Lessons from CMS’ Acute Hospital Care at Home Initiative

Building upon this initiative, CMS began the AHCAH initiative in November 2020, which allowed acute care hospitals that are paid under the inpatient prospective payment system to expand their delivery of inpatient care into patients’ homes. 

The waivers supporting AHCAH include waivers of certain Medicare Hospital Conditions of Participation (CoPs), which are established in federal regulations.[2] These waived CoPs require nursing services to be provided on premises 24 hours a day, seven days a week, and the immediate on-premises availability of a registered nurse for the care of any patient. In addition, the Secretary waived the hospital “physical environment” and “Life Safety Code” requirements, including requirements for fire safety protection standards in a facility meeting healthcare occupancy standards. However, hospitals providing care in patients’ homes were and are still required to meet most health and safety requirements, even in the patient’s home, as well as requirements under various quality reporting programs, which collectively maintain guardrails for patient safety and quality that have long been the standard for inpatient care.    

To participate in the AHCAH initiative, hospitals are required to submit a waiver request through a dedicated CMS portal. Following review, CMS meets with each requesting hospital to assess whether it can provide high-quality and safe care in home settings, compliant with the Medicare Hospital CoPs. Once approved, hospitals can begin admitting eligible patients to their homes for inpatient care. As of October 2024, 366 hospitals have participated in the AHCAH initiative, serving over 31,000 patients in home settings.

The AHCAH initiative would have ended with the termination of the COVID-19 PHE. However, in December 2022, Congress passed the Consolidated Appropriations Act (CAA), 2023, which extended the AHCAH initiative through December 31, 2024.[3] The CAA, 2023, also required CMS to conduct a study to evaluate several aspects of the AHCAH initiative.  The Report on the Study of the AHCAH Initiative was published on September 30, 2024, and describes early lessons on quality, patient experience, and cost of care.[4] 

The study used the best available quantitative and qualitative data to compare AHCAH patients and brick-and-mortar hospital inpatients served by 332 participating hospitals across 38 states from November 2020 through July 2024. Data analysis focused on patient inclusion criteria and demographics, clinical conditions treated, quality of care, cost and utilization of services, and experience of care. 

Patient Demographics

Patient inclusion criteria were developed by each hospital, based on the hospital’s experience and resource capabilities to provide inpatient-level care in the home environment and informed by nationally recognized criteria.[5] Specific patient selection criteria included clinical and psychosocial factors, home environment, and willingness to participate. 

In an analysis of demographic characteristics, statistically significant differences were found between AHCAH patients and brick-and-mortar inpatients receiving services from the same hospital. AHCAH patients were more likely to be white and live in an urban location, while less likely to be Medicaid beneficiaries. 

Quality of Care Comparison

Using the Medicare Severity Diagnosis Related Group (MS-DRG) and Major Diagnostic Category (MDC) classification systems, the study found that the most common illnesses treated through the AHCAH initiative were respiratory (36%), circulatory (16%), renal (16%), and infectious diseases (12%). 

Three different quality metrics were calculated for quality-of-care comparisons: 30-day mortality rates; 30-day readmission rates; and hospital-acquired condition rates. CMS analysis found that AHCAH beneficiaries generally had a lower 30-day mortality rate than their brick-and-mortar inpatient counterparts. 

Regarding the 30-day readmissions metric, findings from the CMS study demonstrated differences between the AHCAH and inpatient comparison groups for half of the conditions. Readmission rates were significantly higher in the AHCAH group for two MS-DRGs (177-Respiratory infections and inflammation with mucociliary clearance (MCC) and 871-Septicemia or severe sepsis without mechanical ventilation > 96 hours with MCC) but significantly lower for three other MS-DRGs (194- Simple pneumonia and pleurisy with complication or comorbidity (CC), 195-Simple pneumonia and pleurisy without CC/MCC, and  191-Chronic obstructive pulmonary disease with CC). See Table 1.

Table 1.

