Who rescues the hospital-at-home patient at 2 a.m.?
On a hospital unit, a deteriorating patient is a call light away from a nurse, and a rapid response team is down the hall. In a hospital-at-home program, that same patient may be miles from the nearest emergency department.
The model has momentum. Congress extended the CMS Acute Hospital Care at Home waiver through 2030, and health system leaders running the programs told Becker’s their outcomes match or beat traditional inpatient care. But the leaders who run these programs, the nurses who oppose them and the executives weighing them disagree on a more basic question: whether the safety net that makes a hospital a hospital can be rebuilt in a living room, and for which patients.
Momentum has not guaranteed survival. Greensboro, N.C.-based Cone Health said Oct. 14 it will wind down its hospital-at-home program in the fourth quarter, citing changing reimbursement models, operational complexity and long-term sustainability, despite reporting no patient deaths and no healthcare-acquired infections in its first year.
How rescue works at home
Programs build their safety nets in layers, starting with who gets admitted.
Kent Hospital at Home in Warwick, R.I., part of Providence-based Care New England, screens patients medically and inspects their homes for running water, working electricity, smoke detectors and a safe way out. Patients wear a chest patch and bracelet that track blood pressure, pulse, respirations, oxygen saturation and heart rhythm, and detect falls.
“We’re really looking at their home as an inpatient bed,” said Melissa Frias, BSN, RN, interim president and COO of the Visiting Nurse Association of Care New England and executive director of Kent Hospital at Home, Geriatrics and Palliative Care.
Overnight, a nurse in a command center monitors the video feed, and a physician is on call around the clock. When something looks wrong, the nurse calls the patient and the physician. If the physician is concerned, EMTs or paramedics drive to the home and start a video visit with the physician from the patient’s tablet, which the hospital provides to each hospital-at-home patient.
The patient may receive medication and stay home, return for testing or be transferred back to the hospital. Ms. Frias said Kent treats that last step as an inpatient transfer, akin to moving a patient from a medical-surgical unit to telemetry, rather than a new admission.
Tampa (Fla.) General Hospital’s TGH at Home program uses a similar protocol. Patients wear an armband printed with the program’s phone number, and every patient gets an iPad on FirstNet, the first-responder cellular network, that connects to a dedicated command center in a few taps. Paramedics respond overnight, and the program is adding registered nurses to night shifts.
“I think the difference with hospital at home is we don’t have home field advantage,” said Peter Chang, MD, senior vice president and chief transformation officer of Tampa General. “We have total control here in the hospital. When you go to hospital-at-home, you have to think about every particular scenario that could happen and how you’re going to put safeguards in place.”
Dr. Chang said TGH requires patients to live within 30 minutes of one of its emergency facilities, a stricter reading of the waiver’s emergency-response requirement, and meets with Tampa Fire Rescue and Hillsborough County’s fire department twice a year, so EMS crews recognize hospital-at-home patients.
The case that home is safer
Dr. Chang argued that for some patients, home is the safer place.
He said TGH at Home’s patients are as acutely ill as those on its medical-surgical units, yet the program’s hospital-acquired infection and mortality rates are lower. On a typical med-surg unit, a patient without telemetry may get vital signs every four hours overnight. A continuously monitored TGH at Home patient gets them every 10 to 15 minutes, he said.
“This is one of the things where I’ll actually argue that hospital at home is potentially even safer than being in the hospital,” Dr. Chang said.
Still, he said remote monitoring technology has not caught up. TGH has tried three or four products. “There’s not one out there that does it all very well,” he said. Because many platforms lack strong automated alerts, command center staff check patient dashboards several times an hour.
Ms. Frias said Kent has had no catheter-associated urinary tract infections in hospital at home and a 99.7% likelihood-to-recommend score across more than 1,800 patients since 2022.
Where leaders draw the line
Other leaders said the model works because of who is excluded.
Pittsburgh-based Highmark Health does not admit hospital-at-home patients who need continuous monitoring, said Mona Siddiqui, MD, senior vice president of home and community care.
“If they need continuous monitoring, then we’re not taking them right now,” she said.
Highmark is discussing whether to take higher-acuity patients but would move “very slowly, very incrementally,” Dr. Siddiqui said, because “the capabilities that we have right now are going to need to evolve if we were to take somebody who required greater monitoring.”
Dr. Siddiqui has described the home as a “black box” for clinicians who send patients there. “There’s no closed-loop communication,” she said.
