What is hospital-at-home, and what's the debate about it?

More patients are skipping the brick-and-mortar hospital to heal at home instead with hospital-at-home programs. And more health care systems are adopting the programs and offering them to patients, especially those 65 and older. The age group makes up a sixth of the U.S. population, and can be at increased risk for secondary infections or falls.

The model is part of health care in other countries too. But critics warn more regulation needs to happen before it is widely adopted in the U.S.

On a recent morning in California, Scripps News met with Pippa Shulman, chief medical officer of Medically Home. The company has partnered with hospital systems like the Mayo Clinic and Kaiser Permanente. The decentralized health care company invited the media to see how their hospital-at-home service works.

"It could be anywhere electricity, running water, an access to a bathroom, everything else. We can help mitigate and support the patient," said Shulman.

Hospital-at-home, or acute at-home hospital care is for stable, acute-care patients. It could be used for someone who could be admitted to a hospital with a bad infection, COPD, or heart failure, for example. Medically Home operates a decentralized care model for patients with serious, complex or high-risk illnesses in partnership with health systems to safely care for their patients at home, across the care continuum. The patients are discharged more quickly or stay at home completely to heal in their own dwelling.

The model uses telehealth and technology. Think calls with doctors and nurses, and devices like a watch that reads vitals or a medication dispenser, for example, supplemented by visits from health care workers for therapies or tests.

"We can do in-home ultrasound, we can do in-home blood testing, we can do in-home x-ray," Shulman explained.

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On the other end, medical professionals — doctors, nurse practitioners, nurses — are either working from home or in their own command center,  having appointments, looking at a patient's vitals, livestreaming, video chatting, and giving them medical advice in real time.

"People think of the tech as sensors and remote this and monitoring," said geriatrician Dr. Bruce Leff. "All-important, all true. But I think what they forget, on the other side, is that the tech and the software platforms allow programs to build high-quality, highly safe care, and the ability to coordinate services."

Leff is an early pioneer of hospital-at-home. He started a program at Johns Hopkins in 1994, conducting some of the first clinical research looking into health outcomes for patient care in and out of hospital. The first participants were patients who needed hospital care, but when offered, refused. Hopkins' institutional review board also required the patients to be monitored 24/7 in person.

"Interestingly, more than half the patients refused that because they thought it would be weird to have someone sitting in their home and watching them sleep."

The trend really boomed out of the COVID pandemic, when hospitals were overrun, and some were working with makeshift wards. In November 2020, Medicare rules changed due to the public health emergency. Hospitals were paid the same amount if an acute patient was in the actual hospital room or in their home. Hospitals were also no longer required to provide 24/7 in-person nursing care.

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Those Medicare rules were extended that same year. They're now set to expire December 2024, and while law requires the centers for Medicare and Medicaid services to evaluate the program by then, what happens after is uncertain.

Nearly 300 hospital at-home programs exist in 37 states. And the market is expected to grow to $254 billion over the next seven years.

"My view ... is that in the future, hospitals will become big ERs, ORs and ICU beds. Everything else could and should be moved out to the community," said Leff. "As the tech gets better, we'll see more acuity taken care of in the home. I think ... we'll have improved approaches for engaging with family members in terms of maybe more standardization across programs ... Better training for caregivers, which I think is something we need to be working towards."

But acute health care at home has been met with criticism. The largest nurses' union calls it "home all alone."

"Acute care means that your condition is likely to change and you are likely to experience, or at high risk to experience, complications. So even if you're feeling well, that could change quickly," explains Michelle Mahon, RN. She's the assistant director of nursing practice for National Nurses United. 

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National Nurses United also worries the cost will fall onto patients and taxpayers, and warns about the impact on caregivers.

A recent report from the Center for Economic and Policy Research argues that private equity, hedge funds and venture capital getting in the hospital-at-home game without more regulation and enforcement systems means there would be "incentives for financial interests to take advantage of taxpayer subsidies for private gain and at the risk of lower quality care or heightened inequality across diverse populations."

Dr. Leff is a clinical advisor to Medically Home, and Dispatch Health (another at-home health care provider), among others. He says he thinks "it's always good to be suspicious of how money is moving through the health system."

He also added, "There's absolutely some private equity money in this, but a lot of the money is actually coming in the form of investor partners as opposed to private equity. So take Dispatch Health and Humana, take Medically Home with the Mayo Clinic and Kaiser Permanente. Those investments are being provided by investor partners who have a strong interest in creating a credible, safe, high-quality model."

The big question is: Does hospital-at-home work? Johns Hopkins' research in their hospital-at-home program showed the cost of hospital-at-home is a couple thousand dollars less, and length of stays were shorter. Cases of delirium — a complication — were dramatically lower.

A 2021 analysis in the Journal of American Medical Association of several studies of hospital-at-home patients found treatment lasted an average of five days longer and had a similar mortality risk. Hospital readmission risk went down 26%.

Limited research shows at-home acute care patients sleep better and have more physical activity. But the latest studies show many patients eligible for at-home acute care are still skeptical. One found more than 60% of patients offered the program turned it down, opting to stay in a hospital.