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Acute care at home has demonstrated strong patient satisfaction and quality metrics, especially for the Medicare population. Despite the recent interest in and success of the model, there is uncertainty surrounding its sustainability in a post-pandemic era. For broader adoption, organizations will have to think about long-term funding strategies and reimbursement, cross-industry partnerships, and overcoming the logistical challenges of providing acute care in the home.

A care model that offers patients who typically require hospitalization the option to receive acute-level care in their home. It is often referred to as hospital-at-home. The structure and implementation of acute care at home could vary depending on factors like staffing, conditions treated, the number of visits per day, or the length of the care episode.

The acute care at home model has seen widespread implementation internationally, but the United States has seen slower adoption due to reimbursement challenges. The Covid-19 pandemic and the advancement of telehealth promoted growth as providers sought to treat patients with Covid-19, preserve inpatient capacity, and protect vulnerable patients. In 2020, the Center for Medicare and Medicaid Services (CMS) gave hospitals the flexibility to care for Medicare patients in their homes with the Acute Hospital Care at Home program. The waiver established Medicare payment for acute care at home and stipulated patients can only be accepted into the program from either the emergency department or after an inpatient admission. By June 2022, more than 242 hospitals across 107 health systems in 36 states were approved by CMS to provide hospital services in a home setting. CMS continues to monitor the effectiveness of the waiver and its application in a post-pandemic environment.

There is widespread interest across the health care industry to grow the acute care at home model. The belief is that the patient’s home, for those who qualify, should be considered an extension of the hospital and serve as a place for high-quality care. Proponents of the model argue that it can reduce costs, improve outcomes, and enhance the patient experience. However, while acute care at home has proven positive from a patient satisfaction and quality standpoint, there isn’t enough evidence of the sustainability of this model in a post-pandemic era. Widespread adoption has and will be hindered by workforce shortages, patchwork reimbursement policies, and the logistical challenges of shifting care to patients’ homes.

Through our research and conversations with thought leaders on acute care at home, we have uncovered the following three insights:

1. The aging population will contribute to the growth of acute care at home.

As the number of older adults increases, providers and payers are interested in care models that can keep them in the lowest cost setting possible. Well-monitored, at-home treatment can be safer, cheaper, and more effective than traditional hospital care—especially for older adults who are susceptible to infections or other complications from inpatient hospital care. The ongoing demographic shift is also prompting providers to meet older adults’ desire to age in place and better manage chronic disease. Providers who have set up programs during the pandemic to meet these needs, and who have experienced growing acceptance, aren’t likely to backtrack when the pandemic ends.

2. Despite the current wave of interest, acute care at home will serve a small portion of the eligible population.

There is a lot of interest and investment in acute care at home. However, large-scale adoption of this model will likely be hindered by the inherent operational challenges of providing acute-level care in the home. To create a sustainable program, providers will need to generate sufficient volumes while maintaining the staff expertise and infrastructure needed to deliver all the services patients need.

Advisory Board has estimated that 30 percent of current hospital inpatient volumes could theoretically shift to the home, however only five percent of inpatient volume is currently performed in the home even in the most advanced programs. An external analysis by Milliman also suggests that five percent of Medicare admissions are likely to be able to move to the home. Factors limiting the shift in volume includes that patients:

Overall, the shift of inpatient volumes to an acute care at home program will likely be slow and concentrated in niche services.

3. The acute care at home model is best suited for specific use cases.

For providers operating under fee-for-service (FFS), the main use case for acute care at home is to preserve inpatient capacity. Providers can identify candidates for an acute care at home program when they’re in the ED or inpatient hospital bed. There is a potential to improve case mix index and use of hospital inpatient beds for more complex acute care. The CMS waiver currently makes this financially and logistically possible. Pre-pandemic, providers often relied on a bundled payment approach, where they would contract with health plans in risk-based arrangements for 30-to-60-day episodes of care.

For providers in value-based contracts, acute care at home can be an effective way to help lower costs of care while improving patient and caregiver engagement and satisfaction. Cost reduction can come from eliminating facility expenses and reducing the length of hospitalizations and re-admissions.

Examples for how to generate positive ROI from acute care at home programs

For broader adoption of the acute care at home model, the health care industry must consider the following conditions:

Explore the collection of resources that our team has developed to help you understand how the industry is currently caring for older adults (ages 65+), why change is essential, and how industry stakeholders can collaborate to build a better care model for seniors.

To create a sustainable acute care at home program, providers will need a standardized reimbursement structure that is not tied to a public health emergency. Temporary CMS waivers, and the associated start-up financing and grants, will not be enough to guarantee long-term success. Although feasible under FFS, providers are increasingly considering a standard reimbursement structure under risk. The pandemic tested the limits of FFS care, and many provider organizations struggled with inconsistent, and at times, insufficient revenue. Acute care at home inherently aims for quality care, improved patient experience, and reduced adverse health events—all at a lower cost.

Lasting success of acute care at home programs will depend on consensus around the collection, documentation, and reporting of quality metrics. Key metrics around escalation and mortality are required by the CMS Waiver program. However, the relatively small number of patients in acute care at home programs can limit the usefulness of the escalation rate metric at the overall hospital level. Organizations should consider tracking other metrics besides escalation and mortality to support ongoing quality improvement efforts. There is no perfect set of metrics, and each program can use what works best for them. However, many different stakeholders will be invested in the data, so acute care at home programs should take a multi-stakeholder approach to their quality reporting strategy.

For acute care at home to achieve the largest level of growth, industry stakeholders must take a deliberate approach to partnerships. They should partner as necessary to overcome logistical challenges like bringing technology to a patient’s home, setting up transportation, and selecting and staffing the right care team. A coordinated approach prevents negative, cross-industry ramifications like jockeying for market share or expanding care only to patients who have existing access. An effective strategy will require partnership not only with community and advocacy groups, but also between some combination of providers, payers, governments, and the suppliers and technology vendors that are increasingly making acute care at home possible. If each player maximizes the value of their own offerings, they will be able to expand care to larger patient populations at greater numbers.

Mount Sinai and Contessa Health

The Mount Sinai Health System is a hospital network in New York City; Contessa Health operates a risk-based, home care model in six states

Mount Sinai and Contessa are in a joint venture that coordinates care for acute care at home patients with Mount Sinai physicians and Visiting Nurse Service of New York (VNSNY) nurses. Contessa coordinates all logistics of care via their tech platform and their recovery care coordinators (typically RNs). They perform daily visits with VNSNY and Mount Sinai medical team, answer patient questions, address social needs, and schedule all follow-up care. Across their partnerships, Contessa has increased patient satisfaction by 22 percent, reduced average length of stay by 35 percent, and reduced readmissions rates by 44 percent.

Most leaders in the industry are focused on trying to secure a competitive edge in the market. What they’re not always considering are the challenges and impacts of delivering acute-level care in the home. Industry partners will have to overcome the following challenges to realize the full potential of these models.

The growth of acute care at home will create ripple effects throughout the health care industry. Below, we’ll look at specific impacts for health care stakeholders.

Although acute care at home has great potential, there are serious hurdles to scale. The shift to acute care at home will be slow and concentrated. It's a model that has significant implications for strategy, and not all will be able to generate a positive ROI from launching a program. Looking towards the future, leaders should consider the following:

For additional information about caring for an aging population, check out www.advisory.com/seniors.

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