Highmark’s answer is to keep oversight inside the hospital. Hospital-based providers document home care in the same Epic record, and a dedicated team of physicians and nurses works only in the program, so clinicians build “that intuition of when to escalate,” she said.
Highmark also owns the home health, home medical equipment and home infusion companies that support the program, which she said prevents lapses in care.
Dr. Siddiqui said the program saw a slight increase in falls a few years ago. In response, the team gave patients night lights, added education on fall-prevention steps before bed and introduced a patient self-assessment of fall risk, a Highmark spokesperson said. The system declined to share specific outcomes figures.
Donna Berizzi, DNP, RN, executive director of oncology at Johns Hopkins Hospital and associate chief nursing officer of oncology for Johns Hopkins Health System in Baltimore, draws a sharper line between hospital at home and cancer infusions at home.
“I support our patients remaining in the home for as much care as they can receive, but it has to be safe, and safety has to be at the infrastructure of whatever we’re going to make decisions to do at home,” she said.
Dr. Berizzi said infusing anti-neoplastic drugs at home raises three questions: whether a second nurse, in person or by video, can independently verify the drug and dose; whether care is moving home because an insurer requires it; and who manages symptoms after the nurse leaves.
“Are we moving the care to the home because the insurance company tells us that it has to be moved to the home?” she said.
When a payer’s reimbursement policy nudges a patient out of the hospital, Johns Hopkins works through a decision tree. Leaders first check whether the patient can be treated at an off-campus oncology infusion site, considering whether the insurer will agree, whether the drug is available and whether the patient is willing to travel. If not, they look at a Hopkins infusion area that mostly treats non-oncology patients.
Before home infusion, oncology leaders confirm the home care team can provide a second RN, reaction medications and side-effect medications. Home care nurses who are not oncology-trained “may not know what they’re missing,” Dr. Berizzi said, and a virtual double check “is only as good if it has the same accountability and rigor that we utilize in the infusion setting.”
The case against
The New York State Nurses Association opposes the model outright. In May, the union said it kept a hospital-at-home provision, including an expansion to Medicaid patients, out of New York’s state budget. New York hospitals can still operate hospital-at-home programs through CMS’ waiver.
“When a patient declines or when a patient is found to be unstable, it’s too late,” said Michelle Jones, MSN, RN, secretary of NYSNA’s board of directors and a nurse practitioner at Flushing (N.Y.) Hospital Medical Center. “Then you have to call emergency services. How long is it going to take for emergency services to come to that person’s home?”
Ms. Jones said frequent remote vital signs cannot replace a nurse at the bedside. Readings can be wrong if a pulse oximeter is incorrectly placed or a blood pressure cuff is too loose, she said, and in-person nurses catch decline through a patient’s color, speech and responsiveness.
Vital signs do not equal subtle signs noted in person, she said: “We’re not talking about just monitoring patients with vital signs, we are talking about using our five senses.”
She said programs highlight favorable infection and readmission rates while shifting care responsibilities to families and reducing hospital nursing staff. Asked whether safeguards such as staffing or response-time requirements would ease NYSNA’s concerns, she said no.
“No, we are not comfortable with it,” Ms. Jones said. “We want our nurses to be in the hospital giving care to these patients.”
A safety metric the field has not standardized
Every program leader Becker’s interviewed said they measure hospital at home against inpatient benchmarks: readmissions, infections, falls and patient experience. None named a rescue-specific measure, such as how often patients are escalated back to the hospital or how long it takes help to arrive.
“We try to look at the same metrics that an acute setting would be looking at,” Dr. Siddiqui said.
Researchers have proposed one. A study published in March in The Journal of Advanced Home Medicine examined 3,114 hospital-at-home patients at Boston-based Mass General Brigham, Epworth Hospital in Australia and Singapore’s National University Health System. Between 6.1% and 6.5% of patients at each site had an unplanned escalation back to the hospital, and about 2% were transferred to an ICU within 24 hours of escalation.
The authors called unplanned escalation “a viable and standardisable safety metric” for hospital at home.
A shared measure would give programs a common way to answer the question their critics keep asking: how often patients decline at home and how quickly help arrives. Leaders on both sides say they want the evidence to decide.
“I can have a feeling. It doesn’t really matter what that feeling is, because we have to look at the data and the outcomes for our patients to drive that conversation,” Dr. Chang said. “From what I’ve seen, both in nationally published studies and in our own experience, [hospital at home] is a safer environment as it pertains to hospital-acquired infections and overall mortality rate.”
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