Care delivery has been steadily moving away from hospital campuses toward more convenient, cost-effective settings. Ambulatory surgery centers and retail clinics were the early trailblazers, proving that high-quality care can be delivered outside the four walls of a hospital. Virtual care followed. Care at Home (C@H) is the next phase of this evolution.
With hospital bed capacity stretched thin and expected to further deteriorate, the cost of new facility construction soaring, and an urgent need to improve outcomes and reduce the cost of care, healthcare leaders are seeing C@H as a long-term solution. Historically viewed as home health or skilled nursing care, the scope of C@H is expanding to include more care delivery models. Our latest report, Care at Home Today, examines the growing trend of C@H, which we define as physical, in-person care delivered directly to patients in their homes.
We partnered with the Hospital at Home Users Group, a collaborative of nearly 200 health systems, to interview leaders at health systems and insurers to get a deeper understanding of the current landscape. Here are our topline findings. The full report is available for download below.
Operational and organizational structures to support care at home
Shifting care into the home requires more than just moving patients from hospital floors to their bedrooms. It demands a fundamental rethinking of operational models, staffing, technology, and resource allocation. Our interviews revealed that many health systems are still experimenting with different organizational structures. Some programs are managed under innovation departments; others sit within virtual care or population health units.
Centralization appears to be a key success factor. One health system that consolidated its C@H operations under a single leader achieved notable efficiencies and faster growth. The degree of centralization differs based on a system’s geographic footprint. For example, a multi-state system may opt for decentralized management of individual local vendors, such as oxygen or meals, while merging certain command center operations and leveraging a common technology stack.
Funding care at home programs
It’s important to understand the cost-benefit analysis of implementing C@H programs. Leaders we interviewed said H@H, for instance, typically required $2 million to $3 million in upfront costs. Some of that involved vendor set-up fees, technology implementation, and staff training. In most cases, existing resources such as a medical director and an operations manager were used, rather than incurring new leadership costs. Some C@H programs were often considered an extension of the H@H program — post-acute and emergency care — and carried much lower launching costs.
All the hospital leaders we spoke to were growing their H@H programs, which require ongoing financial investment to enable scale. Given this, the systems had limited ability to parse out investment costs versus steady-state costs for an at-home acute care stay, making it challenging to provide an apples-to-apples cost comparison to traditional inpatient stays. However, after four years of optimization efforts, systems that have achieved larger scale estimates that the direct costs incurred are 2%–5% lower for home stays, relative to an equivalent encounter at a traditional inpatient facility.
Challenges to scaling care at home
There was consensus around the biggest roadblocks to scaling C@H, including workforce, regulatory, and physician engagement.
Common challenges cited among those top roadblocks include:
Workforce and training: Finding and training clinicians comfortable with delivering acute care in non-traditional settings is a challenge. C@H programs are competing with the same limited supply of clinicians as other care sites.
Regulatory issues: Interviewees with nascent programs cited the future of the Centers for Medicare and Medicaid Services’ (CMS) Acute Hospital Care at Home initiative as the biggest factor in their investment decisions. The initiative will expire at the end of March without congressional action. Since 2020, 378 hospitals from 140 health systems have had waivers approved. More developed programs are committed to including C@H in their strategies regardless of waiver status. Other regulatory issues mentioned were coverage limitations for critical access hospitals and Medicaid patients.
Payer interest: Lack of payer engagement could also hinder growth. Some insurers we interviewed were indifferent, while others want reimbursement discounts for care at home. Concerns about quality standards and geographic coverage, especially in rural areas, were also cited.
Physician engagement: We observed a common challenge here — the ability to push patients to C@H versus needing to pull them in. An environment that supports a push culture enables clinicians at such sites of care as the emergency department to proactively screen and refer patients to a C@H program. However, it is currently more common for hospitals to have a pull approach, where the C@H team scans electronic medical records and/or places staff in the emergency department to identify eligible patients to be cared for at home.
Making a strategic commitment to care at home
Our research uncovered a divide between cautious, small-scale adopters and systems that view C@H as a strategic imperative. The latter group is making investments and integrating home-based care into their core operations. As one leader put it, "If you don't scale, you fail."
Healthcare leaders who are serious about addressing capacity challenges, improving patient satisfaction, and controlling costs should look at the potential of C@H. The journey isn't easy, but for those who commit to the model and tackle the operational complexities head-on, the rewards could be substantial.
