Home Comforts: Hospital-at-Home and the Evolution of Patient Care

Publication Date: 04/03/2024

Cranfield, UK, 4th March 2024 – The Hospital-at-Home market has received much attention in the wake of the COVID-19 Pandemic as a means to alleviate hospital bed shortages, reduce costs, and improve health outcomes for appropriate patients. Advances in remote patient monitoring technologies and a supportive policy environment offer much promise, but formidable obstacles remain.

Laying the Foundations

While Hospital-at-Home had been kicking around as a concept since at least the mid-1990s, the onset of the COVID-19 pandemic upped the ante. In March 2020 the CMS’ established its ‘Hospitals Without Walls Programme’, essentially allowing the transfer of acute hospital patients into non-acute healthcare facilities. Building on this, in November 2020 the Acute Hospital Care at Home (AHCaH) initiative was launched, allowing individual CMS-approved hospitals to provide inpatient-level care in the home for Medicare fee-for-service and non-managed care Medicaid beneficiaries. Typical of COVID era policies, the AHCaH is temporary and is set to expire, barring further extension, on the 31st of December 2024.

Hospital-at-Home has continued to generate much excitement. However, whilst over 130 health systems have had programmes authorised by the CMS, the absolute numbers of patients being treated in this way remains limited. A well circulated study in Jama Health Forum (Adams et al, 2023) stated that 11,159 patients were admitted under the Waiver between the 25th of November 2021 and the 20th of March 2023.

CMS data accessed through a freedom of information request by the Data Liberation Project reveals that, as of September 2023, just over 18,000 ‘discharges’ under the ACHaH Waiver had taken place. However, a discharge in this case does not necessarily equate to an individual patient. Caveats aside, both figures reveal the relatively low uptake of the ACHaH Waiver. Meanwhile, running in parallel, numerous non-waiver-related Hospital-at-Home programmes, sometimes referred to as ‘Acute RPM’, have also been established by healthcare providers along value-based-care (VCB) principles.

Vendors planning long-term investments have, justifiably, linked the impending cut-off date of the ACHaH waiver in December 2024 to the lack of greater adoption. Few expect a complete withdrawal, however. Recent developments, including the introduction of a Bill to expand the ACHaH waiver to cover observation status patients, and the state of New Jersey’s recent expansion of its own ACHaH programme to Medicaid and private insurance, would appear to bear this out.

This is not to downplay the myriad of medical, technical, and financial obstacles that vendors must deal with. These include high upfront set-up costs, staffing shortages (particularly nurses), the inherent challenge of identifying suitable patients, and scepticism among healthcare professionals as to its efficacy and safety. Concerns have also been raised that isolated communities, far from healthcare facilities and lacking requisite connectivity, could also be overlooked.

Every breath you take

No single vendor can provide an all-encompassing solution to challenges that requires specialism in staffing, logistics, patient engagement and education, healthcare IT interoperability, connectivity and networking, and medical devices. Those that have come closest, such as Medically Home, Contessa Health, and Dispatch Health, still rely on a combination of high-end monitoring devices (and supporting software platforms) from vendors including Biofourmis, BioIntellisense, VitalConnect, and Vivalink.

Despite no requirement for continuous monitoring of patients under the ACHaH waiver, vendors should be under no illusions; the capability to continuously monitor basic vital signs such as body temperature, pulse rate, respiration rate, blood pressure, and SpO2, are the table stakes for this market. Many vendors have moved beyond this and include the continuous monitoring of other biometric signals relating to activity, falls, and sleep.

The inclusion of continuous ECG monitoring is another point of differentiation that is likely to become more prevalent as the market matures, particularly given advancements around the application of AI to ECG interpretation. VitalConnect and Vivalink are two Ambulatory ECG vendors whose continuous wearable ECG monitoring devices (7 and 14 days respectively) are being used in Hospital-at-Home programmes.

The majority of Acute-RPM (i.e., non-waiver) programmes are already continuously collecting patient’s biometric data and automatically syncing this to a cloud-based platform via a mobile app or home hub device. The leading vendors in this sector are further differentiating themselves through the application of AI and data analytics to provide patient management and clinical decision support.

