COVID-19 Propels Innovations for Care at Home: CLA (CliftonLarsonAllen LLP)

Key insights

HaH helps patients receive care at home and limits their exposure to other illnesses, all while freeing up hospital space for acutely ill patients.
Understand the key reasons why HaH models were deployed rapidly during the pandemic.
SNF-at-home or rehab-at-home programs can also provide different long-term opportunities for many post-acute care providers.

Have questions about care-at-home models?

Last year we provided an article on the hospital-at-home (HaH) model, which highlighted how that model was gaining traction in the United States. Little did anyone know what 2020 would hold and how it would help propel the general concept of care at home.

Overview of HaH

For a recap, the HaH model provides hospital-level care to patients in their homes. Ultimately, the goal is to deliver high-quality and individualized care in the most appropriate and cost-effective setting. HaH garnered interest prior to 2020 because it:

Protects vulnerable patients from contracting other illnesses during longer hospital stays
Decompresses busy emergency departments (EDs)
Addresses a patient’s desire to recover at home in a more comfortable care setting
Fits well into the move to value-based payments (bundles or other alternative payment models)
Aligns with the ongoing movement toward delivering care in the home
Leverages the use of telehealth and other virtual care delivery, like remote patient monitoring
Complements other services, like palliative care and care management

Developed by Johns Hopkins and used in the U.S. since the 1990s, the model has been used with positive results by other preeminent institutions, like Mount Sinai and Marshfield Clinic. As mentioned in our previous article, HaH was also a forerunner to other models, such as palliative care at home, observation at home, or skilled nursing facility (SNF)/rehabilitation at home.

COVID-19 HaH Waiver Flexibility Approved by Centers for Medicare & Medicaid Services (CMS)

To address surge capacity during COVID-19, on November 25, CMS announced that its Hospitals Without Walls waiver flexibilities would be extended to include certain HaH models. The flexibilities would also allow for reimbursement under Medicare.

An expedited waiver process is in place for those that have treated 25 or more patients via a HaH model. CMS announced that the following six health systems already providing HaH care were approved for the new waiver flexibility immediately: Brigham and Women’s Hospital (Massachusetts); Huntsman Cancer Institute (Utah); Massachusetts General Hospital (Massachusetts); Mount Sinai Health System (New York City); Presbyterian Healthcare Services (New Mexico); and UnityPoint Health (Iowa).

The U.S. Department of Health and Human Services anticipates more waiver applications. A more detailed waiver process will be required for those hospitals without HaH experience.

COVID-19 and care at home

While we expected the HaH model to gain traction, COVID-19 accelerated the pace of that uptake. For example, the Mayo Clinic announced in June that it would launch a new HaH program in its Jacksonville, Florida, and Eau Claire, Wisconsin, locations.

A Mayo release describes Mayo’s model as offering “comprehensive and restorative health care services, including infusions, skilled nursing, medications, laboratory and imaging services, behavioral health, and rehabilitation services” at home. Others, like Atrium Health (AH), launched HaH models rapidly as COVID-19 set in.

In reviewing these programs, consider several reasons from our earlier list that explain why the pandemic is propelling this model forward, faster.

When medically appropriate, keeping care at home limits vulnerable patients’ exposure to other illnesses when hospitalized. Keeping those patients at home also limits potential transmission of COVID-19 or illnesses to others — namely, staff and patients — in the hospital.
As COVID-19 spiked, emergency rooms and hospital beds were needed for more acutely ill patients. Care at home was an option to decompress hospitals and treat some patients outside of the physical hospital building to maintain adequate bed capacity in the hospital.
COVID-19 exponentially ramped up the use of telehealth and remote patient monitoring. Virtual care is an important element for a program like HaH. Further, with CMS providing considerable flexibility through various regulatory waivers for telehealth and virtual health, deploying care virtually was both clinically and financially reasonable.
Care management programs have been developed to treat and manage illness in an ongoing manner to address symptoms as they arise and protect patients from hospital readmission. These programs help create a foundation for care-at-home models.

Atrium Health: HaH and observation at home

Atrium Health Hospital at Home (AH-HaH) was deployed early to address COVID-19 patients. Built on Atrium Health’s current virtual care platform and transition services program, the model also leveraged existing community paramedic and care management programs.

Under AH-HaH, a multidisciplinary team provided care via two units — a Virtual Observation Unit (VOU) and a Virtual Acute Care Unit (VACU). Similar to existing HaH programs, clinical protocols and scoring algorithms (among other considerations) were used to assess whether patients were suited for either unit. Patients were provided with a home monitoring kit, including blood pressure cuff, pulse oximeter, and thermometer, and interacted with care teams at all times. Patients received daily virtual visits by physicians and in-person visits via community paramedics or nurses.

Atrium Health indicates the model ran from March 23, 2020, through May 7, 2020 and a total of 1,477 patients received care. Atrium Health found considerable success with the program in treating COVID-19 patients. Their full results were recently published in a study and available online.

Rehab-at-home and SNF-at-home models percolating

Mount Sinai had one of the earliest HaH programs in use and has been using that program to help address COVID-19 surge capacity. In addition, they now use a rehab-at-home program. In this model, patients who may need to go to a rehab center or SNF have the option of completing their rehab at home. Mount Sinai’s website indicates this program provides:

Access to nurses and other care providers
Lab services, IV medications, and other equipment or therapy to be received in the home
24/7 response for urgent or immediate needs
In-person visits from nurses
Rehab services as needed
Social worker assistance

Other organizations are in the development process of a SNF-at-home model, including UnityPoint and Josephine at Home, among others.

Looking at this trend through a different lens, some have already been working to keep patients out of SNFs (i.e., diversion), sending them home with appropriate home care follow-up. COVID-19 exacerbated that trend. Whatever the reason, a SNF-at-home or rehab-at-home program will continue to provide different long-term opportunities for many post-acute care providers.

Impediments to care-at-home models

While evidence supports the use of these newer models, the same impediments highlighted in our earlier article still exist:

Reimbursement — Outside of some Medicare Advantage plans or other negotiated contracts, HaH models are not generally reimbursable models under programs like Medicare. At least for the duration of the pandemic, the CMS HaH waiver flexibility would provide reimbursement and be helpful. For those not under the waiver flexibility, there may be a potential case to make that COVID Provider Relief Funds could be used to offset the incremental costs of an HaH or observation at home model if the model was established to address COVID-19, hospital bed capacity, or related issues.
Reticence — Some physicians and patients are still reluctant to refer patients to or use the HaH model, believing inpatient care is more effective. With time, we predict that the use of the model and evidence-based research could impact this mindset.
Reconfiguration — This is a new care delivery model and will require different workflows, processes, and technology platforms. This is not necessarily an easy lift in good times, let alone during a pandemic.

Even in light of these reservations, COVID-19 may have actually helped provide additional use cases and recognition that care-at-home models are viable options.

How we can help

Whether you are curious about new models of care or wonder how COVID-19 is impacting health care across the continuum, CLA’s team of professionals can provide insights and assistance. Our goal is to know you and help you.