A national qualitative study of Hospital‐at‐Home implementation under the CMS Acute Hospital Care at Home waiver

Abstract

Background The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID‐19 pandemic. The AHCaH waived the 24/7 on‐site nursing requirement and enabled hospitals to obtain full hospital‐level diagnosis‐related group (DRG) reimbursement for providing Hospital‐at‐Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. Methods We conducted semi‐structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. Principal Findings We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre‐existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. Conclusions Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.

Patients' and caregivers' perceptions of the quality of hospital‐at‐home service: A scoping review

“…The implementation of HaH service is often hindered by various barriers such as patient admission referrals, adequate staffing, performance evaluation and financial funding (Gorbenko et al, 2023; Kadakia et al, 2022; Leff et al, 2022). Patient interactions with the healthcare system and their evaluations of HaH service quality are important indicators for assessing and improving its quality.…”

“…Notably, being the focus of attention for care teams contributed to patients' perceptions of the quality of HaH services, outweighing concerns about privacy when receiving care at home. However, to improve the uptake of HaH services, privacy protection should be considered in the aspects of laws, ethics and regulatory practices(Gerke et al, 2020).To ensure effective HaH services, it is important to involve caregivers in decision-making and communication with healthcare professionals, given the close relationship between caregivers and patients(Gorbenko et al, 2023;Kwame & Petrucka, 2021;Leff et al, 2022;,Levine et al (2021, b),Lai et al (2021),Ko et al (2022),Maniaci et al (2022)…”

“…abling patients to stay connected to their usual care team in the hospital and maintain relationships with the HaH care team. Future studies are necessary to compare the service content in HaH schemes and take advantages of these different initiatives(De- Cherrie et al, 2019;Gorbenko et al, 2023;Leong et al, 2021;Zuke et al, 2022). This can provide valuable insights into strengthening TA B L E 5…”

Home Hospital Outcomes for Acute Decompensated Heart Failure and Factors Associated With Escalation of Care

“…3 While the utilization of and funding for home hospital programs have grown, there is limited contemporary data about characteristics and outcomes of HF hospitalizations in the home hospital model and the drivers of escalation of care from home hospital to traditional brick-and-mortar hospitals. 16,17 In this study, we report contemporary patient demographics, clinical characteristics, and outcomes of HF admissions in 2 home hospital programs based in the United States. We also identify HF-specific factors that are associated with escalation of care and create a least absolute shrinkage and selection operator (LASSO) logistic regression model to predict escalation to traditional hospitalization.…”

What's next for Hospital at Home Programs in the United States: A clarion call for permanent, person‐centered solutions

“…In this issue of the Journal of the American Geriatrics Society, Gorbenko et al 9 noted the rapid and enthusiastic uptake of HaH through the waiver program across the U.S. for a variety of reasons. One participant went so far as to call HaH a “safety valve” to prevent overcapacity due to COVID‐19 surges.…”