In response to hospital capacity challenges brought on by the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) collaborated with external experts to create the Acute Hospital Care at Home (AHCAH) initiative. This initiative will expire on Dec. 31 unless Congress extends it. After three years of implementation, early insights regarding quality, costs and care have begun to shape the future of this program and similar initiatives.
CMS initially launched the Hospital Without Walls initiative in March 2020, using authorities under the Social Security Act that allow the Secretary of Health and Human Services to waive or modify specific facility standards during public health emergencies.
Building on this initiative, CMS introduced the AHCAH program in November 2020. This program enables acute care hospitals that receive payment under the inpatient prospective payment system to extend their delivery of inpatient care into patient homes.
To partake in the initiative, hospitals must submit a waiver request through a dedicated CMS portal. Following a review, CMS meets with each requesting hospital to evaluate its ability to provide high-quality and safe care in home settings in accordance with the Medicare Hospital Conditions of Participation. Once approved, hospitals can start admitting eligible patients to receive inpatient care at home. As of October 2024, 366 hospitals have participated in the initiative, serving more than 31,000 patients in home settings, according to CMS.
In December 2022, Congress passed the Consolidated Appropriations Act (CAA) for 2023, which extended the AHCAH initiative through Dec. 31, 2024. The CAA also mandated that the CMS conduct a study to evaluate several aspects of the initiative. The findings of this study, Report on the Study of the AHCAH Initiative, were published on Sept. 30, 2024.
The study used the best available quantitative and qualitative data to compare patients in AHCAH with inpatients in traditional brick-and-mortar hospitals. This comparison involved 332 participating hospitals across 38 states and covered the period from November 2020 to July 2024. The data analysis focused on several key areas: patient inclusion criteria and demographics, clinical conditions treated, quality of care, costs and service usage and patient experience.
Patient demographics
Each hospital established patient inclusion criteria based on its experience and resources to provide inpatient-level care in a home setting. The criteria also incorporated nationally recognized standards. The specific selection criteria considered clinical and psychosocial factors, the home environment and the patient’s willingness to participate.
An analysis revealed significant differences between patients receiving care at home (AHCAH patients) and those admitted to traditional inpatient facilities from the same hospital. AHCAH patients were more likely to be white and reside in urban areas and less likely to be Medicaid beneficiaries.
Quality of care comparison
The study used the Medicare Severity Diagnosis Related Group (MS-DRG) and Major Diagnostic Category (MDC) classification systems to identify the most common illnesses treated through the AHCAH initiative. The findings indicated that the predominant conditions were respiratory, circulatory, renal and infectious diseases.
Three quality metrics—30-day mortality rates, 30-day readmission rates and hospital-acquired condition rates—were analyzed to compare the quality of care. AHCAH beneficiaries generally had lower 30-day mortality rates than their counterparts in traditional inpatient settings, according to CMS.
However, the AHCAH group experienced significantly higher readmission rates for two specific MS-DRGs—respiratory infections and inflammation requiring mucociliary clearance, as well as septicemia or severe sepsis without mechanical ventilation. Conversely, readmission rates were significantly lower for three other MS-DRGs—simple pneumonia and pleurisy with complications or comorbidities, simple pneumonia with pleurisy without complications, comorbidities, or the need for mucociliary clearance, and chronic obstructive pulmonary disease with complications or comorbidities.
In terms of cost, CMS evaluated the impact on Medicare program spending rather than on individual hospital costs. The analysis of episodes of care—ranging from inpatient admission to discharge—revealed that AHCAH episodes had, on average, less than one extra day in length of stay. Furthermore, AHCAH beneficiaries incurred significantly lower Medicare spending in the 30 days following discharge.
Patient experience
Qualitative data on patient experiences under the AHCAH initiative was gathered through listening sessions, site visits and informal interviews with caregivers. The findings indicate that both patients and caregivers who shared their feedback had positive experiences regarding the care provided through the initiative. This aligns broadly with the positive patient experience outcomes associated with hospital-at-home programs.
Clinicians involved in the initiative also reported primarily positive experiences.
Early lessons from the AHCAH initiative suggest that providers can deliver safe, high-quality inpatient care in home settings for appropriately selected patients. This approach aligns with and supports the CMS Center for Clinical Standards and Quality’s core mission of enhancing lives, health outcomes and care experiences.
Important questions remain, as the initiative expires on Dec. 31. CMS is reportedly exploring opportunities to address these questions should the program be extended.
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