Your Next Hospital Stay May Be at Home:  The Accelerating Movement Towards Hospital Care in the Home Setting

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The next time you step into an emergency room, you may learn the hospital can provide you with hospital-level services to treat your illness in your home.  Until recently, the idea of hospitals providing services to patients in their homes has been studied and implemented only in a limited manner in the United States.  However, over a 100  hospitals across the country have now established new “hospital at home programs” in response to the creation of the “Acute Hospital Care at Home” program by the Centers for Medicare and Medicaid Services (“CMS”).  

What are “Acute Hospital at Home” programs? 

Defined simply, a hospital at home program allows patients to receive inpatient hospital-level care in their homes.  It is not home health, case management, chronic disease management, or skilled nursing.  Notably, until recently, the use of hospital-level care at home programs has been limited in the United States despite studies that have shown that at home hospital services can be safer, less expensive, and more effective than traditional hospital care.  

Why has the CMS Acute Hospital Care at Home program led to an explosion of new hospital at home programs? 

Until November of 2020, chief among the barriers to the establishment of hospital at home programs was the fact that most federal healthcare programs and commercial insurance did not pay for hospital-level care outside of the hospital premises. 

On March 30, 2020, CMS first announced measures to allow healthcare systems and hospitals to provide services in locations beyond their existing walls to address the urgent need to expand hospital capacity and dedicate locations to provide COVID-19 treatment.  These initial measures, called the “CMS Hospitals Without Walls” program, included allowing ambulatory surgery centers to contract with hospital systems to provide hospital services or to enroll as hospitals.  CMS also permitted doctor-owned hospitals to increase their number of beds and allowed hospital emergency departments to set up testing and screening sites for identifying COVID-19 at drive through and off-campus test sites. 

On November 25, 2020, CMS announced additional steps to increase hospital capacity by expanding its Hospital Without Walls program to include an “Acute Hospital Care at Home” program, which offered eligible hospitals the opportunity to treat eligible patients in their home.  By establishing the “Acute Hospital Care at Home” program, CMS began allowing Medicare fee-for-service reimbursement for home-based hospital services for the first time. 

How does the CMS “Acute Hospital Care at Home Individual Waiver” Work?

CMS set up a new website informing hospitals that it was accepting “waiver requests” that would allow eligible hospitals to provide hospital services at home.  Specifically, CMS began accepting waiver requests to waive sections of the federal regulation that requires hospital nursing services to be provided on hospital premises 24 hours a day with immediate availability of a registered nurse.  

The CMS waiver was extended to allow individual hospitals to submit requests to waive the regulatory requirements (this was not a blanket waiver, but requires each hospital to submit individual waiver requests).  The new CMS website provides a simple way for hospitals to apply for waivers and to submit data related to reporting waiver requirements when participating in the Acute Hospital Care at Home program.  

Did Medicare billing and coding requirements or Medicare reimbursement change?

The CMS waiver does not change any Medicare requirements except for the waiver of the federal regulation that requires hospital nursing services to be provided on hospital premises 24 hours a day with immediate availability of a registered nurse.  In fact, Medicare billing and coding requirements remain the same as for other inpatients treated on the hospital premises.  Medicare inpatient payments are the same for all settings, including reimbursement for hospital services provided in the home.  

What are some of the requirements for hospital care in the home? 

First, a physician must evaluate a patient in-person before hospital at home care begins and there must be at least two hospital at home inpatient visits daily.  A minimum of two sets of in-person vital signs are also required, and remote monitoring must be consistent with existing hospital policies and standards of care. Ancillary services can be performed virtually or in-person based on the patient’s needs and conditions. 

How do patients become part of the CMS Acute Hospital Care at Home program? 

Patients must enter the Acute Hospital Care at Home program from either a hospital emergency department or an inpatient hospital setting.  Participating hospitals must establish and conduct screening protocols to determine if a patient qualifies for the program. CMS has stated the Acute Hospital Care at Home program can benefit patients with over 60 acute conditions including congestive heart failure, pneumonia, chronic obstructive artery disease, and asthma. The screening programs also include non-medical factors such as home utilities and physical barriers in the home. 

If the patient agrees to participate in the program (participation cannot be required), the hospital will provide acute care services in their home.  The term “home” can include an assisted living facility.  A nursing home patient can also receive services as long as the hospital works with the nursing home so that there are no duplicate state or federal payments while the hospital is being patient for inpatient level of care.  

Are any South Carolina or North Carolina hospitals participating in the “Acute Hospital Care at Home” program? 

Yes, in South Carolina five Prisma Health hospitals and four Roper St. Francis Healthcare hospitals are participating.  In North Carolina, the participating hospitals include five Atrium Health, two Duke Health, two WakeMed, two UNC Health, and three Novant Health facilities, as well as Scotland Memorial Hospital.  

Is the CMS Acute Hospital Care at Home program permanent? 

Currently, the CMS Acute Hospital Care at Home waiver is set to end when the COVID-19 Public Health Emergency ends.  However, many are now speculating that while brick and mortar hospitals are here to stay (with a focus on critically ill patients), other acute ailments will be managed almost exclusively at home in the future.  One thing is for certain, with over 100 hospitals and 40 health systems approved for the CMS Acute Hospital Care at Home waiver, the healthcare industry is examining whether this expanded level of care in the home setting is an essential new component of hospital care.