continuum": from primary to acute care to rehab, all without "having to be inside of a facility."

3. Mayo Clinic (Rochester, Minn.): 25-30 patients per day

Since launching in July 2020, the health system has treated about 2,800 acute-care patients in their homes. The program is live at Mayo's hospitals in Phoenix, Jacksonville, Fla., and Eau Claire, Wis. Mayo's flagship location in Rochester hasn't adopted home hospital because it doesn't have the same capacity issues (though virtual beds may factor into Mayo's planned $5 billion campus in Rochester).

Quality metrics show the care is "at least equivalent, if not better than a physical hospital," said Michael Maniaci, MD, physician lead for Mayo's hospital-at-home program. The initiative started with a basic diagnosis such as heart failure and cellulitis and has since advanced to post-care for surgeries and transplants such as bone marrow.

Dr. Maniaci said the "most limiting factor" to hospital-at-home programs is logistics.

"It's easy to deliver care to five people, but if you want to do it to 50 people at any one time, you have to build a supply chain of nurses, paramedics and pharmacists in each little town and city you're doing it in," he explained. "It has to be streamlined. It has to have backup, rapid-response systems. If somebody gets sick at two o'clock in the morning and needs help, you need to be there in minutes, not hours. That didn't exist before."

Mayo has built algorithms into its Epic EHR that score patients on their clinical stability and home and social environments. Dr. Maniaci is excited about other technological advances to come. He cited cameras that can sense skin pulsations to detect a variety of health conditions.

Right now, Dr. Maniaci said, hospital-at-home care is the first edition iPhone. "I can't wait for iPhone 15," he said.

"I envision this very slick system of smart devices in the home," he said. "You feel ill, and Alexa connects you to a virtual provider real fast. They do an assessment through your camera on your phone, get your blood pressure, heart rate, and then there can be an instant triage."

4. Kaiser Permanente (Oakland, Calif.): 22-23 patients per day

From a financial standpoint, launching a hospital-at-home program is akin to adding a rounding team in the hospital, said Stephen Parodi, MD, executive vice president of external affairs, communications and brand at the Permanente Federation.

But rather than building its own home hospital IT systems from scratch, Kaiser Permanente joined Mayo Clinic in investing $100 million in Medically Home, a company that provides hospital-at-home logistics and communication technologies.

"What’s going to be incredibly important is that we have the appropriate baseline quality and safety parameters and hold ourselves and other health systems accountable for this type of care," Dr. Parodi said. "We think it should be at least as good as, if not better than, what we provide in a brick-and-mortar facility."

The first three-plus years of the program have borne that out, with fewer readmissions and higher patient satisfaction, he said. Patients are also less likely to experience delirium and physical deconditioning.

Kaiser Permanente has developed videos to "describe the program soup to nuts" to patients and clinicians, as well as a framework to track the quality and safety of the model for physicians and care teams.

It also fits into the health system's "whole person" approach to healthcare, Dr. Parodi said.

"We gain tremendous insights into the lives of our patients when we can go into their homes," he said. "We can see if there's risk of falling, whether there is food insecurity. And the medicines on their tables help us do better, more accurate medicine reconciliation. These insights are tremendously valuable if we want to see what truly ails our patients and the nation to lower the incidence of chronic disease."

5. Mount Sinai Health System (New York City): 15-20 patients per day

Mount Sinai was one of the first hospital-at-home providers, starting its program in 2015 with a CMS grant. Officials there started by visiting Albuquerque, N.M.-based Presbyterian Healthcare Services, which has had "hospital at home" since 2008.

After the grant period, Mount Sinai kept operating the initiative in partnership with managed care plans and hospital-at-home startup Contessa. (Contessa has since been bought by Amedisys, which Optum is in the process of acquiring for $3.3 billion). Mount Sinai was one of the first five institutions approved for the CMS waiver (the others were Presbyterian, Mass General Brigham, West Des Moines, Iowa-based UnityPoint Health, and Huntsman Cancer Institute at University at Utah Health in Salt Lake City).

In the preceding eight years, patients have gotten more comfortable with virtual care and technology has improved to where pulse and oxygen levels and heart and lung sounds can be monitored remotely, said Ania Wajnberg, MD, president of Mount Sinai at Home.

Mount Sinai's biggest challenges have been staffing, particularly nurses, and identifying the right patients, she said. Like other programs, Mount Sinai screens for safe home environments. It also tries to identify patients who aren't at risk for deterioration or likely to need surgery or an ICU stay in the near future. Readmission rates have remained below 10% even as the program has grown.

That being said, there are reasons most hospital patients won't be getting treated at home anytime soon. "Healthcare changes slowly, and we all have to be patient," Dr. Wajnberg said. "This is a very disruptive and new model. And we're swimming against the centralization of healthcare over the last few years. But there's huge potential for it if we can get over the challenges."

Hospital-at-home could also be a hard sell for health systems already struggling to fill beds or don't have the staffing or financial bandwidth to take it on, she said.

Two health systems — Roseville, Calif.-based Adventist Health and Toledo, Ohio-based ProMedica — recently discontinued their programs. Meanwhile, Winston-Salem, N.C.-based Novant Health and Charleston, S.C.-based MUSC Health don't have "hospital at home" up and running yet despite being approved for CMS waivers in 2021 and 2022, respectively.

