Thinking big

The COVID-19 pandemic accelerated the adoption of home-based, acute care as hospitals reached capacity.

Philadelphia-based Jefferson Health enrolled about 600 COVID-19 patients in its emergency department at-home program. About three-quarters of the patients had successful follow-up visits at home without any additional intervention.

In the future, Jefferson would like to treat higher-acuity patients at home, but given the fragmented reimbursement system and underdeveloped regulatory framework, that program is best suited for observation-level patients, said Stephanie Conners, Jefferson’s chief operating officer.

“It is going to take a major shift in the mindset of payers and regulators to enable us to do this at the scale we can do it,” she said.

The regulations for hospital-at-home programs are lacking, Mayo’s Maniaci said. There should be more guidance as to the scope of practice for advanced practice practitioners, traveling nurses and paramedics, he said.

“There are different licenses for each state. Why can’t there be a national license?” Maniaci asked. “That’s why we’re partnering with academic institutions so we can come up with a set of rules to weed out bad actors.”

Cost and staffing have also been barriers, experts said. The startup expenses are often more than anticipated, said Cheryl Warren, senior managing director at FTI Consulting.

“The programs I have seen set up are so costly from the standpoint of staffing, equipment and the sheer burden of receiving calls from patients 24/7,” she said.

“Staffing is the No. 1 issue right now, and you can’t just hire a home health agency to provide acute-level inpatient care without any additional training,” said Monica Hon, vice president at healthcare consultancy Advis.

Those costs will likely come in the form of a facility fee, be baked into alternative payment models or result in a higher, place-of-service differential for the non-facility fees, like there is now with the resource-based relative value scale physician fee schedule, industry observers said.

Jefferson and Hackensack Meridian Health, which recently set up a hospital-at-home pilot program in Edison, New Jersey, don’t know if they would charge a facility fee, executives said.

“Hospital-at-home programs can really help in terms of improved outcomes and enhanced patient experience, which have the potential to bend the cost curve and make healthcare more affordable,” Hackensack CEO Bob Garrett said.

“Until we have established payment and reimbursement structures, there remains a lot of unanswered questions,” Jefferson’s Conners said.