Hospital-at-home lags in rural settings. Is that a problem?
The federal AHCAH waiver has spurred hospital-at-home growth, but adoption is uneven between urban and rural hospitals, raising concerns about equity and access.
When CMS launched its Acute Hospital Care at Home (AHCAH) waiver program in 2020, it ushered the hospital-at-home model into a new era. Nearly 400 hospitals have been approved for the waiver in the past five years, indicating the model's rising popularity. However, recently published research highlights geographic gaps, with urban hospitals far more likely than rural hospitals to adopt hospital-at-home programs.
One can correctly surmise that financial challenges and resource constraints are keeping rural hospitals from participating more expansively in hospital-at-home efforts. But that is only part of the story.
Rural health experts highlighted other reasons rural hospitals may be less inclined to adopt hospital-at-home programs, including the fact that they do not face the capacity constraints of their urban counterparts.
What the research tells us about hospital-at-home adoption
Though the future of the AHCAH waiver is uncertain, its impact on hospital-at-home adoption is undeniable. As of Feb. 21, 2025, 383 healthcare facilities across 39 states had received waiver approval.
With the March deadline looming, the study's findings are especially pertinent to understanding the waiver's uptake. Researchers from the University of California, Los Angeles, and the University of Pennsylvania Perelman School of Medicine set out to provide an overview of the uptake, focusing on whether the characteristics of participating hospitals have changed over the years.
Study author Hashem E. Zikry, MD, was interested in examining adoption trends after seeing how hospital-at-home efforts could impact emergency department capacity.
"I work in the emergency department every day, and anything that's going to help create capacity in our EDs and anything that will help offload patients to get the care that they need faster is kind of fascinating to me, especially something as innovative as taking care of patients in their own home," said Zikry, an emergency medicine physician and a scholar in the National Clinician Scholars Program at UCLA.
The research team conducted a cross-sectional analysis using the 2022 American Hospital Association Annual Survey to obtain data on hospital characteristics and publicly reported data to identify hospitals participating in the AHCAH waiver program as of March 1, 2024. Hospitals granted a waiver between November 2020 and December 2022 were grouped as "pre-extension," and those that applied and received the waiver later were grouped as "post-extension." They published their findings in JAMA.
Of the 2,953 hospitals included in the study, 299 (10%) obtained an AHCAH waiver, 249 in the pre-extension period, and 50 post-extension.
In some places, like where I live, Los Angeles, there's no blueprint to see how this is being done. And so, there's nothing to mimic. Whereas Boston Medical Center or UMass are looking at the Mass General model, and they're really kind of taking notes, and they're running with it.
Hashem E. Zikry, MDEmergency medicine physician and a scholar in the National Clinician Scholars Program at University of California, Los Angeles
Nearly half of the hospitals participating in the waiver program were large, with 49% having 300-plus beds compared to only 14% with less than 100 beds. The vast majority of AHCAH participants were in metropolitan areas (92%) and were major or minor teaching hospitals (80%). On the other hand, few participating hospitals were in rural areas (2%) or were non-teaching hospitals (20%).
Additionally, researchers noted that participating hospitals tended to group together. For instance, states like Massachusetts, Texas and Florida have high hospital-at-home adoption rates, making it easier for more hospitals in those states to adopt the model.
"In some places, like where I live, Los Angeles, there's no blueprint to see how this is being done," Zikry noted. "And so, there's nothing to mimic. Whereas Boston Medical Center or UMass are looking at the Mass General model, and they're really kind of taking notes, and they're running with it."
Further, the research shows that the characteristics of hospitals that received the waiver post-extension were similar to pre-extension hospitals, although post-extension hospitals were somewhat smaller and had regional differences.
Researchers concluded that as the federal government continues to debate the future of the AHCAH waiver, they should "consider additional strategies to engage a broader set of facilities to develop hospital-at-home programs, particularly non-teaching and rural hospitals."
Exploring the impact of uneven adoption and strategies to close the gap
Strategies to expand the adoption of hospital-at-home programs would need to center on reimbursement.
According to Brock Slabach, COO of the National Rural Health Association, rural facilities need a workable business case for hospital-at-home. Nearly half of U.S. rural hospitals are operating in the red, and given that they do not face the same capacity challenges as their urban counterparts, implementing a hospital-at-home program doesn't make financial sense.
"What is the problem being solved for?" Slabach said. "I think a lot of facilities, if they have looked at this as an option, they have come up with a lack of understanding as to the imperative."
