Home Health Series – The Challenges to Widespread Implementation of Hospital at Home Programs

Hospital-at-home gained the greatest momentum in recent years due to the COVD-19 pandemic. This spurred the launch of the Hospitals Without Walls program in March 2020. This was followed by CMS’s Acute Hospital Care at Home waiver, which establishes Medicare payment for home hospitalizations. Just eight months after the waiver was established, over 140 hospitals across 66 health systems were approved by CMS to provide hospital services in a home setting. 

Today, 296 hospitals in 37 states have been authorized to provide acute care at home, according to CMS. But the simple fact is that while progress has been made, there are still many challenges towards full implementation of these successful programs. What are the challenges to widespread adoption of hospital at home programs? Let’s dive in! 

Legal Risks and Liability: Hospital at home programs, though innovative, are not devoid of legal pitfalls. As healthcare delivery shifts from traditional hospital settings to residential environments, the parameters of patient safety, standard of care, and accountability can become a bit complicated. In case of medical emergencies or adverse events, pinpointing responsibility can become complex. The line between what constitutes professional healthcare versus what falls under home care can blur, potentially leading to legal complications and increased vulnerability to lawsuits. That is why strict eligibility requirements and regulations need to be put in place to ensure that consumers are protected and that providers feel empowered to provide services outside of brick-and-mortar locations. 

Access to Reliable Internet: Another roadblock to the seamless implementation of hospital at home programs is the digital aspect and infrastructure required. Patients are monitored at home via technology that allows systems to see their vital signs, and hospitals have 24/7 access to that data. Thus, reliable internet access is foundational for monitoring patients remotely, ensuring their safety, and guaranteeing effective communication between healthcare providers and patients. 

However, many patients, especially in rural areas or economically disadvantaged communities, lack consistent or high-speed internet. This poses significant challenges in terms of real-time data transfer, video consultations, and ensuring that patients receive the care they need when they need it. Patients must also be close enough, in many cases within 30 minutes of the closest facility for safety purposes should an urgent issue arise. This is again a problem that often makes hospital at homes program unattainable for rural communities that are not close to a facility. 

Family Members as Quasi Nurse’s Aides: A major concern highlighted in discussions about hospital at home programs is the inadvertent pressure placed on family members. In many cases, family members find themselves transitioning into roles resembling nurse’s aides, bearing the brunt of responsibilities for basic patient care including delivering meals, helping with hygiene, turning individuals over in bed, and more. This can lead to significant family stress. While the intention is to provide patients with familiar and comfortable surroundings, the inadvertent emotional and physical toll on family caregivers can be substantial. There is not enough data on the effects of hospital at home programs on caregivers, but this is something that does need to be emphasized and potential caregivers need to be included in the decision-making process. 

Adequate Staffing: Adequate staffing remains a significant obstacle to the widespread implementation of hospital at home programs. The healthcare industry, even in traditional settings, has been grappling with persistent staffing shortages, particularly among specialized nurses. This scarcity is exacerbated in the hospital at home model, where skilled medical professionals need to travel to individual homes. This requires more time and resources compared to seeing multiple patients in a single hospital setting. Additionally, the unique demands of home healthcare require professionals to be adaptable and versatile, possessing a broad skill set to handle the unpredictability of home environments. As these models grow in popularity and more players come into the market to meet the demand for services, it intensifies the pressure on an already strained workforce, challenging the healthcare industry’s capacity to offer consistent and high-quality home-based care. When implementing hospital at home programs, it is paramount that quality of care and patient satisfaction are always at the forefront. No matter who the services are being provided by, they need to not only have adequate staff to handle the demand, but also have properly trained individuals to deliver the services to ensure quality care. 

Lack of Insurance Company Buy-In: Despite the evident benefits, hospital at home models have struggled to gain the full confidence of insurance companies. Many insurers remain skeptical about the efficacy and financial implications of this model. They are often reluctant to cover these services at rates comparable to in-hospital care, questioning the quality and effectiveness of care provided at home. This lack of buy-in from insurers poses significant financial challenges to scaling and sustaining these programs.