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Early Uptake of the Acute Hospital Care at Home Waiver

ARTICLE: Early Uptake of the Acute Hospital Care at Home Waiver

AUTHORS: David M. Levine, Linda V. DeCherrie, Albert L. Siu, Bruce Leff

JOURNAL: Ann Intern Med. 2021 Oct 26. doi: 10.7326/M21-2516. Online ahead of print.


Background: Hospital at home (HaH) provides acute hospital-level care in a patient's home as a substitute for traditional inpatient hospital care. The HaH model has been the subject of multiple randomized controlled trials and systematic reviews and has been shown to provide safe, high-quality, patient-centered care (1–4). Despite a robust evidence base, dissemination of HaH has been limited. One important barrier to scaling HaH has been the lack of a payment mechanism in traditional fee-for-service Medicare.

To help meet the challenges of delivering health care services in the midst of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) issued “Hospitals Without Walls” regulatory guidance that waived certain physical environment and Life Safety Code Medicare hospital conditions of participation. As the COVID-19 pandemic continued, on 25 November 2020, CMS announced a comprehensive strategy to enhance hospital capacity, including the Acute Hospital Care at Home (AHCaH) individual waiver. For the duration of the public health emergency, the program provides a hospital-level waiver that waives the requirement for 24/7 onsite nursing. Hospitals with waivers must follow all other conditions of participation, attest that they will be able to provide hospital-level services in patients' homes, and commit to reporting data on their program outcomes to CMS on a regular basis. Hospitals qualifying for the individual waiver receive the full hospital-level diagnosis-related group payment for services provided at home.

Objective: To describe early uptake of the AHCaH waiver in the United States.

Methods: We analyzed data from the AHCaH CMS dashboard, including applicant volume and characteristics. We linked hospitals holding a waiver to the American Hospital Association's 2019 Annual Survey to determine hospital characteristics. Two hospitals that opened recently and were not in the survey were omitted.

Findings: Between 25 November 2020 and 29 July 2021, 144 hospitals in 66 health systems were approved for the AHCaH individual waiver (Table), with a stable but lower rate of hospital waivers approved after the first few months (Figuretop). Hospitals with waivers represented 32 states in 69 health referral regions (Figurebottom). Most were nonprofit hospitals (79%), were minor teaching hospitals (56%), were metropolitan hospitals (92%), and had more than 299 beds (51%). Twenty-three percent owned their own home health agencies.

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Kelsey Bennett