'Definitions matter': Cleveland Clinic's approach to hospital at home

Cleveland Clinic has grown its hospital-at-home program by "demonstrating value to patients and gaining adoption from brick-and-mortar caregivers," a leader told Becker's.

The health system has one of the largest acute hospital care at home initiatives in the country, with an average daily census of 24 patients (and peak census of 26). The program is available to patients at Cleveland Clinic's five Florida hospitals, with plans to expand to Ohio in late 2025.

Becker's caught up with Richard Rothman, MD, chief medical operations officer of Cleveland Clinic Florida, about how hospital at home has evolved at the health system and what comes next. The conversation has been edited for clarity and brevity.

Question: What has changed since we last spoke for a story in April?

Richard Rothman: The volume of patients has increased since April. We've admitted nearly 3,000 patients, one of the fastest ramp-ups in the country. We're now live with hospital-at-home across all of Cleveland Clinic Florida, which includes five hospitals spanning about 150 miles. Patient outcomes have been strong, with trends suggesting outcomes as good as or better than hospital care for chronic diseases like COPD and heart failure.

We recently published a paper in the American College of Cardiology journal on heart failure patients, exploring whether the optimism around hospital-at-home is warranted.

Since we last talked, we, along with Mayo Clinic, developed the Cleveland Clinic-Mayo Clinic Home-Based Care Consortium. This created a registry combining deidentified patient data to study outcomes at scale. Outside of CMS data, this is the largest registry for clinical research.

We're also focusing on defining hospital-at-home. Many programs labeled as such are actually discharging patients from the hospital and providing post-acute care, which differs from the CMS waiver's definition. We published an editorial in the Journal of Hospital Medicine about this issue.

From an outcomes perspective, most patient results are as good as or better than brick-and-mortar hospitals. However, readmission improvements are less significant than some early studies suggest. We need larger studies to confirm whether this model consistently delivers better care.

Q: Are some programs mixing CMS waiver patients with others receiving post-acute care?

RR: Yes. Some large programs exclusively provide post-acute care, not true hospital-at-home care under the CMS waiver. This distinction is crucial to understanding patient outcomes and cost-effectiveness. Programs not under the CMS waiver may jeopardize patient safety and fail to meet inpatient care standards.

Q: Have the types of patients you're treating changed?

RR: We're treating more patients with complex wounds, tube feeding, postoperative needs, and neutropenic fever.

Q: What challenges have you faced?

RR: Decentralizing healthcare is inherently complex, requiring robust coordination and creating challenges for caregivers and family members. Additionally, adoption remains limited — our census represents about 5% of inpatient admissions. Nurses are also adapting to virtual care, which has a steep learning curve.

Q: What are the startup costs for this program?

RR: Startup costs are significant, in the millions, covering technology and infrastructure.

Q: What's next for the care model?

RR: Extending the CMS waiver is critical. Without it, we couldn't admit high-acuity patients directly to their homes. Programs would shift to post-acute care, which is less resource-intensive but not true inpatient care.

Q: Any final thoughts?

RR: The narrative needs to shift from growth to patient outcomes. Definitions matter — outcomes must be based on inpatient populations, not post-acute care.

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