Happy New Year! For my first post of 2025, I'd like to talk about an innovative approach to healthcare delivery that recently appeared on my radar. Toward the end of 2024 I attended several events on Capitol Hill related to healthcare. The days before and immediately after the U.S. presidential election were an exciting yet exhausting time filled with snap reflections and bold predictions.

In other words, the boundless optimism of the healthcare policy crowd wasn't in short supply.

On "team optimism" I ran across a group of healthcare providers-turned-policy-advocates from the appropriately-named Advocate Health, a nationwide healthcare system, who'd traveled to the Hill from Charlotte, North Carolina to advocate for the continuation of a program called the Acute Hospital Care at Home (AHCAH) initiative.

Featured prominently among the speakers on Capitol Hill was Colleen Hole, a Person-Centered Healthcare Advisor working on the front lines of delivering value-based healthcare. The Advocate Health team was advocating for the continuation of CMS waivers (which I'll explain in more detail below) beyond the end of 2024. I subsequently interviewed Colleen for a forthcoming episode of the Dragon Tree Podcast, so I'll update this post when the video is available.

Spoiler alert: the aforementioned waivers were extended by the American Relief Act, 2024, through March 31, 2025; however, without action by Congress to extend the initiative further, CMS will no longer accept waiver requests for participation in the initiative.

But I'm getting ahead of myself.

When I first read the advertisement for the Capitol Hill briefing, the whole concept of acute care patients receiving equivalent medical care at home seemed alien to me. I suppose I'd heard of Hospital at Home (HaH) care before, but the event announcement made it seem like, at least for certain patients who would under most circumstances have to seek care in a brick-and-mortar hospital, they could now receive care in the friendly confines of their homes.

According to a recently-released report (PDF file) on the AHCAH, the concept has its roots in the UK: "The first trials, held in the United Kingdom (UK) in the late 1970s for patients experiencing acute myocardial infarctions, found that hospitalizations conferred no benefits over home-based acute care. Since then, HaH programs have been established in the UK, Italy, Australia, Canada, Israel, and other countries with government-run health systems."

The report goes on to say that similar studies were made in the U.S. in the 1990s, but the approach doesn't seem to have been adopted to any significant extent here. So it stands to reason that, while HaH has been used to good effect elsewhere, I was new to the AHCAH, a CMS-sanctioned care delivery approach that takes this brand of home care to the next level.

The initiative, which was authorized by CMS in the Acute Hospital Care at Home Individual Waiver in the opening days of the COVID-19 pandemic, served as a way to relieve pressure on overstretched care facilities. It allowed certain hospitals to begin treating patients with inpatient-level care at home, with a goal of improving their outcomes and experience, while at the same time reducing hospital costs.

This waiver covers Medicare patients at Atrium who are eligible for enrollment into the AHCAH. Regarding Medicaid patients, however, an AMA Future of Health Case Study (PDF file) spotlighting Advocate's HaH program notes that, "as of November 1, 2023, North Carolina Medicaid covers this program under the existing diagnosis-related group (DRG) methodology."

The case study notes that coverage for Medicaid patients was meant to run through the end of 2024, and I was unable to find out if, like the plan covering Medicare patients, this, too was extended. I'll update this post if I find further information. But whatever the case may be, AHCAH proved a revolutionary approach to care delivery during the pandemic, when brick-and-mortar hospitals were becoming overrun by COVID patients. Many will remember that especially during 2020, the prospect of someone with non-emergent issues stepping foot inside a care facility was met with serious skepticism.

Despite a short runway for takeoff, the AHCAH initiative proved a big success in places like Charlotte. In that city, Atrium Health – which is part of Advocate Health and is an integrated nonprofit health system operating the Atrium Health Hospital at Home (AH-HaH) program, a version of the AHCAH – has achieved impressive results (PDF file). To date, they've enrolled over 8,400 patients across 10 counties in the Charlotte region. This has resulted in nearly 30,000 bed days saved since March 2020.

The goal of Advocate Health's AHHaH program, which is a strategic partnership between a traditional brick-and-mortar health system and a technology company, is to "build and scale a program that enables patients to continue their care and recovery at home." There was good reason at the outset to think the program would prove useful in stemming the flow of patients flooding hospitals in 2020, and that, if properly implemented, it could continue once COVID rates started falling.

