LAS VEGAS—Francisco Dizon, 77 years old, sat comfortably in his living room as a team of clinicians took his vital signs and administered IV medications to treat his urinary tract infection. While he received medical treatment, his wife, Esperanza, stood close by, speaking with the medical team and graciously offering them something to eat.
The couple, who were college sweethearts and have been married 56 years, are now familiar with the realities of managing serious health challenges as Francisco, who has diabetes, makes frequent trips to the hospital.
Instead of another hospital stay, they opted for DispatchHealth’s hospital alternative care-at-home program, called advanced care, to address Francisco’s UTI. Opting for hospital-level services in their home meant Esperanza could stay by Francisco’s side in a place that’s familiar and where they can continue their daily routines. It eliminates the stress of driving back and forth from the hospital and fears that her husband will get a hospital-acquired infection.
“It’s more comfortable here [at home],” Esperanza said, and then she added with a laugh, “I can cook for him.” She says her husband sleeps better at home and enjoys her home-cooked meals. As a caregiver, seeing Francsico resting comfortably at home also gives her peace of mind.
Having care teams come to the home feels more personal, she noted.
“They are really good,” she added, referring to the DispatchHealth clinicians who were making daily visits to their home, including nurse practitioner Ronnie Bordador, Richard Harris, lead registered nurse and registered nurse Paul Manabat. The advanced care program includes twice daily in-person hospital-style rounding support.
Patients also have 24/7 access to medical providers through DispatchHealth’s registered nurse command center. At the same time, remote monitoring devices and biosensors provide care teams with real-time health data and will alert clinicians to any adverse change in Francisco’s health.
UTIs are responsible for one million emergency room visits in the U.S. and 100,000 hospitalizations each year, according to 2017 data.
Francisco is one of thousands of patients who have received hospital-level services in their homes as health systems and payers move more care out of the four walls of hospitals and into patients’ homes.
“They’re pros, they know what they are doing,” Francisco said while the clinicians ran his bloodwork using a handheld blood analyzer device and chatted with him about his medical regime and medications.
“They call and check on you, especially when I had a fever, that's nice,” Francisco said. “They can also see it from there," he said, motioning to a tablet on a nearby table displaying his vital sign readings. “They can see my blood pressure, my oxygen, so if there’s a problem, they come right away.”
Bordador, a nurse practitioner, previously worked in hospital intensive care units and sees the value of at-home care models. “It's a different approach to the hospital. Here, I can see how patients evolve and how the care evolves. For Francisco, he doesn't need to stay in the hospital for 10 days just for the IV antibiotics,” he said.
Mark Prather, M.D., and his partner Kevin Riddleberger launched DispatchHealth in 2013 to combine mobile technology with an old-school service: the house call.
DispatchHealth started by offering urgent medical care at home as an option for patients to receive same-day treatment for serious health concerns. In 2019, the company expanded to offer a home-based alternative to hospitalization called its advanced care program. The company also offers post-acute care in the home and “last-mile care” to support population health initiatives.
Dispatch sends medical teams to patients' homes armed with mobile blood work labs, portable ultrasounds, in-home imaging and IV medication, most of the standard equipment found in hospitals, to diagnose and treat patients.
DispatchHealth claims that in the past decade, its medical teams have treated more than one million people in their homes across more than 30 states in the country. The company has expanded the capabilities of its advanced care model to treat patients across 100-plus diagnostic-related groups (DRGs).
Proponents of hospital-at-home services tout quality and safety benefits leading to positive patient outcomes as well as significant cost savings.
DispatchHealth evaluated more than 1,000 patients treated over 18 months and found that its at-home services resulted in 58% emergency room avoidance, nearly half the average 30-day hospital readmissions (national average of 20% compared to 9.3% among DispatchHealth patients) and sky-high patient satisfaction rates (98%), according to DispatchHealth data published in a white paper.
The company says it’s one the first providers in the country to also onboard patients directly into its alternative hospitalization program without the patient ever setting foot into a brick-and-mortar facility.
The company’s analysis aimed to build the case that home-based care could be safe, high quality and produce excellent outcomes, Patrick Kneeland, M.D., vice president of medical affairs at DispatchHealth, said in an interview.
“As policies are coming into play and as payers are thinking about where to invest their time and resources, the analysis shows that this is a model that's viable and safe for patients,” Kneeland said.
Lobbying CMS and Congress to support hospital-at-home
Hospital-at-home programs got a big boost in 2020 when the Centers for Medicare and Medicaid Services (CMS) launched the Acute Hospital Care at Home Waiver during the COVID-19 pandemic.
