Fact Sheet: Report on the Study of the Acute Hospital Care at Home Initiative

On September 30, 2024, the Centers for Medicare & Medicaid Services (CMS) released a report on the agency’s 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 (PHE), the Consolidated Appropriations Act, 2023 (CAA, 2023) extended the waivers and flexibilities associated with the AHCAH initiative until December 31, 2024. The CAA, 2023 also required CMS to conduct a study and analysis on the AHCAH initiative and post such a report on a CMS website by September 30, 2024. 

The study released today fulfills the requirement in the CAA, 2023, and evaluates several aspects of the AHCAH initiative, including: 

• Criteria participating hospitals used to determine which individuals would qualify to receive services under AHCAH.
• Demographic information on beneficiaries treated under the initiative.
• Clinical conditions treated and diagnosis-related groups associated with discharges from the inpatient setting versus those under AHCAH.
• Quality of patient care for those patients treated in the brick-and-mortar inpatient setting relative to patients with similar conditions and characteristics treated under AHCAH. 
• Beneficiary and caregiver experience with AHCAH.
• Medicare spending and utilization for patients who received care in the inpatient setting and through AHCAH.
• Quantity, mix, and intensity of services furnished through brick-and-mortar inpatient care relative to those served under the AHCAH initiative.

The September 2024 study used the best-available quantitative and qualitative data on AHCAH to draw comparisons between 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.  

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 to determine which individuals would qualify for AHCAH services. These criteria were largely rooted in published hospital at home (HaH) literature [1] , 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 developed and utilized with the intent to ensure that eligible patients were willing and able to participate in a HaH program, that such patients were clinically and psychosocially appropriate to safely receive care in the home, and that patients’ home and community environments were conducive to the safe and effective provision of acute inpatient care at home.

Demographic Characteristics of Beneficiaries Treated Under AHCAH

With respect to Medicare beneficiary demographic characteristics, AHCAH patients were found to be meaningfully different from inpatients receiving services furnished by the same hospital facility (hereafter referred to as “brick-and-mortar inpatients”). 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 appropriate for HaH care, as discussed in greater detail in the report.

Clinical Conditions Treated and Diagnosis-Related Groups (MS-DRGs) Associated with AHCAH Discharges

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. More detailed findings on AHCAH clinical conditions treated, and discussion regarding the interpretation of the underlying data and analysis, are presented in the report.

Quality of Care Comparison Brick-and-Mortar Inpatient vs. AHCAH

The study examined the quality of care furnished to individuals treated in the inpatient hospital setting, as compared to individuals with similar conditions and characteristics treated through the AHCAH initiative, and specifically looked at 30-day mortality rates, 30-day readmission rates, and Hospital Acquired Conditions (HAC) 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, consistent with existing HaH literature. Results of the 30-day readmissions metric analysis demonstrated some 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. HAC rates observed for beneficiaries served by the AHCAH initiative were lower than HAC rates observed in the brick-and-mortar inpatient comparison group for all six types of HACs evaluated, though the differences in these rates were not statistically significant. More detailed findings on the quality-of-care impact of the AHCAH initiative, the interpretation and limitations of the underlying data, and analysis are presented in the report.

Cost and Utilization Comparison: Brick-and-Mortar Inpatient vs. AHCAH

With respect to the costs and utilization, the study focused on select metrics, including length of stay per episode, the Medicare spending in the 30 days after hospital discharge, and hospital service utilization, including services provided in-person and virtually through telehealth. The analysis showed that AHCAH inpatient episodes had, on average, a slightly longer length of stay than comparable brick-and-mortar inpatient episodes. Additionally, there was, on average, lower Medicare spending for services furnished in the 30-day post-discharge period for AHCAH episodes, as compared to brick-and-mortar inpatient episodes, across more than half of the top 25 MS-DRGs in the AHCAH group. The differences attributable to AHCAH patient selection criteria and clinical complexity, as measured across the two groups, make it difficult to conclude that the AHCAH initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care. More detailed findings on the cost and utilization impact of the AHCAH initiative and the interpretation and limitations of the analysis, are presented in the report.

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 anecdotal 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 the care provided in the home setting through the AHCAH initiative. The feedback was generally consistent with evidence concerning patient experience with HaH programs more broadly.[2] This positive 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.

Future Considerations for AHCAH

This study used the best available quantitative and qualitative data to draw comparisons between the AHCAH and brick-and-mortar inpatient comparison groups, subject to time and data limitations discussed in the study. The results offer new insights for future research into the AHCAH initiative. In the course of administering and studying the AHCAH initiative, there have been multiple lessons learned regarding the continuous quality improvement efforts for improving health and safety of inpatients in the home setting, and opportunities to further develop more targeted measures of cost, quality, and utilization. CMS remains committed to further studying data related to the AHCAH initiative.

Additional Background on AHCAH 

CMS initially launched the broader “Hospital Without Walls” initiative in March 2020 using waiver authorities under section 1135 of the Social Security Act (the Act), which permits the Secretary to waive certain facility standards during declared public health emergencies (PHEs) like the COVID-19 PHE. CMS then launched the AHCAH initiative in November 2020; the AHCAH initiative allows certain Medicare-certified hospitals to treat patients with inpatient-level care in their homes. To address challenges with respect to hospital bed capacity during the COVID-19 PHE, CMS issued waivers under section 1135 of the Act,[3] including waivers of specific Medicare Hospital Conditions of Participation (CoPs) established in federal regulations, specifically 42 CFR 482.23(b) and (b)(1). These 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 care of any patient. In addition, under section 1135 of the Act, the Secretary waived the hospital “physical environment” and “Life Safety Code” requirements for delivering care in the patients’ homes. However, hospitals providing care in patients’ homes continue to meet all health and safety requirements, as well as requirements under various quality reporting programs, that were not waived through the public health emergency waiver authority under section 1135 of the Act. For example, the immediate availability requirement for 24/7 nursing services for inpatient care was not waived under section 1135 authority. A hospital with an AHCAH waiver must ensure the availability of nursing services (virtual and/or in-person as clinically appropriate) 24 hours each day to patients receiving inpatient care in the home. Even though the COVID-19 PHE has ended, this initiative continues because the CAA, 2023 extended the waivers and flexibilities associated with the AHCAH initiative until December 31, 2024. Continuation of the AHCAH initiative beyond December 31, 2024, is contingent on Congressional action.

For more information, please visit: https://qualitynet.cms.gov/acute-hospital-care-at-home

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