Home hospital study shows strong results with Medicaid patients

Researchers have examined home hospital programs in a number of settings, but a new study offers hope that those programs can offer high-quality care for patients with lower incomes.

Mass General Brigham and UMass Chan Medical School researchers studied Medicaid patients in hospital-at-home programs and found encouraging results.

In a study of about 1,000 patients who use Medicaid, researchers found low mortality rates and low rates of readmission to a brick-and-mortar hospital. The findings were published earlier this month in the Journal of the American Geriatrics Society.

Dr. David Levine, lead author of the study and the clinical director of research & development at Healthcare at Home at Mass General Brigham Healthcare at Home, says that the study is significant in answering another important question about the safety and quality of home hospital programs.

He tells Chief Healthcare Executive® that he’s excited about the good results for Medicaid patients getting acute care in the home.

“We haven't been able to show in this big of a cohort of patients with Medicaid their outcomes before,” Levine says. “And I think there have been people around the country that have questioned whether folks that are unfortunately living in poverty can have a very, very excellent outcome when they get their care at home.”

“And so it's a huge win, I think, for this care model to show that it can really treat everybody. Doesn't matter how rich or poor you are, the outcomes are actually quite good in this population as well,” he says.

Levine says that the study of Medicaid patients suggests that home hospital programs can offer a way to provide more equitable care for patients.

“This is a care model that can be delivered to all sorts of patients,” Levine says.

“It allows us to deliver care with a great sense of equity, which we know is often not the case in our brick-and-mortar hospitals,” he explains. “We know that folks who are from a lower income bracket or who live in rural areas don't have as good outcomes after hospitalization, but we don't see that difference here in home hospital.”

• Read more: Envisioning hospital-at-home as the ‘future of healthcare’

‘The secret sauce’

Researchers evaluated the outcomes for Medicaid patients in hospital-at-home programs at Mass General Brigham and UMass Memorial Medical Center. The mortality rate during the study was 1.2%.

Levine says he was encouraged by the fact that a small percentage of patients needing care at home needed to return to a brick-and-mortar hospital. About 9% of the home hospital patients ended up going back to a brick-and-mortar hospital, while 4% were discharged to a nursing home or some other type of post-acute facility.

Medicaid patients in brick-and-mortar hospitals tend to be at greater risk for readmission than other patients due to issues such as difficulty getting medications or problems with transportation to get to follow-up appointments. “Things fall apart, as a result,” Levine says.

But patients in home hospital programs can also get assistance with problems that can hinder their recovery or pose risks for other health concerns.

“Part of the secret sauce of being in the home and getting your acute care is that team can work with you right there,” Levine says. “The team can see that the cupboards are empty, the refrigerator is empty. The team can see that maybe you are in public housing and you have a broken window that needs to be fixed.”

“We can bring resources to you that never would have been visible in the brick-and-mortar hospital,” he adds.

About 15% of the patients in the Medicaid home hospital study were Black, which roughly matched other studies of home hospital programs. Almost 40% of the patients in the new study were Hispanic, well above other studies of acute care at home, Levine says. And he says that’s another encouraging finding to see good outcomes among Hispanic patients.

“I think again it shows that this is a care model that works for all, does not matter what your race or ethnicity is, does not matter what your income is,” Levine says. “We are still seeing really positive outcomes from this population.”

High levels of sickness

Researchers recently found good results in hospital-at-home programs in rural communities, which Levine said was important because there had been limited data on the success outside of urban and suburban communities. Other studies have found low mortality among patients getting acute care at home.

In the latest study, patients in home hospital programs were dealing with serious conditions. The most common conditions among those patients were heart failure, septicemia, and respiratory infections.

The Medicaid patients had “quite a bit of burden of sickness,” Levine says. Some patients enrolled in Medicaid and Medicare had higher levels of sickness, but he says those patients still did well.

Levine stresses it’s important to recognize that the patients in the latest study were seriously ill and getting acute care in the home.

“This is home hospital care,” Levin says. “It's substitutive. It's care that normally would have been delivered in a brick-and-mortar setting, and we're instead delivering it in your home as a substitute to traditional hospitalization. That is a key thing, and I think that that bears out in our data.”

More health systems introduced home hospital programs during the COVID-19 pandemic. Under Medicare’s rules, health systems offering acute care at home must provide a minimum of two visits from nurses in the home each day, while doctors and specialists also check in virtually and are available around the clock. Typically, patients in home hospital programs must be within a relatively short distance of a physical hospital.

As of April 29, there were 365 home hospital programs operated by 137 health systems in 37 states, according to data from the Centers for Medicare & Medicaid Services.

In February, President Trump and Congress approved legislation extending federal approval for hospital-at-home programs into September 2030, much to the relief of health systems and medical associations. Hospital groups had been imploring policymakers for a multi-year extension of approval for home hospital programs, arguing that health systems need some degree of certainty before launching or expanding programs.

Now, Levine and other healthcare leaders say that they are enthusiastic that more health systems will start new programs or expand services.

“I think this is a very exciting time for home hospital,” Levine says. “Previously, totally understand the CFO conservatism of launching essentially an entire business line with an uncertain payment infrastructure in front of it, and we don't really have that problem anymore. We have a five-year extension right now. That's a really nice runway. We are, of course, hoping to find permanence after 2030, but right now we have a nice runway for a care model that has a lot of evidence base behind it.”