CMS allowed certain Medicare-certified hospitals to treat patients with inpatient-level care at home using Section 1135 waivers of the Social Security Act. CMS waived specific hospital Conditions of Participation that require 24-hour onsite nursing for patients.
Home-based services for lower-acuity patients help hospitals address critical capacity issues by freeing up hospital beds for the sickest patients without increasing health system costs, proponents of the programs say.
“For us, this a pressure release valve and it's desirable by consumers and patients and so it's a win-win all around in relieving some of the burden that our brick-and-mortar facilities face day in and day out," Heather O’Sullivan, president of Healthcare at Home at Mass General Brigham, one of the largest programs in the country, told Fierce Healthcare last fall.
And demographic trends will drive demand for these services, experts say. As the population ages — the percentage of the global population aged 65 and above is expected to rise from 10% in 2022 to 16% in 2050 — at-home care will be crucial to meet healthcare demand and help older seniors age in place.
As of March 1, 315 hospitals across 131 systems in 37 states have been approved to participate in the Acute Hospital Care at Home program. Before the waiver, 20 of these programs existed across the U.S.
However, that CMS waiver is set to expire at the end of this year and legislative action is needed to extend the waiver or make the program permanent.
Healthcare heavyweights, the American Medical Association and the American Telemedicine Association joined major health systems like Geisinger and Mass General Brigham along with tech-enabled companies to pen a letter to congressional leaders calling for at least a five-year extension to the CMS waiver.
“Without an extension, Medicare beneficiaries will lose access to Hospital-at-Home programs that have been demonstrated to provide excellent clinical outcomes and lower the costs of care,” the groups wrote in the letter released today.
The American Academy of Home Care Medicine, Moving Health Home, Best Buy Health, DispatchHealth and Biofourmis were among the organizations who signed the letter.
Hospital-at-home programs grew rapidly in the past three years despite the uncertainty of future Medicare reimbursement for the services, the groups noted in the letter.
“The waiver must be extended to enable hospitals and health systems nationwide to continue building out the logistics, supply chain, and workforce for Hospital-at-Home (HaH) and to encourage multiple payers outside the Medicare program, including Medicaid programs, to enter the HaH market,” the groups wrote.
Many proponents would like to see CMS and Congress make the waiver permanent, but a five-year extension would provide more certainty as regulators and lawmakers continue to evaluate the outcomes.
“For the program to continue to grow, health systems need to get a policy signal that this is something that lawmakers care about and want to see move,” said Krista Drobac, founder of Moving Health Home, an organization that advocates for policy reform to support care at home.
Hospital-at-home has moved from experimental to a strategic priority for many health systems, Drobac noted. “The evidence and the fact that patients are happier is driving the momentum and excitement behind this movement,” she said.
Building the case for high-quality care in the home
While hospital-at-home programs have grown, there have been concerns about the quality of care provided in patients’ homes and whether it’s on par with hospital-based treatment. There also questions around cost savings and patient safety.
There are also concerns that care at home may shift undue burden onto family caregivers.
According to a DispatchHealth case study, the hospital-at-home model can help alleviate rather than exacerbate caregiver stress. More caregivers (95%) preferred in-home care over the traditional hospital setting and the majority (96%) found in-home care to be less stressful. Family caregivers said they felt more informed about the patient’s daily care plan during in-home treatment, the study found.
Critics of these programs, led by the largest union of registered nurses, say care-at-home technologies are unproven and cite a lack of research comparing the cost and quality of hospital and at-home care. National Nurses United calls these programs “home all alone” and published a report in September 2022 condemning the waiver program, calling it a “grave threat to patient care.”
Recent research has shown positive patient outcomes from hospital-at-home programs. CMS released data in November based on 11,000 patients admitted into Acute Hospital Care at Home programs between November 2021 and March 2023. According to that research, published in the Journal of the American Medical Association Health Forum, patients who received hospital-level care at home through the waiver program had low mortality rates and minimal complications related to escalations back to brick-and-mortar hospitals. The overall proportion of patients transferred from home back to the hospital was 7.20%.
One study conducted by researchers at Mass General Brigham looking at 6,000 patients across the country found low rates of mortality, less use of skilled nursing facilities, and less need for escalation in medical care for patients taken care of at home instead of in the hospital.