And Advocate Health's optimistic outlook is shared by other HaH participants, including Mt. Sinai. The New York-based healthcare system recently reported that it has doubled the number of providers involved in its program. Part of the reason for their success is that they began providing home-based care a decade ago. From the article:

"The health system already has one of the oldest hospital-at-home offerings in the country, starting in 2015, before the CMS waiver that propelled many health systems to launch the care model. So Mount Sinai has learned to provide acute inpatient care at home in the face of regulatory uncertainties."

These "regulatory uncertainties" have likely put a damper on wider, nationwide uptake of the AHCAH programs, along with, as Ania Wajnberg, MD, president of Mount Sinai at Home, puts it in the article, "people-heavy" aspect of the business. New York requires that HaH patients receive two in-person visits per day, and that these visits be made by nurses, the latter of whom seem to be in relatively short supply in relation to the demands of the program.

Dr. Wajnberg and her team have mitigated this challenge by opening the program up to a wider array of patients, including "patients who need dialysis, post-surgical care, or monitoring for complex cardiac conditions." The fact that they've managed to double their HaH staff speaks to the confidence Mt. Sinai leadership has in the program.

Reminiscent of the UK study I quoted earlier, the previously-mentioned CMS report on the AHCAH provides evidence for the efficiency of this care approach: "A variety of studies and systematic evidence reviews have demonstrated that HaH is similar to or better than in-hospital stays across a variety of measures, including costs, mortality, length of treatment, health care usage, readmissions, long-term care admissions, anxiety and depression, and patient and caregiver satisfaction."

This success can, at least in part, be attributed to the fact that, to ensure that the initiative carries out its intended purpose, AHCAH sites have to be selective when choosing which patients to enroll. As a fact sheet on the previously-quoted report attests, although hospitals were given some latitude to decide on inclusion criteria for participating patients, "Participating hospitals indicated that these criteria were developed and utilized with the intent to ensure that eligible patients were willing and able to participate in a HaH program, that such patients were clinically and psychosocially appropriate to safely receive care in the home, and that patients’ home and community environments were conducive to the safe and effective provision of acute inpatient care at home."

It's temping to think about home care purely in terms of a CMS-funded initiative, since it was the AHCAH waiver that triggered outfits like Atrium Health to go all in on home care. But in the intervening years the program has grown, and, like Atrium, participant sites have begun accepting a diverse mix of payers for their program.

As the AMA case study attests, Atrium (through Advocate Health) accepts patients who are enrolled in Traditional Medicare, select Medicare Advantage plans, North Carolina Medicaid, and "select commercial payers." As the same case study makes clear, however, "Coverage by commercial payers is inconsistent."

Similarly, Mt. Sinai has incorporated a dynamic payer mix into its program. According to the Becker's article, "Mount Sinai has been at this so long it has contracts with payers outside of Medicare." This seems to be a key way to hedge against the uncertainty of whether or not, at some point, Medicare patients may be dis-enrolled from the initiative.

Keeping in mind that patients other than those strictly on Medicare or Medicaid participate in acute care at home programs, it's instructive to look at the skew of Medicare versus Medicaid enrollee participation. In the previously-mentioned report, CMS found that, when compared to patients receiving comparable services in brick-and-mortar hospitals, the demographics of those enrolled in the AHCAH initiative were, on average, skewed toward Medicare beneficiaries. As the report states, "In general, 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 care delivery approach lasted for the duration of the pandemic and has only gained traction in the intervening years. As a sign of its enduring value, at the end of the public health emergency, the Consolidated Appropriations Act, 2023 extended the waivers and flexibilities associated with the AHCAH initiative until December 31, 2024. And, as mentioned earlier, it was recently extended again through March of 2025.

In addition to expanding its insurance payer mix, teams like Advocate Health have found innovative ways to improve the program and help more people. For instance, in 2023, Atrium partnered with Best Buy Health to diversify its technological toolkit. Best Buy Health offers its own care at home platform called Current Health, which debuted in 2021 and "brings together remote patient monitoring, telehealth and patient engagement into a single solution for healthcare providers."

Through this partnership, Atrium is able to enhance its patient education along with enabling in-home technology offerings with the assistance of Geek Squad Agents, Best Buy's 24/7 support agents who are available to provide logistics and technical help.