6. UMass Memorial Health (Worcester, Mass.): 14-16 patients per day

Launched in August 2021, the program has since treated about 1,400 patients in the home. Patient satisfaction is among the highest in the health system.

"Part of that is that they're in their own home. They're sleeping in their own bed," said Taki Michaelidis, MD, director of UMass Memorial's hospital-at-home program. "We don't always offer the best bed and the best food in our hospital, even though we try really hard to do so. And there's a benefit of having autonomy and control in your own environment. You can go and sit on the couch and watch your favorite movie or TV show, or have your beloved pet next to you. So those things tend to be comforting."

Getting buy-in from physicians who are used to the old way of doing things has been an obstacle, Dr. Michaelidis noted. But they tend to become sold once they see the results.

UMass' program is at 2.5% of its total bed capacity, but hopes to double it in the coming years and one day reach 10% to 20%. UMass partners with Best Buy subsidiary Current Health on the in-home technology, including the internet hub, wireless backup, tablet and vital sign monitoring equipment. Atrium Health and Mass General Brigham also work with Best Buy Health for their programs.

UMass invested $1.5 million to $2 million to get the program up and running, so the CMS waiver becoming permanent is paramount, Dr. Michaelidis said. Getting commercial payers onboard can also be an issue. UMass recently had to pause Blue Cross Blue Shield commercial insurance patients after the payer dropped reimbursements by 25%.

"We have to pay for SUVs for nurses to get to the homes through snowstorms, we have oxygen backup — all these systems to make sure that there's redundancy in place and that obviously has some cost," he said.

But the cost is roughly similar during the care episode, he added, but can save payers money long term from reduced readmissions and less need for skilled nursing facilities.

7. ChristianaCare (Newark, Del.): 12-13 patients per day

ChristianaCare admitted its first hospital-at-home patient in December 2021, building its own program after working on the design with Medically Home.

"We really believe that the future of healthcare is virtual and digital and that anything that can be done virtually will be done virtually," said Sarah Schenck, MD, executive director for ChristianaCare's Center for Virtual Health.

The program has a readmission rate of less than 10%, which would be "very low" for a brick-and-mortar hospital, Dr. Schenck said. Its net promoter score the past two months has been 100, the highest possible.

"We actually had a patient that we took care of in our program at the beginning," Dr. Schenck recalled. "And recently she came back into our emergency department with a separate illness and they were rolling around on the gurney and she said, 'I left my key under the mat for the hospital care at home. Tell them to go set up and I'll be home.'"

Like some of the other systems, ChristianaCare employs paramedics for the program to make up for the nursing shortage. (With this care model, clinicians visit the home at least twice a day while physicians meet with the patients virtually once daily).

Dr. Schenck is also excited about where this all goes next.

"We're really building a virtual health system, where patients can get care where they are not where we are," she said. "We have a virtual primary care practice that's 100% virtual, we offer virtual specialty care, we do remote patient monitoring. This is the future of medicine and hospital medicine."

"It's really important for our system and other systems to think about building the digital infrastructure to allow for this kind of care in the home," she added. "It's no longer about building more buildings. Home is the new venue of care."

8. Saint Luke's Health System (Kansas City, Mo.): 10 patients per day

One of the newer hospital-at-home programs, Saint Luke's launched in July 2022 (also with Medically Home). But it's grown fast. It is now available at four of Saint Luke's 14 hospitals, including a recent expansion to Kansas.

The program currently only accepts Medicare and Medicare Advantage but hopes to start piloting with commercial payers by early next year. Congestive heart failure has been the most common diagnosis.

"I'm a cardiologist by training so perhaps I'm a little biased, but I think it's the perfect hospital-at-home diagnosis," said Michael Nassif, MD, medical director of Saint Luke's Hospital In Your Home program. "Patients often just need IV diuretics. You need daily labs to watch their electrolytes and renal function. Especially for the elderly Medicare population, it's much better to keep them home in a familiar environment while you do that then uproot their normal routine and risk them getting debilitated and delirious in a brick-and-mortar hospital."

Like other programs, Saint Luke's designs its technology kit for people of all ages (its average patient is 80). It includes a landline phone they just pick up and it calls their nurse directly. The tablet comes already connected to the internet, and has a home screen outfitted with their daily schedule and a huge touchscreen button to reach a provider virtually.

Patient satisfaction rates are "almost" 100%, Dr. Nassif said, with the top feature being the ease of contacting nurses.

One interesting concern was how to handle patient waste. Hospitals have specific rules and regulations on destroying medical waste, which can include toxic chemicals like chemotherapy byproducts. Saint Luke's Hospital In Your Home had to have meetings with state departments of transportation and natural resources to make sure its process was compliant.

But it's been worth the planning, Dr. Nassif said. "We looked at our exact same patients that we took care of previously in a brick-and-mortar hospital. About 10% of the time they ended up being discharged to a nursing home. Now it's about 1%," he said. "And it's a better environment than a chaotic brick-and-mortar hospital to build patient-doctor relationships."

Editor's note: This article was updated Dec. 8 at 9:10 a.m. CT.

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