Hospital at Home in the Carolinas: Recent Legislation Green Lights H@H Programs

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Until recently, the idea of hospitals providing acute-care hospital services to patients in their homes had been studied and implemented only in a limited manner in the United States. However, during the COVID-19 Public Health Emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) and a number of States began allowing the creation of “Hospital at Home programs” (H@H).  In fact, as of June 16, 2023, 125 hospital systems and 283 hospitals in 37 States have been approved by CMS to participate in the CMS H@H waiver program.^[1]

This article discusses the current status of H@H programs at the federal CMS level as well as recent legislation allowing H@H in South and North Carolina and the benefits and risks of running a H@H program.

H@H on the Federal Level.  H@H allows for in-home, hospital acute care level to be administered in a patient’s home.  It is not home health, case management, chronic disease management, skilled nursing, or admission prevention.^[2] 

On November 25, 2020, CMS announced it was expanding its Hospital Without Walls program to include an “Acute Hospital Care at Home” program, which offered eligible hospitals the opportunity to treat patients in their home.^[3]  The CMS H@H program was originally based on a PHE waiver and was set to expire at the end of the federal PHE (May 11, 2023). However, Congress passed an Omnibus Appropriations bill which was signed into law on December 29, 2022, which included a provision that extended the Acute Hospital Care at Home Program until December 31, 2024.^[4]  The legislation also included a provision requiring and funding a H@H program evaluation study to be conducted by CMS.^[5] 

To participate in the CMS H@H program, a hospital must request a waiver.^[6] Hospitals which previously provided H@H services to at least 25 patients can participate in an expedited process and hospitals which treated fewer than 25 patients or have never provided at home acute hospital services can participate in a more detailed waiver request.^[7] 

The Status of H@H in South Carolina.  Initially, South Carolina licensing laws created a barrier to participation in the CMS H@H program. During the South Carolina PHE, the Department of Health and Environmental Control (DHEC) initially approved H@H programs, allowing for flexibility during the State PHE.  However, when the State PHE was lifted in June 7, 2021^[8], DHEC began turning down additional applicants for the H@H program, stating that H@H programs violated hospital licenses.^[9] 

To clear the path for H@H programs, the South Carolina Legislature included Budget provisos for fiscal years 22-23 (34.61)^[10] and 23-24 (34.58)^[11] that included language specifically stating that “a hospital approved by the Centers for Medicare and Medicaid Services to participate in an Acute Hospital Care at Home waiver program may not be deemed to be in violation of its hospital license solely on the basis of its participation in the program. Additionally, the department shall not subject such a hospital to any form of adverse enforcement action relating to its participation in the program.”

With the licensing barrier removed, there are currently three hospital systems running H@H programs in South Carolina: Prisma Health (8 locations), Roper St. Francis Healthcare (4 locations), and the Medical University of South Carolina (7 locations).^[12]

The Status of H@H in North Carolina.  North Carolina hospitals faced similar licensing barriers at first, but a recent bill, S206, was signed into law on May 19, 2023, which allows the operation of H@H programs in the State.^[13]  Bill S206 provides for an extension of the H@H program and, to the extent a hospital receives a waiver from CMS to participate in its H@H program, compliance with the North Carolina Health Care Facilities statutes are waived to the extent the statutes prohibit or conflict with a hospital's ability to operate in accordance with the CMS H@H program.  The new North Carolina law also specifically provides that care provided to patients at home does not count as licensed bed capacity and that hospitals do not need to obtain a home health care license or certificate of need approval to provide H@H services.^[14] 

North Carolina has seven hospital systems participating in the H@H program:  Atrium Health (7 locations), Duke Health (2 locations), WakeMed (2 locations), Scotland Memorial (1 location), UNC (4 locations), Novant Health (10 locations), and Cone Health (1 location).^[15]

The Benefits of H@H Programs.  Generally, the H@H program works well with medium acuity patients who need hospital-level acute care but are considered stable enough to be monitored in their homes.^[16]  Studies have shown that the costs for H@H are about 30% lower than in a hospital setting.  In addition, patient satisfaction is higher in the H@H program and there is no difference in six-month mortality or hospital readmission rates.^[17] 

Risks of H@H Programs. While the potential benefits of H@H programs are high, risks can involve hazards created by the home environment, including infection control, sanitation, and physical layout. There can also be challenges related to in-home patients and their caregivers if adequate communication, education, and training is missing.  A lack of continuous health monitoring can also create risk.^[18]

In addition, as mentioned earlier, H@H is not intended to be home health, case management, chronic disease management, skilled nursing, or admission prevention.  Hospitals need to be vigilant in limiting H@H care to only appropriate eligible patient candidates.  Audit activity surrounding patient eligibility is likely to increase as H@H programs develop and hospitals submit claims for reimbursement for H@H services.

Overall, most studies and the experiences at industry pioneers like the Johns Hopkins program have found H@H to be beneficial in both cost and patient experience for the right patients.  With CMS and the Carolinas allowing H@H programs to move forward for now, it will be interesting to see if the positive outcomes will continue under the expanding H@H programs.

If you have any questions concerning H@H programs in the Carolinas, please reach out to Maynard Nexsen’s health care team for assistance. 

[1] CMS Approved Facilities/Systems for Acute Hospital Care at Home:  https://qualitynet.cms.gov/acute-hospital-care-at-home/resources
[2] TRACIE 2021 fact sheet at Acute Care Delivery at Home (hhs.gov)
[3] CMS Announces Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge | CMS
[4] https://www.aha.org/special-bulletin/2022-12-20-appropriations-committees-release-omnibus-spending-bill-health-provisions
[5] Id.
[6] Available at https://qualitynet.cms.gov/acute-hospital-care-at-home
[7] Id.
[8] https://www.wbtv.com/2021/06/07/gov-mcmaster-ends-state-emergency-south-carolina-related-covid-19-pandemic/
[9] https://www.postandcourier.com/health/hospital-at-home-programs-may-help-some-patients-but-face-roadblocks-in-sc/article_4f0a8f38-8db3-11ec-8223-2bda19541629.html
[10] https://www.scstatehouse.gov/sess124_2021-2022/appropriations2022/tap1b.htm#s34
[11] https://www.scstatehouse.gov/sess125_2023-2024/appropriations2023/tap1b.htm#s34
[12] https://qualitynet.cms.gov/acute-hospital-care-at-home/resources
[13] https://www.ncleg.gov/BillLookUp/2023/S206
[14] Id.
[15] https://qualitynet.cms.gov/acute-hospital-care-at-home/resources
[16] https://www.aha.org/system/files/media/file/2020/12/issue-brief-creating-value-by-bringing-hospital-care-home_0.pdf
[17] Id.
[18] https://hbr.org/2019/10/5-obstacles-to-home-based-health-care-and-how-to-overcome-them#:~:text=These%20include%3A%20environmental%20hazards%20such,needs%20of%20patients%20receiving%20home