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The Issue

The hospital-at-home (H@H) model — where patients receive acute level care in their homes, rather than in a hospital — has emerged as an innovative and promising approach to provide high quality care to patients in the comfort of their homes. Since the start of the program, Congress has extended the waivers twice, first in 2022 (Consolidated Appropriations Act of 2023) for two years and then again in 2024 (H.R. 10545 the American Relief Act) for 90 days. Both extensions received no score from the Congressional Budget Office. The waivers were extended until Sept. 30, 2025, as part of the continuing resolution passed earlier in the year.

AHA Take

The AHA supports the Hospital Inpatient Services Modernization Act to extend the H@H waiver for five years.

Hospitals and health systems see H@H programs as a safe and innovative way to care for patients in the comfort of their homes. This kind of care is well suited for medium acuity patients who need hospital level care but are considered stable enough to be safely monitored from home. Rather than staying three days or longer in the hospital, these patients can be treated safely by their doctor and a team of medical professionals along with the patient’s support system at home.

A long-term extension will not only provide additional time to continue gathering data on quality improvement, cost savings, and patient experience, but will also provide much needed stability for new programs and may ease state concerns about updating Medicaid policies to allow for coverage of these services.

Background

To allow hospitals and health systems the ability to respond to the COVID-19 pandemic effectively and efficiently, the Centers for Medicare & Medicaid Services (CMS) provided a number of waivers and flexibilities that eased several Medicare restrictions and requirements. These included waivers to certain conditions of participation for approved H@H programs.

To receive approval to participate in the H@H program, hospitals must submit an individual waiver request to CMS. The request specifically asks CMS to waive §422.23(b) and (b)(1) of the Medicare Conditions of Participation, which require nursing services to be provided on premises 24 hours a day, seven days a week, as well as the immediate availability of a registered nurse for the care of any patient. Once the waiver request is received, CMS divides the applications into two categories, allowing more-experienced hospitals a quicker approval process so they can rapidly expand their H@H program; less-experienced hospitals have to demonstrate they are capable of meeting the requirements associated with the provision of H@H services.

As of November 2024, 378 hospitals, across 140 systems and 39 states, have been approved to provide H@H services to patients. Other health systems and hospitals have indicated they are interested in standing up H@H programs but are hesitant to do so without a long-term extension from Congress. In October 2024, CMS released a report that adds to the growing body of literature which demonstrates that H@H is a safe, effective program. Specifically, CMS found that generally H@H patients had lower mortality rates, lower readmission rates, and lower spending in the 30-days post-discharge. But the benefits went beyond quality and costs as patients and caregivers also expressed predominantly positive experiences with the program. While the report found that AHCAH patients were more likely to be white and live in an urban location and less likely to receive Medicaid or low-income subsidies, this can in part be attributed to the variability in state Medicaid coverage of H@H
programs. As of June 2024, only 12 states provide Medicaid coverage for H@H.