Hospital executives have questions about hospital-at-home

The impermanent nature of a waiver flexibility and intensified staffing shortages leave health systems that have not yet moved forward with "hospital-at-home" programs in a policy-driven, wait-and-see limbo. 

The centricity of the home during pandemic life brought renewed attention to the "hospital-at- home" model, but the model dates to the mid-1990s, when it was developed by Bruce Leff, MD, a geriatrician and health services researcher at Johns Hopkins University in Baltimore. His expertise has been even more widely sought since March 2020, as hospitals looked to move care outside of their walls to meet the demands of COVID-19's earliest surges.

"My phone didn't stop ringing for weeks," he said

The pioneering hospital-at-home strategy struggled to gain traction for years, in part because Medicare didn't reimburse for services under the model. That changed in November 2020, when CMS used its emergency authority to waive several regulations under the Medicare Hospital Conditions of Participation — suspending requirements for nursing services to be provided around the clock on premises and the immediate availability of a registered nurse. It then launched its Acute Hospital Care At Home program to let Medicare-certified hospitals treat patients with inpatient-level care at home for more than 60 medical conditions. 

"CMS anticipates patients may value the ability to spend time with family and caregivers at home without the visitation restrictions that exist in traditional hospital settings," the agency said. The agency has since approved 201 hospitals representing 91 health systems to receive reimbursement for acute hospital care delivered in the home, with payments equal to those received if the care were provided in the traditional inpatient setting.

The impermanent nature of a waiver flexibility is now leaving hospitals that have not yet moved toward hospital at home in a policy-driven, wait-and-see limbo. The HHS public health emergency is set to expire April 16 unless the department renews it for another 90 days. HHS has pledged to provide a 60-day notice before lifting the emergency, which would unwind waiver-authorized operations and programs, including CMS reimbursement for hospital at home.

"Until we know CMS has been granted authority through federal legislation to continue the HAH program and make it an option available under Medicare, there's a real risk to the hospitals who choose to stand [these programs] up," Nancy Foster, the American Hospital Association's vice president for quality and patient safety policy, told Becker's. "They may not be able to continue those programs post-pandemic, or there may be a time in between when the public health emergency ends and when legislation is adopted. A lot of folks are looking at this with a great deal of interest and thinking about how they might move forward without taking on all the risk themselves." 

While 201 hospitals have CMS approval for the hospital-at-home model, applications for the program have tapered off in the last couple of months, according to Mark Howell, senior associate director of policy at the AHA.

"Not because there's not enough interest in the program, but if you haven't stood it up already, there's uncertainty of what it looks like in future," Mr. Howell said. 

If hospitals are going to invest in the infrastructure and hire and/or train staff to deliver care in the home, they need a guarantee that it's something they can do for a while. Staffing problems exacerbated by the pandemic only add to the uncertainty hospitals with less hospital-at-home maturity are experiencing. 

Although health systems and health information technology companies draw attention to the remote-monitoring technology that helps enable hospital-at-home programs, CMS still requires at least two daily in-person visits for its approved programs, with registered nurses playing a central role in care planning and delivery. Here's where supply and demand may diverge.

RN staffing problems have intensified since December 2020, when CMS established reimbursement for hospital at home, and hospital executives are more concerned about shortages of this specific role than they have been for nearly two decades. Hospital CEOs ranked personnel shortages as their No. 1 concern in 2021, beating hospital finances for the first time in 17 years in the American College of Healthcare Executives' annual survey. Although chiefs are worried about personnel shortages of all types, most CEOs (94 percent) identified the deficit of RNs as most pressing. 

Staffing hospital-at-home models was hardly a breeze pre-pandemic. Albuquerque, N.M.-based Presbyterian Health Services launched its hospital-at-home program in 2008 based on the model developed by Dr. Leff. In a 2016 case study, the system noted that finding the right staff to power the program can prove challenging. Specific experience or skill sets make all the difference. Presbyterian administrators found that nurses who've worked in EDs or critical care units, and are accustomed to decision-making with quickly changing circumstances, are stronger fits for hospital-at-home models than home health nurses. 

Hospitals and health systems with less hospital-at-home experience than Presbyterian may find it difficult to even conceptualize staffing for a new care delivery model right now, especially if CMS reimbursement for care in the home setting isn't a sure thing.  

"When we talk about caring for patients at home, where are the resources to do that?" the CEO of a Northeastern health system told Becker's, noting the hospital-at-home model is not currently on the table for his organization. "The whole staffing situation changed our ability to think about it. We're not really marching toward it. It's a great concept, but right now I don't even know how to introduce it."

Other systems are looking to nontraditional staffing sources to supplement their workforce for hospital-at-home care delivery. Johnson City, Tenn.-based Ballad Health secured CMS waivers for hospital at home for four of its 17 acute care facilities in October 2021. The system, which serves 29 counties across Tennessee, Virginia, North Carolina and Kentucky, piloted a program in the first surge of COVID-19, called Safe at Home, to monitor COVID-19-positive patients with milder symptoms in their homes, which helped Ballad qualify for the CMS hospital-at-home waiver.

The system is supplementing its hospital-at-home workforce with community EMTs, who will work closely with Ballad's registered nurses to carry out care prescribed by a hospitalist.

"We do recognize that we don't have enough nurses in our facilities currently to manage the volume of patients we have," Ballad CMIO Mark Wilkinson, MD, told Becker's. "We leveraged RNs in leadership roles, most recently, and they volunteered to help with the Safe at Home program. As we look beyond our initial foray into HAH, because of the nursing shortage, we will be leveraging community paramedics for visits twice a day, virtual tech telemedicine to have those visits occur with our hospitalist staff, and then we'll have central nursing resource, which will allow us to have some scale despite the low availability of RNs in this region, generally speaking."

Ballad had 600 open nursing positions and about 500 travel nurses in place at the time of publication. 

Clay Runnels, MD, chief physician executive for Ballad, said the system will take its resource challenges as they come and scale accordingly, noting the entire leadership team feels heading toward hospital at home is the right direction, given Ballad's patient population and geographic breadth.

"We cover a very large rural area," he noted. "We cover an area about the size of New Jersey — it's very difficult for some of these people to feel comfort far from home in the hospital."

Sources from the AHA made clear the group is interested in having federal reimbursement for hospital at home extended, as are hospital CEOs. Lessons and wins from the waiver can inform a framework for a nimble, pragmatic, operationally sound and patient-centered push into hospital at home outside of a clunky waiver process that was born of necessity. 

"CEOs are interested; they just need that guarantee that it's an investment that'll go into the future," the AHA's Mr. Howell told Becker's. "There are conversations happening around extending this waiver beyond a public health emergency, which would give some time as a runway for a more permanent program to be developed. This was a good way to manage the pandemic, and it's taught us a lot about how HAH can work. As part of that learning process, we need to think about what care delivery in the home can look like." 

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