“For hundreds of years, since the inception of hospitals, we’ve told patients to go to a hospital to get acute medical care. But in the last 40 years, there’s been a global movement to bring care back to the home,” said corresponding author David Michael Levine, M.D., clinical director for research and development for Mass General Brigham’s Healthcare at Home. “We wanted to conduct this national analysis so there would be more data for policymakers and clinicians to make an informed decision about extending or even permanently approving the waiver to extend opportunities for patients to receive care in the comfort of home.”
Many advocates for hospital-at-home contend that it can be safer for patients by reducing the risk of hospital-acquired infections.
On any given day, one in 31 facility-based patients will be diagnosed with a secondary infection, which, according to Centers for Disease Control and Prevention research, results in at least $28.4 billion in direct medical costs annually. According to DispatchHealth's analysis, there were no secondary infections among a cohort of more than 1,000 patients treated at home through its program.
Proponents of these programs also point out that sending providers into patients’ homes gives them a broader, 360-degree view of a patient’s life to identify things like fall risks, malnutrition or other social needs. DispatchHealth clinicians say they are literally in the kitchen with their patients, often learning more than what most primary care doctors know about their patients. Taking this a step further, the company now works with Instacart to enable its providers to prescribe food interventions, much like traditional medications, right to patients' homes.
"Often, in the hospital, the family is not directly involved in the care, they don’t know what’s going on,” Harris, a lead R.N. at DispatchHealth, said. “We get the family involved, we get the patient involved and we have the same nurses working with patients day in and day out so everybody communicates well and we all are on the same page about the patient care. It just creates a much better experience.”
Is the living room the future of hospital care?
McKinsey & Company estimates that up to $265 billion worth of care services, representing up to 25% of the total cost of care, for Medicare fee-for-service and Medicare Advantage beneficiaries could shift from traditional facilities to the home by 2025 without a reduction in quality or access.
“That number represents a three- to fourfold increase in the cost of care being delivered at home today for this population, although how the shift will affect reimbursement rates is not yet clear,” McKinsey & Company senior partners wrote in the 2022 report.
Investors also are banking on a shift to more at-home care. Investment in health-at-home solutions reached $4.7 billion in 2021 from $2.2 billion in 2022, according to data from VC firm 7WireVentures.
Medically Home, a clinical, logistical and technological model for hospital-at-home care, has raised $275 million backed by investors including medtech company Baxter International and medical transportation and mobile medic company Global Medical Response. The company works with health systems, physician groups, and payers to deliver care to patients in their homes for approximately 20 organizations in as many states. Health system partners include Mayo Clinic, Kaiser Permanente, Cleveland Clinic, ChristianaCare and OSF HealthCare, among others.
DispatchHealth has raised $417 million backed by investors like Tiger Global, Humana, Alta Partners, Echo Health Ventures, Oak HC/FT and Questa Capital. The company provides its urgent medical care service in 57 distinct markets and its hospital alternative advanced care program in 14 cities.
The company has built up partnerships with major insurance companies for its mobile services including Humana, UnitedHealthcare, Aetna, Cigna and Anthem BlueCross BlueShield.
“A lot of the work we've done over the past five years of developing this program has been creativity with payers and our experts in healthcare contracting to figure out the novel mechanisms that will allow payers to put this in one of their benefits, and do so in a way that is within the regulatory landscape,” Kneeland said. “We have some interesting intellectual property around how you actually implement the payer models and the payer partnerships around this because it's not ‘out of the box.’”
Many health systems across the country have been hesitant to invest in hospital-at-home programs without a permanent reimbursement structure. But others have doubled down on their investments to build out their at-home care programs.
Mass General Brigham was an early adopter, and its Home Hospital program is one of the largest acute home-based care models in the country. MGB has made Healthcare at Home one of its most strategic priorities, with plans to shift 10% of inpatient care to patients' homes over the next five years.
Health systems and companies like DispatchHealth continue to face the challenge of building the case to payers and regulators that these programs can improve outcomes and lower costs.
“There’s the question of scale. How do you continue to scale this so that the resources put into these models reach the biggest potential patient impact? We need to continue to prove out that we're able to scale these models well and reach a patient population that is nationally significant in terms of bending the cost curve,” Kneeland said.
Expanding these programs geographically and reaching rural populations will be critical to the growth of hospital-at-home, experts say, and to do that, providers will need to lean heavily on tech, specifically advanced virtual care and remote monitoring technologies.
Providers and payers will continue to work through the complex operational and financial issues required to stand up and build these services.
But in living rooms and bedrooms across the country, patients like Francisco and his wife Esperanza see it as an easy choice, an alternative option that moves health closer to home.