Not only does hospital-at-home solve a problem that many rural hospitals don't have, but operating them would add to workforce and resource challenges. For instance, hospital-at-home programs typically require additional clinical staff. Slabach noted that with rural hospitals struggling to fill their open positions, adding new staff for home-based inpatient care would create an unnecessary challenge.
Rural hospitals would also have to train staff, implement telehealth and remote patient monitoring (RPM) technologies, and develop new workflows to successfully adopt hospital-at-home programs. Given the limited resources available in rural settings, this could prove an uphill battle.
Further, rural patients often have to travel long distances to a hospital. Typically, hospital-at-home programs admit patients from the emergency room or inpatient setting after clinical teams verify that the patient would be a good candidate for the program.
"The assumption would be that a patient has already arrived to the hospital for the emergency that they have, so they're already in the building," Slabach said. "And so, the issue would then just be transferring them down the hallway to a bed versus having to set them up back at their home. For the facility, it's probably an easier lift to just admit them into one of their many empty beds rather than having to transfer the patient home and set up monitoring devices and other medication delivery systems to take care of the patient at home."
However, if rural hospitals receive the support they need to adopt hospital-at-home programs, the programs could provide various downstream benefits.
Anecdotally, the patients have been very happy. They have really appreciated being able to be in their home and receive the care that they've received.
Susan JarvisCOO of Sanford Health Fargo and Health Network–North
Susan Jarvis, COO of Sanford Health Fargo and Health Network–North, pointed out that its hospital-at-home program is helping create capacity to accommodate patients coming in from far-flung rural areas. The program is being piloted at the Fargo hospital, which accepts referrals from other Sanford locations in North Dakota and beyond.
"We are a referral center for a large part of the state of North Dakota and Northwestern Minnesota," she said. "It was one of the reasons we did [hospital-at-home] just because we do have capacity issues, and we really do want those patients to be able to get transferred to us when they need that level of care."
The Fargo location is also facing a sustained rise in patient volumes following the COVID-19 public health emergency, further underscoring the need for the hospital-at-home model. The hospital applied for the waiver over a year ago and launched the program in December 2024.
At Sanford, the model includes two mandatory in-person visits daily with a community paramedic and a nurse and virtual visits with hospitalists, in addition to 24/7 RPM. Jarvis credited the hospital's ability to launch and operate its hospital-at-home program to being part of a more extensive rural health system.
She noted that the Fargo location had access to the components needed for the hospital-at-home model, including community paramedics and engaged hospitalists, and also had experience running other virtual healthcare programs, like virtual nursing.
Research has consistently shown that hospital-at-home programs are associated with high-quality outcomes, including shorter lengths of stay and positive patient experiences. Though the program is relatively new, Jarvis shared that the hospital is getting positive feedback from patients.
"Anecdotally, the patients have been very happy," Jarvis said. "They have really appreciated being able to be in their home and receive the care that they've received."
Thus, lower hospital-at-home adoption in rural areas could impact rural health. It may prevent rural patients, who are already medically underserved and face significant health disparities, from experiencing the above benefits. And though there is no data to show that uneven hospital-at-home adoption adds to healthcare gaps between urban and rural areas, it does not appear to mitigate those gaps.
I don't want to give the impression that I don't think that this is a model that is going to work. I think this is a model that will work in rural [settings], I just don't think yet it's ready.
Brock SlabachCOO of the National Rural Health Association
Zikry stated that further research will be critical to better understand these gaps.
"I don't think we know the answer yet about if [hospital-at-home] is currently being offered equitably or inequitably," he said. "I will say that I think that it is ripe for potential manipulation, which is a huge problem."
In addition to the urban-rural divide, Zikry believes that future research needs to assess how hospital-at-home impacts family caregivers and whether hospitals use the program to create inpatient capacity for more profitable cases.
As for rural hospitals currently interested in hospital-at-home, their best bet would be advocating for an extension of the AHCAH waiver and new reimbursement models that make the programs financially viable for them. Slabach believes that the model will eventually become more widely adopted in rural hospitals, which means that rural hospitals must keep one eye on the future.
"I don't want to give the impression that I don't think that this is a model that is going to work," he said. "I think this is a model that will work in rural [settings], I just don't think it's ready yet. But do I think that, in a decade or two, this is going to be the way most care is delivered? I think there's every chance that could be the case."
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.
