Hospital systems are increasingly investing in hospital-at-home programs, a previously niche offering that's become a significant trend amid the pandemic. But while the trend may be here to stay, hospital systems still must navigate a host of significant challenges to bring their investments to scale.

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Hospital-at-home care is growing

In hospital-at-home programs, patients with certain conditions are offered high-acuity care within their homes, aided by 24/7 remote monitoring, daily provider visits, and—for some programs, if needed—access to home care support such as food. The programs typically provide all monitoring and communication tools, as well as a hospital bed, when needed, Kaiser Health News reports.

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In November, the hospital-at-home industry received a boost when Medicare announced it would reimburse hospitals for home care as part of a broader effort to enable hospitals to focus on Covid-19 patients by limiting the number of hospitalized non-Covid patients. Since that announcement, more than 100 hospitals have received approval from Medicare to participate in hospital-at-home care—although, according to KHN, not all of them are set up yet.

Most recently, two major stakeholders—Kaiser Permanente and Mayo Clinic—have invested a total of $100 million in Medically Home, a company that provides resources for hospital-at-home care. These systems join several others that are scaling up their hospital-at-home services, including Johns Hopkins Medicine, Presbyterian Healthcare Services, and Massachusetts General Hospital, KHN reports.

The goal for programs is to eventually shift at least 10% of current hospital patients to hospital-at-home care, KHN reports. "In a lot of ways, this remains aspirational; this is the early innings," Dean Ungar, VP and senior credit officer at Moody's Investors Services, said. However, Ungar predicted "hospitals will increasingly be reserved for acute care [such as surgeries and ICUs]," with other patients treated at home.

The benefits of a hospital-at-home program

According to Bruce Leff, a geriatrician at Johns Hopkins Medical School, research indicates that hospital-at-home programs can produce better health outcomes for patients than being admitted to a hospital. At the same time, the programs can also save hospitals money by limiting their need to expand, reducing readmissions, and helping patients avoid nursing homes.

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Raphael Rakowski, co-founder of Medically Home, said hospital-at-home models also prevent facility transfers while patients get better. "We stay with the patient until they're fully recovered, and that averages anywhere from 20 to 30 days, sometimes longer," he said. "So we substitute not just for the hospital, but for all the care that follows."

And Margaret Paulson, leader of Mayo Clinic's new home care program, said once patients understand that hospital-at-home care is just as good as inpatient hospital care, they prefer it. "Especially for patients who have been in the hospital a lot, to know that they can actually go home and sleep in their own bed and be with their family and have their pets by their side, it's just really reassuring," she said.

Significant challenges remain

But hospital-at-home care doesn't necessarily fit every patient, Kavita Patel, a physician and health policy fellow at the Brookings Institution, said. Patients must have good internet access, they need to live close to emergency care (typically no more than 30 minutes away), and they can't be too ill.

"This can't be something where it's so complicated that you are monitoring a patient, worried that they could crash and need to be in the ICU within minutes," Patel said.

And while hospital-at-home care can save hospitals money by limiting the need for expansion, hospitals that have already expanded with expensive inpatient facilities now face the challenge of needing patients to fill up their beds to recoup their investments, KHN reports.

"[T]he financials of it are, frankly, a little tough," Jeff Levin-Scherz, co-leader of the North American Health Management practice at Willis Towers Watson, said. "[H]ospitals that have surplus capacity, whether because they have newly built beds or shrinking populations or are losing business to competitors, are not going to be eager about this."

Gerard Anderson, a health policy professor at Johns Hopkins University Bloomberg School of Public Health, acknowledged the potential for "huge profit margins" for hospitals delivering care in patients’ homes. But he worries that expanding hospital-at-home programs could exacerbate existing health inequities.

"It's realistic in middle- and upper-middle-class households," he said. "My concern is in impoverished areas." Those areas may lack adequate internet access and have a higher incidence of social factors such as living alone or living in crowded conditions.

Alexandra Drane, CEO of Archangels, a for-profit group that works with employers to support unpaid caregivers, added that not every household may be equipped with enough resources to make at-home care work.

"I love the concept for a resourced household where someone can take this job on," she said. "But there's a lot of situations where that's not possible. What if I have a full-time job and two children, when am I supposed to do this?" (Appleby, Kaiser Health News, 5/24; O'Neill, "Shots," NPR, 5/20).