BALTIMORE, Maryland—The Centers for Medicare and Medicaid Services (CMS) released a report on its study of the acute hospital care at home (AHCAH) initiative, which allows certain Medicare-certified hospitals to treat patients with inpatient-level care at home. While the initiative was launched during the COVID-19 public health emergency, the Consolidated Appropriations Act of 2023 (CAA) extended the waivers and flexibilities associated with the AHCAH initiative until Dec. 31, 2024. Additionally, the CAA required CMS to conduct a study and analysis on the AHCAH initiative and release the report results by Sept. 30, 2024.
The study used quantitative and qualitative data on AHCAH to compare the AHCAH and brick-and-mortar hospital inpatient comparison groups. The report presents the study findings and identifies future considerations to address existing data, analytic and measurement limitations. The study fulfills the CAA requirement and evaluates several aspects of the AHCAH initiative. The full details of the study’s evaluations are listed below.
Inclusion Criteria for Individual Hospitals Participating in AHCAH
The study found that AHCAH-approved hospitals used a variety of sources and methods to establish patient selection criteria and determine which individuals would qualify for AHCAH services. These criteria were largely rooted in published hospital-at-home (HAH) literature, in addition to the individual hospital’s experience and resource capabilities to provide inpatient-level care in the home environment. Participating hospitals indicated that these criteria were utilized with the intent to ensure that eligible patients were willing and able to participate in a HAH program, clinically and psychosocially appropriate to receive care in the home and the patients’ home and community environments were conducive to acute inpatient care at home.
Demographic Characteristics of Beneficiaries Treated Under AHCAH
Regarding Medicare beneficiary demographic characteristics, AHCAH patients were found to be significantly different from inpatients receiving services provided by the same hospital facility (brick-and-mortar inpatients). The study found that, in general, AHCAH patients were more likely to be white and live in an urban location and less likely to receive Medicaid or low-income subsidies. These different characteristics of the AHCAH population may be partially attributable to the inclusion and exclusion criteria developed by participating hospitals for the purpose of identifying patients that are appropriate for HAH care.
Clinical Conditions Treated and Diagnosis-Related Groups Associated with AHCAH Discharges
The study found that patients in AHCAH were primarily treated for a relatively small set of conditions. The study found that the most common Medicare severity diagnostic related groups (MS-DRGs) and major diagnostic categories (MDCs) treated through the AHCAH initiative included respiratory conditions, circulatory conditions, renal conditions and infectious diseases. The report presents more detailed findings on AHCAH clinical conditions treated and a discussion regarding the interpretation of the underlying data analysis.
Quality of Care Comparison Brick-and-Mortar Inpatient versus AHCAH
The study examined the quality of care provided to individuals treated in inpatient hospital settings compared to individuals with similar conditions and characteristics treated through the AHCAH initiative. Specifically, the study examined 30-day mortality rates, 30-day readmission rates and hospital-acquired conditions rates. The study found that beneficiaries who received care under the AHCAH initiative generally had a lower mortality rate than their brick-and-mortar inpatient comparison counterparts, which is consistent with existing HAH literature. The results of the 30-day readmissions metric analysis revealed differences across the AHCAH and inpatient comparison groups, with readmission rates being significantly higher in the AHCAH group for two MS-DRGs, but significantly higher in the inpatient comparison group for three MS-DRGs. Additionally, hospital-acquired conditions rates for beneficiaries in the AHCAH initiative were lower than hospital-acquired conditions rates in the brick-and-mortar inpatient comparison group for all six types of hospital-acquired conditions evaluated. However, the differences in these rates were not statistically significant.
Cost and Utilization Comparison: Brick-and-Mortar Inpatient versus AHCAH
The study focused on select cost and utilization metrics, including length of stay per episode, Medicare spending in the 30 days after hospital discharge and hospital service utilizations, including in-person and telehealth services. The analysis showed AHCAH inpatient episodes averaged a slightly longer length of stay than brick-and-mortar inpatient episodes. Additionally, AHCAH episodes averaged lower Medicare spending for services provided in the 30-day post-discharge period compared to brick-and-mortar inpatient episodes, across more than half of the top 25 MS-DRGs in the AHCAH group. The differences were attributed to AHCAH patient selection criteria and clinical complexity, as measured across the two groups. As a result, the AHCAH initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care.
Patient Experience of Care Under AHCAH
CMS hosted a series of four virtual listening sessions with various groups of stakeholders, including patients and caregivers who had participated in the AHCAH initiative, to learn about their experiences with care and gather feedback on ways to improve the program. Additionally, CMS collected information on shared lessons learned through site visits, direct correspondence with patients and hospital program operators and other means, contributing to the qualitative analysis of beneficiaries’ experiences with the AHCAH initiative. Overall, the information collected and detailed in the study suggests that patients and caregivers had positive experiences with in-home care provided through the AHCAH initiative. The feedback was generally consistent with evidence concerning patient experience with HAH programs more broadly. This feedback was mirrored by clinicians’ experiences providing care to patients under the AHCAH initiative. More detailed findings on the patient experience of care under AHCAH and the interpretation and limitations of the underlying data and analysis are presented in the report.
