Adoption of 'hospital-at-home' programs remains concentrated among larger, urban, not-for-profit and academic hospitals

The findings are among the first to portray the landscape of hospitals participating in this rapidly growing care model, said Dr. Hashem Zikry, a participant in the National Clinician Scholars Program at UCLA and lead author on the paper, which will be published in the peer-reviewed JAMA.

"If CMS' goal is to continue to expand hospital-at-home, these findings suggest that different incentives or outreach may be needed for smaller, rural, and non-teaching hospitals," Zikry said.

Established in November 2020, the CMS program allows hospitals to deliver care for acute medical illness to patients in their own homes in lieu of a traditional hospital admission.

"Imagine, for example, a 70-year-old who needs treatment for pneumonia," Zikry said. "Instead of being admitted to the brick-and-mortar hospital, hospital-at-home allows this patient to get the same resources, such as antibiotics and vital sign monitoring, in her own home." An initial motivation for promoting hospital-at-home was to lessen capacity strain on hospitals -- a problem that was exposed and exacerbated by the Covid-19 pandemic. "Many hospitals are operating at 100% capacity almost all the time," said Zikry, "so anything that might free up beds and mitigate that capacity crisis is tremendously appealing to heath systems."

Initially scheduled to expire in December 2022, Congress extended the hospital-at-home waiver program through the end of 2024 and recently introduced legislation to extend it for another five years. Early participants in the CMS program tended to be large, urban, not-for-profit, academic hospitals. In light of the current proposal to extend the waiver, Zikry and coauthors were curious to see whether participation continued to grow after the initial 2022 extension and whether the characteristics of participating hospitals had changed over time.

The researchers conducted a cross-sectional analysis of short-term acute care hospitals in the United States and used the 2022 American Hospital Association Annual Survey to obtain data on hospital characteristics. They compared hospitals that applied for the waiver between November 2020 and December 2022 (pre-extension hospitals) and those that applied afterward (post-extension). Of about 3,000 hospitals included in the study, 299 obtained the waiver, with 249 of them pre-extension and 50 post-extension.

The study found that adoption of the waiver remained concentrated among large, urban, not-for-profit, and academic hospitals. The characteristics of post-extension hospitals were similar to pre-extension hospitals, although the former were somewhat smaller and demonstrated regional differences.

Among their findings:

• Geographically, 49 (98%) post-extension and 226 (91%) pre-extension hospitals were in metropolitan areas
• Post-extension facilities were most often located in the northeastern (16 hospitals, for 31%) or western U.S (10, for 20%), compared with 30 (12%) and 26 (10%) pre-extension hospitals, respectively. In the south, 19 (38%) were post-extension and 143 (57%) pre-extension
• Of the post-extension facilities, 24 (48%) had 100 to 299 beds and 20 (40%) had more than 300 beds, compared with 86 (35%) and 126 (51%) pre-extension, respectively
• Non-profits comprised 46 (92%) post-extension and 201 (81%) pre-extension hospitals
• Among academic hospitals, 27 (54%) were minor teaching hospitals and 11 (22%) were major teaching hospitals post-extension, compared with 137 (55%) and 64 (26%) pre-extension, respectively.

There are multiple implications of this research, according to Zikry. For one, if CMS wants to expand the reach of hospital-at-home, more work must be done to incorporate smaller, rural, and non-teaching hospitals. The data is clear that these types of hospitals are not seeking to create these programs on their own, potentially because of the resources involved in creating and sustaining their operation until they scale.

Moreover, additional research is needed to understand the practical implications and tradeoffs of hospital-at-home.

"Resources are being poured into these programs around the country," Zikry said, "yet we still don't have a comprehensive understanding of how the programs are functioning on the ground."

Many questions remain, he said.: "Are family members of these patients acting as unpaid caregivers during these admissions? Could these patients do just as well in other care settings? Do patients actually prefer to be at home? And are health systems leveraging this program equitably?"

Study co-authors are Dr. David Schriger of UCLA and Dr. Austin Kilaru of the University of Pennsylvania.