CMS hospital-at-home waiver linked to high-quality care

A new federal report provides a detailed analysis of CMS' Acute Hospital Care at Home program, showing it is associated with positive patient experiences and high-quality outcomes, though demographic differences in participation persist.

The CMS report assessed the AHCAH initiative launched in November 2020. AHCAH waivers allow hospitals to use remote clinician services in combination with in-home nursing services to provide inpatient-level care in the patient's home.

In 2022, Congress passed the Consolidated Appropriations Act, 2023, which extended the AHCAH waiver through Dec. 31, 2024. As of Oct. 7, 2024, 365 healthcare facilities had been approved for the waiver.

The CAA, 2023 also requires CMS to study the initiative. The 2024 report analyzed several aspects of the AHCAH initiative, including demographic information on beneficiaries treated under the program, clinical conditions treated, quality of patient care relative to patients treated in brick-and-mortar inpatient settings, patient experience, and Medicare spending and utilization.

According to the report, AHCAH patient demographics were meaningfully different from those of patients receiving inpatient care services by the same hospital facility. AHCAH patients were 5% more likely to be white and 8% more likely to live in an urban location. They were also 10% less likely to receive Medicaid and 0.4% less likely to receive low-income subsidies.

However, the report highlighted that differences in population characteristics are partly due to the AHCAH inclusion and exclusion criteria developed by participating hospitals.

"A closer review of hospital data on decisions related to AHCAH would reveal how often household conditions and/or clinical complexity prevent patients from participating in AHCAH," the report stated. "This information could help identify opportunities for hospitals to take additional steps to help make homes more conducive for inpatient-level care, as well as opportunities to adjust patient selection criteria without jeopardizing patient safety."

The most common conditions treated through the AHCAH initiative were respiratory (36%), circulatory (16%), renal (16%) and infectious disease (12%) conditions, the report showed. The distribution of conditions indicated that clinical care episodes were tightly clustered, with these top four diagnostic categories accounting for 80% of all AHCAH episodes.

The quality of care provided under the AHCAH program was on par with or better than that provided in brick-and-mortar inpatient settings. The report revealed that the AHCAH initiative was linked to lower mortality rates than its brick-and-mortar counterpart. Hospital-acquired condition rates were also lower in the AHCAH program than in brick-and-mortar inpatient settings, though the differences were not statistically significant.

However, 30-day readmission rates varied across the AHCAH and inpatient comparison groups, with readmission rates significantly higher in the AHCAH group for two Medicare Severity Diagnostic Related Groups but significantly higher in the inpatient comparison group for three MS-DRGs. On average, AHCAH care episodes had a slightly longer length of stay than comparable brick-and-mortar inpatient episodes.

Further, the 30-day post-discharge period for AHCAH episodes resulted in lower Medicare spending, on average, than brick-and-mortar inpatient episodes across more than half of the top 25 MS-DRGs treated in the AHCAH initiative. But the report noteed that the AHCAH patient selection criteria and clinical complexity "make it difficult to conclude that the AHCAH initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care."

Still, virtual listening sessions and anecdotal information revealed that patients and caregivers had positive experiences with the AHCAH initiative, as did clinicians.

Thus, CMS concluded that the study results "appear consistent with the intentions of AHCAH." The agency also noted that the study revealed several lessons regarding continuous quality improvement efforts and the need to develop more targeted cost, quality and utilization measures.

The federal study results came as hospital-at-home programs grow more popular in the United States.

Survey results released in June showed that the overwhelming majority of U.S. adults are likely to participate in a hospital-at-home monitoring program to get back home more quickly. Of 1,025 older adults polled, only 15.58% said they are not likely to participate in a hospital-at-home program to return home sooner.

Of those who had experienced hospital-at-home monitoring, 84% reported positive experiences, and nearly half said they found the remote patient monitoring devices easy to use.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.