Few Deaths, Complications Among CMS Hospital-at-Home Waiver Patients

Patients receiving at-home hospital care under the Acute Hospital Care at Home waiver experienced a low mortality rate and minimal complications resulting in admission to brick-and-mortar hospitals, according to recent research.

Published earlier this month in JAMA Health Forum, the study aimed to assess patient outcomes during the first 16 months of the Acute Hospital Care at Home initiative. The Centers for Medicare & Medicaid Services (CMS) launched the initiative on Nov. 25, 2020, to help mitigate capacity issues during the COVID-19 public health emergency.

Hospitals approved for the Acute Hospital Care at Home waiver can provide inpatient-level care in the home for Medicare fee-for-service and non-managed care Medicaid beneficiaries. The waiver lifts certain Conditions of Participation (COP) requiring 24-hour onsite nursing and mandating that patient homes meet certain structural and physical environment criteria.

CMS performs an offsite review of hospitals as part of the waiver approval process to ensure they can provide the necessary administrative, regulatory, and safety elements. These include durable medical equipment, food services, and one daily clinician visit, which can be remote after the initial in-person history and physical examination.

The study conducted by researchers from the CMS Center for Clinical Standards and Quality examined patient outcomes at the 277 hospitals with approved waivers as of March 20, 2023. A total of 11,159 patients received care under the waiver, including 8,417 with Medicare fee-for-service insurance, 1,705 with non-managed care Medicaid insurance, and 1,011 with both.

Hospitals self-reported two data measures to CMS as well as patient volume. The measures were ‘patient escalation of care,’ defined as a patient returning to the hospital to complete their care, and ‘unexpected patient mortality,’ defined as a patient death while receiving hospital care at home, excluding those transferred to hospice.

The most common conditions cared for under the waiver were respiratory infections and inflammations with major complications or comorbidity (MCC), heart failure and shock with MCC, and septicemia or severe sepsis without mechanical ventilation for more than 96 hours with MCC.

The overall proportion of patients transferred from home to the hospital was 7.20 percent. Thirty-eight unexpected deaths (0.34 percent) occurred in participating hospitals.

Most of the unexpected deaths occurred among COVID-19 patients that progressed to more severe illness symptoms. Except in three cases, each patient who died had been transferred back to the hospital.

The Acute Hospital Care at Home initiative will expire on December 31, 2024. The Consolidated Appropriations Act of 2023, which extends various pandemic-era telehealth and remote monitoring waivers and flexibilities, requires CMS to publish a comprehensive study of the initiative by September 30, 2024.

As of November 21, 305 hospitals across 129 health systems in 37 states were participating in the initiative.

Hospital-at-home services have widespread support from healthcare provider organizations.

The Advanced Care at Home Coalition, created by Mayo Clinic, Medically Home, and Kaiser Permanente and launched in 2021, aims to address regulatory and legislative barriers to at-home acute care, share best practices, provide thought leadership, and support additional health systems to participate in this care model. Numerous other health systems, including Johns Hopkins Medicine, ChristianaCare, and Geisinger, are members of the coalition.

Recently, Mass Brigham General struck a partnership with Best Buy Health to scale its Home Hospital and develop new hospital-at-home solutions and processes.

“Patients and clinicians alike love the therapeutic relationship afforded through the home-based environment,” Stephen Dorner, MD, chief clinical and innovation officer for Mass General Brigham Healthcare at Home, told mHealthIntelligence. “What could be more patient-centric than a care delivery model focused on supporting healing and recovery in a patient’s own home?”