The Acute Hospital Care at Home waiver program from the Centers for Medicare & Medicaid Services has grown to 125 health systems and 289 hospitals in 37 states in less than three years. A number of other health systems and hospitals have secured waivers but haven't yet implemented a program.

Others haven't scaled, because they are discovering that managing all the clinical and nonclinical services associated with hospital-level care in the home is a major undertaking. One way some provider organizations are managing is offloading many services to a technology and services vendor.

Kuldeep Singh Rajput is CEO and founder of Biofourmis, a remote patient monitoring and telehealth technology and services company. We interviewed him to get his expert views on the Acute Hospital Care at Home waiver program, implementation challenges, how hospitals and health systems can overcome these challenges, and market trends pointing to a permanent hospital at home program from CMS.

Q. For those who don't know, please describe the Acute Hospital Care at Home waiver program from the Centers for Medicare & Medicaid Services.

A. The waiver program launched in November 2020 in response to the massive bed shortages hospitals experienced during the early waves of COVID-19. The waiver program has provided hospitals and health systems with the option to deliver hospital-level care inside patients’ homes and receive the same reimbursement as if the patient were inside a medical facility.

Payment parity was the remaining obstacle facing any hospital-at-home initiative before the waiver program, given that health tech, data science and consumer technology by that point were already more than capable of supporting such a program.

The CMS program and the pandemic were catalysts in this change that was inevitable, but had been very slow-moving. In less than a year, nearly 200 hospitals across 34 states had earned a waiver; and now nearly 300 hospitals are on board.

Even with the public health emergency declared over, a federal budget agreement signed into law in late 2022 extended waivers through the end of 2024. It’s widely believed that both CMS and private insurers will ultimately put into place some type of permanent reimbursement for care-at-home, including hospital-at-home.

The funding extension will certainly motivate more hospitals to launch and expand programs and give everyone more time to study the clinical outcomes and cost impacts, which have widely demonstrated that home-based acute care delivers the same or better outcomes with lower costs than facility-based care. Health systems are also expanding their care-at-home programs beyond hospital-level care to support timely hospital discharge, which helps address capacity and staffing challenges.

This approach enables patients who were admitted to a facility to be released sooner and then managed at home for a set time period through virtual visits, in-home services and remote data collection and analysis that flags early signs of any potential issues that require intervention.

Q. What are the challenges to implementing an Acute Hospital Care at Home program?

A. Implementing any new initiative involves challenges. Without the right support, the changes required to launch and scale hospital-at-home programs can push organizations beyond their comfort zone – operationally, clinically and financially.

Compounded by existing challenges such as staffing limitations, economic shifts and technology integration, taking the strategic step into hospital-at-home can be daunting for some organizations.

Building the right staffing model amidst shortages of clinicians often comes up. Hospitals typically want to ensure their facilities are fully staffed before considering care-at-home clinical teams. That is why we have expanded our own virtual clinical care teams and have partnered with local and national in-home providers to fill staffing and scheduling gaps to ensure care-at-home patients have around-the-clock care access.

In addition to staffing challenges, health systems must also coordinate a wide range of in-home services. Inside a hospital, clinical and ancillary services such as wound care, phlebotomy, radiology, and physical and occupational therapy are available with a mouse-click or phone call.

Delivering these services in the home can require forging agreements with new vendors or modifying contracts with existing service providers on a local, regional and national level. Contract management is highly time-consuming, as is managing the plethora of services – especially if systems and processes are fragmented between departments or facilities.

Manually accessing multiple IT systems or customer portals, making follow-up calls, and confirming fulfillment with patients or families is a recipe for cost overruns, service disruption, wasted time and lost data – not to mention stressed-out clinicians and frustrated patients and families.

We recently began offering in-home services management as part of our solution for health systems that want to launch and scale without worrying about that part of providing acute or post-discharge care-at-home.

Lastly, integrating new initiatives, data or insights into technology workflows such as the EHR is a historical barrier that has reached the breaking point. Increasingly, leaders recognize they will not be able to scale and sustain these new tech-enabled care-at-home models using the disconnected, piecemeal or workaround approaches relied on in the past.

Rather, creating a seamless clinical and operational ecosystem serving the patients’ homes similar to the ecosystem that serves the hospital environment is required in this new era of care delivery.

Q. How can hospitals and health systems overcome these challenges? And what role does health IT play?

A. Uniting IT systems, service and equipment procurement, and clinical and ancillary workflows across one connected platform is essential in order to save massive amounts of time for hospital staff and to deliver better care and experiences for patients.

That is the main lesson coming from the pioneers and early adopters of hospital-at-home, as well as those delivering post-acute care and complex chronic condition management in the home. It’s clear that using disparate, disconnected point solutions for different clinical and care services negates the inherent efficiencies and cost savings that can be realized by shifting care to the home.

Using a single, connected and comprehensive care-at-home platform fully embedded in the EHR offers remote care navigators and clinicians seamless visibility over all of their patients’ care and services in much less time and burden than relying on multiple disconnected applications.

A fully embedded platform speeds workflows, but also helps health systems identify and enroll patients in care-at-home programs more efficiently. Once enrolled, clinicians can then more easily access and interpret real-time data from patients in their homes, communicate with them, and order care and ancillary services.

These systems can be used to help clinicians monitor and manage patients’ care journeys in their homes through continuous biomarker collection and analysis that helps drive clinical decision-making. Centralized, virtual command centers offer comprehensive clinical teams of physicians, nurses and other professionals that can comanage patients with hospital staff and can intervene when a potential clinical concern is identified during non-peak staffing hours.

With this type of connected platform, hospital-at-home care navigators also can order ancillary clinical services to be delivered to the patient’s home, as well as equipment and supplies. However, instead of performing all of the vendor contract management and service fulfillment coordination, health systems can offload those functions to their health IT partner so they can more easily scale their care-at-home programs.

Q. You say there are market trends pointing to a permanent hospital-at-home program from CMS. Please describe the trends, and why you think this might become permanent.

A. The two-year extension of the waiver program is a big indicator that CMS – as well as private insurers – will likely create a more permanent program. Many other market trends in healthcare are pointing toward more care at home across the continuum – acute, timely discharge and chronic condition.

First, health systems are still faced with massive labor resource constraints, which can be eased through tech-enabled care-at-home, especially if they work with care partners. Another major trend is that the last Baby Boomers will turn 65 by 2030 and will require more hospitalizations and other forms of care associated with older age.

The evidence thus far points to care-at-home being less costly than facility-based admissions, and equally or more clinically beneficial, both of which will certainly influence CMS’s decision.

Industry experts, such as Chilmark Research and others, have issued reports and other intelligence indicating hospital-at-home is here to stay. A Chilmark report from May 2023 estimates that hospital-at-home adoption will double by 2026, reaching $72 billion out of a potential $300 billion total addressable market.

Similarly, survey results from consultancy firm Chartis showed 78% of health system leaders intend to launch a hospital-at-home program in the next five years, up from 65% the year before.

Another trend impacting hospital-at-home adoption is the health inequities that continue to widen across the U.S. and other countries and the urgent need to address them. Tech-enabled care-at-home can be a bridge to the urban and rural communities that have been underserved by the industry to date.

From their home, wherever that may be, these patients can more easily access the safe, effective and guideline-directed care they deserve, but have been unable to receive due to social determinants of health and other issues that make access to care difficult to impossible. Closing those care gaps and reducing health inequalities is what I am passionate about and this is one powerful way to do that.

Care-at-home across the continuum is the most cost-effective, highest-quality and patient-centered way forward for the entire industry.

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