Devices that can provide a full-days monitoring between charges should be considered the minimum requirement. Vendors who can provide a monitoring solution that lasts beyond 5 days will remove another point of friction for patients and providers. BioIntelliSense’s BioButton, used by Medically Home in hospital-at-home and Medtronic for in-hospital and post-discharge monitoring, can last for up to 60 days. However, at present it lacks SpO2 monitoring (the company has developed this technology but is currently licensing this to third-party device vendors).

Another factor for vendors to consider is whether to make their devices disposable or reusable. There are legitimate reasons for healthcare providers to prefer disposable devices for use with acute patients, such as infection control. Israeli vendor BioBeat changed tack to offering a disposable chest patch together with its reusable wrist monitor for this very reason. A disposable option also negates many of the logistical complications around collecting, sanitising, and re-issuing of devices that are not core-competencies for a cutting edge MedTech company. That said, prevailing narratives around Environmental, social, and corporate governance (ESG) and sustainability, to say nothing of recent inflationary pressures and supply chain reconfigurations, will surely push the market further towards reusable solutions.

Another brick in the wall

Given many of the constraints, Hospital-at-Home will only ever comprise one component of a healthcare system. As with other adjacent markets, such as non-acute RPM or Ambulatory Diagnostic Cardiology, the most technologically advanced solutions will fall flat if they fail basic tests around interoperability with existing clinical workflows and healthcare infrastructure.

In the traditional Patient Monitoring market, dominated by industry leaders such as GE Healthcare, Philips, and Mindray, vendors have long been exploring flexible monitoring solutions that can track a patient throughout their hospital journey. Hospital-at-home, or hospital-to-home (i.e., post-discharge) is a natural extension of this, so integrations between incumbents and emerging vendors are inevitable.

Another adjacent market that will influence the development of Hospital-at-Home is the Home Health Care sector, encompassing segments including Hospice Care and Palliative Care. In July 2021 Contessa Health, one of the leading turn-key Hospital-at-Home companies in the US, was acquired by Baton Rouge-headquartered Amedisys, a home health, hospice, and personal care company, for $250 million.

Barely two years later, in July 2023, Amedisys itself agreed an $3.7 billion all-cash deal to be acquired by UnitedHealth’s Optum unit (both parties are hoping for a final close on the deal in early 2024). Commenting on the deal, Optum, which had previously snapped up home health provider LHC Group for $5.4 billion in March 2022, noted that acquiring Amedisys would accelerate its “seamless provision of value-based care in the home”.

Final thoughts

The technology required for monitoring acute patients in the home has come on leaps and bounds in recent years. This technology is now being integrated by vendors with the clinical, staffing, and logistical expertise required to safely carry out these programmes. Aside from the fee-for-service-driven ACHaH waiver, Acute-RPM programmes based on VBC models are being rolled out by major health systems. A new bill before Congress seeking to expand ACHaH waiver coverage, and the expansion of coverage announced recently in New Jersey add to Hospital-at-Home’s tailwinds. Given the challenges mentioned above, it will need them. Ultimately, Hospital-at-Home needs to be judged on the contribution it can make to a more integrated health system.

Related Research

Hospital-at-Home – Patient Monitors – 2024

This is a topical report looking at some of the key developments around the Hospital-at-Home market, including legislation and policies, reimbursement and funding, and an overview of the competitive landscape.

About The Author

Gareth joined Signify Research in 2021 as Senior Market Analyst in the Digital Health team, where he covered emerging markets including Remote Patient Monitoring (RPM) and Ambulatory Diagnostic Cardiology. In 2023, Gareth joined Signify’s Clinical Care team where, his coverage areas will include Diagnostic Cardiology and Patient Monitors. Prior to Signify Research, Gareth gained 13 years of research experience in South Africa.

About the Clinical Care Team

The clinical care team provides market intelligence and detailed insights on the clinical care equipment and IT markets. Our areas of coverage include patient monitoring, diagnostic cardiology, infusion pumps, ventilators, anaesthesia devices, and high-acuity IT. Our reports provide a data-centric and global outlook of each market with granular country-level insights. Our research process blends primary data collected from in-depth interviews with healthcare professionals and technology vendors, to provide a balanced and objective view of the market.

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