Hospital-at-Home: Multistakeholder Considerations for Program Dissemination and Scale

Tags:
Perspective
Topics:
US Health Care Reform Health Care Practice / Quality

Policy Points:

  • Hospital-at-Home (HaH) is a home-based alternative for acute care that has expanded significantly under COVID-19 regulatory flexibilities.
  • The post-pandemic policy agenda for HaH will require consideration of multistakeholder perspectives, including patient, caregiver, provider, clinical operations, technology, equity, legal, quality, and payer.
  • Key policy challenges include reaching a consensus on program standards, clarifying caregivers’ issues, creating sustainable reimbursement mechanisms, and mitigating potential equity concerns.
  • Key policy prescriptions include creating a national surveillance system for quality and safety, clarifying legal standards for care in the home, and deploying payment reforms through value-based models.

In 2019, US hospitals accounted for 36 million admissions and $1.2 trillion in spending (31% of national health expenditures).1 Acutely ill older adults, specifically Medicare Part A enrollees with chronic diseases, accounted for 10.5 million discharges in 2019.2, 3 Inpatient care, however, is characterized by inefficiencies, as articulated in the Institute of Medicine’s report, Crossing the Quality Chasm.4 Research has also identified “post-hospitalization syndrome,” which encompasses physical decline (e.g., decreased mobility), mental complications (e.g., delirium), and an increased risk of 30-day readmissions, all of which are attributable to the allostatic stress of facility-based care.5, 6 These gaps in care access and quality are amplified when examined through an equity lens, with disparate outcomes in readmissions, morbidity, chronic disease management, and overall health among racial minorities.7

Nevertheless, population aging is expected to intensify the utilization of hospital services. This and the gaps in hospital quality exposed by the COVID-19 pandemic highlight the need to redesign acute care to better serve older adults and minorities. Consequently, the National Academy of Medicine (NAM) convened a multistakeholder meeting to discuss the post-pandemic future of acute care, with a particular focus on Hospital-at-Home (HaH) as an alternative to facility-based approaches. The meeting’s objectives were to (1) define the current scope of HaH care models, (2) create a shared understanding across stakeholders of the priority areas and challenges for HaH, and (3) identify sector-specific levers to maximize HaH’s benefits and scalability.

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References

  1. Centers for Medicare & Medicaid Services. National health expenditures fact sheet. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet. Accessed October 1, 2021.
  2. Agency for Healthcare Research and Quality. Most common diagnoses for inpatient stays. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb277-Top-Reasons-Hospital-Stays-2018.pdf. Accessed August 31, 2022.
  3. Centers for Medicare & Medicaid Services. All Medicare inpatient hospitals: utilization, program payments, and cost sharing for original Medicare beneficiaries, by type of entitlement, calendar years 2014–2019. https://www.cms.gov/files/document/2019cpsmdcrinpthosp1.pdf. Accessed October 1, 2021.
  4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.
  5. Sager MA, Rudberg MA, Jalaluddin M, et al. Hospital Admission Risk Profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc. 1996; 44(3): 251- 257.
  6. Krumholz HM. Post-hospital syndrome: an acquired, transient condition of generalized risk. New Engl J Med. 2013; 368: 100- 102.
  7. Fiscella K, Sanders MR. Racial and ethnic disparities in the quality of health care. Annu Rev Public Health. 2016; 37(1): 375- 94.

Citation:
Kadakia, K.T., Balatbat, C.A., Siu, A.L., Cohen, I.G., Wilkins, C.H., Dzau, V.J. and Offodile 2nd, A.C., Hospital-at-Home: Multistakeholder Considerations for Program Dissemination and Scale. Milbank Q. September 23, 2022. https://doi.org/10.1111/1468-0009.12586