*not statistically significant                                         

Regarding cost, CMS evaluated the impacts on Medicare program spending rather than costs to individual hospitals participating in AHCAH. The episodes of care from inpatient admission to discharge showed that AHCAH episodes had on average, less than one day longer length of stay but AHCAH beneficiaries accounted for significantly lower Medicare spending in the 30 days after discharge. Specifically, Medicare spending was approximately 20% less for most of the top 25 MS-DRGs in the AHCAH group, as shown in Table 2. However, the differences in clinical complexity across the two groups make it difficult to conclude definitively that the AHCAH initiative resulted in lower Medicare spending overall. 

Table 2.

Patient Experience 

Qualitative data on the patient experience under AHCAH was collected through listening sessions, site visits, and anecdotal feedback through informal interviews with caregivers. Findings suggest that patients and caregivers who provided feedback had positive experiences with the care provided through the AHCAH initiative, which is broadly consistent with patient experience outcomes with Hospital at Home programs. 

This is one example of the experience of a patient who received inpatient care in the home under the AHCAH initiative in 2022:

“I have chronic lymphocytic leukemia and had recently started treatment. They advised me to drink between 4-5 liters of water every day to avoid tumor lysis syndrome, which I did. After a couple of days, I started to feel sick and went to the emergency department. I was found to have severe hyponatremia and admitted to the hospital. With water deprivation, my sodium level began to return to normal; however, I started to have renal insufficiency, which was attributed to the reduced water intake. My doctor felt that I needed to stay hospitalized until my lab stabilized. It was at that point that I was asked if I was interested in a new federal program that would allow me get hospital level care in my home. I agreed to try it out and was transported home by ambulance. They installed a Wi-Fi phone system with a direct line to nursing and primary care staff. An iPad with wireless connectivity was set up to record my vital signs, fluid balance, and facilitate teleconference calls.  A 24-hour telephone line was established for support as well. In addition, a nurse came twice a day to assess my condition and collect blood samples. In my opinion, I received the same level of care at home as I did in the hospital, and it was much more comfortable. I was much happier to be at home. It is always better to be at home than in a hospital if you have the choice.”

Feedback from clinicians who participated in AHCAH reflected mostly positive experiences. 

Limitations

The AHCAH study provided preliminary, time-limited comparisons, and did not evaluate the long-term efficacy or financial viability of this care delivery and payment model. Additional limitations of this study included the inability to conduct a rigorously controlled study comparing AHCAH and brick-and-mortar hospital patients; difficulty analyzing Medicaid data; and lack of standardized inclusion criteria for each hospital or detailed cost information. Future studies are needed to make definitive conclusions about the impact of the AHCAH initiative.  

Conclusion

The mission of the CMS Center for Clinical Standards and Quality (CCSQ) is to improve lives, health outcomes, and care experiences by advancing quality, safety, and equity. Early lessons from the AHCAH initiative suggest that providers can deliver safe, quality inpatient care in home settings for appropriately selected patients, aligned with and helping to advance CCSQ’s core mission.

With the AHCAH initiative set to expire on December 31, 2024, important questions remain, and CMS is exploring opportunities to answer these questions should the program be extended. One such opportunity pertains to the inclusion of additional measures of cost, including costs to individual hospitals, as well as additional measures of quality and utilization. A second opportunity relates to the homogeneity of the current AHCAH patient participants, CMS is considering ways to work with hospitals to diversify patient populations receiving care through AHCAH, particularly lower-income and rural populations. 

Lastly, CMS has begun to engage in greater outreach and educational efforts for the AHCAH community and the hospital community at large. These efforts include sharing technical assistance on the use of technology and its integration in home settings, resource and funding needs for hospital participants, training requirements for the range of clinicians providing care, and optimizing support for patients and caregivers. 

The CMS AHCAH initiative was created in a time of crisis. CMS will continue to study and share findings regarding AHCAH outcomes and costs, which will be needed for program sustainability in the long term if this initiative is extended.