CMS Home-Based Hospital Care Waiver Called ‘Enormous Step Forward’

The Brigham Health Home Hospital program has been shown effective in reducing cost of care.

In a randomized controlled trial published a year ago in the Annals of Internal Medicine, the adjusted mean cost of Home Hospital acute care episodes was 38% lower for home patients compared to control patients receiving traditional hospital care.

HealthLeaders recently discussed the new CMS hospital at home waiver and Brigham Health Home Hospital with David Levin, MD, MPH, MA, medical director of strategy and innovation for Brigham Health Home Hospital, and an assistant professor of medicine at Harvard Medical School. The following is a lightly edited transcript of that conversation.

HealthLeaders: What is the impact of getting Medicare fee-for-service reimbursement for hospital at home care?

David Levin: This is the change that we all have been waiting for. It is an enormous step forward for the field because it opens the care pathway to large numbers of patients who have Medicare as their only insurance.

For our program, we have been in a very fortunate position, where our population health team has supported our Home Hospital work at the enterprise level and our hospital has supported our Home Hospital work significantly. However, we have been constrained budgetarily. When you cannot bill for most of your services and you must rely on a fixed budget from central sources, that constrains the size and scope of your program. So, we are excited that we will be able to recoup much of the care costs from delivering care to patients. It will allow us to expand the program.

HL: What are your plans to expand Brigham Health Home Hospital?

Levin: We consider ourselves to be an innovation shop in home hospital care. So, we are continually adding sensors, new technologies, and different care pathways. Having a stable revenue source for our program allows us to expand in a very stable and guaranteed way.

On one end, we are continuing our innovation pathways and pursuits. That means different kinds of patients will be able to get Home Hospital care than before. We will hopefully be able to increase the quality, safety, and patient experience of the care that we deliver through new technologies and new care pathways.

On the other end, we are going to be able to offer this care to more people. Previously, our Home Hospital program was always full—it was capped because as soon as we discharged a patient, we took on another patient. We did not have a large care team to take care of all the patients who wanted Home Hospital care. With a more stable revenue source, we will be able to expand this offering to more patients.

HL: What was your previous cap on Home Hospital patients and what are your plans to increase the number of patients in the program?

Levin: A year ago, our cap was four patients. With COVID-19, we expanded to nine patients, and I am hoping we will be at 12 to 16 patients soon.

HL: Did Brigham Health Home Hospital have to be modified to participate in the CMS Acute Hospital Care At Home program?

Levin: The largest change is that the CMS Acute Hospital Care At Home waiver requires that a nurse either see the patient in person or by video at least once a day.

Our program is at the leading edge of using mobile integrated paramedics, who have a higher level of training than regular paramedics. We use mobile integrated paramedics quite frequently; oftentimes, they will see one of our patients twice a day along with a physician visit. That way of caring for patients does not fulfill the requirement of at least one daily touch by a nurse, so we have altered our practice to include a nurse visit daily. We will likely be having split visits—in the morning, the patient may be seen by a paramedic, and in the afternoon the patient may be seen by a nurse, or vice versa.

HL: What kind of special training and skills do mobile integrated paramedics have?

Levin: These are paramedics who build additional skills in acute care medicine such as administering more kinds of medications. For example, paramedics usually do not administer antibiotics, but mobile integrated paramedics do. Our paramedics can do more procedures such as putting in a Foley catheter, which is not something that paramedics usually do but we do it in the hospital, so that is a skill that our paramedics learn.

Mobile integrated paramedics also develop social and emotional skills. They function almost like a community health worker or a social worker. Finally, there is care coordination training.

The fundamental aspect is that paramedics are well trained, and they are often underutilized. They have intense expertise in the home. They have intense expertise in acute management. They have expertise in medication reconciliation. So, adding very thoughtfully to their skill set has been a boon to our program.

HL: What do you think the future holds for the hospital-at-home care model?

Levin: I am extremely enthusiastic about the future of home hospital care. We have been seeing an explosion in the number of programs and the use of this care model throughout the country. The CMS waiver has taken the next step to helping these programs to thrive and spread.

Presently, the CMS waiver is only authorized through the public health emergency; but, hopefully, we will be able to formalize the waiver in a rule that is much more permanent and final.

We need more next steps. We definitely need to see other payers follow CMS’ lead. We need to see commercial fee-for-service payers to follow CMS’ lead. We need to see Medicaid agency’s follow CMS’ lead—CMS has already signaled that change. We need to see the full fee-for-service structure embrace home hospital care.