Could the Hospital at Home movement upend SNFs?
By Eric Wicklund
With a five-year waiver extension in hand for CMS’ Acute Hospital Cate at Home (AHCaH) program, healthcare organizations are taking a closer look at what a Hospital at Home strategy might accomplish in the long run.
Some say it could lead to a radical redesign of the SNF.
Skilled Nursing Facilities play a valuable role in the healthcare ecosystem, but the model is plagued by a lack of beds and staff and challenged by financial uncertainties and poor clinical outcomes. Studies have suggested that as many as half of all patients discharged from a hospital to an SNF don’t make it home.
When it hit the spotlight during the COVID pandemic, the Hospital at Home strategy was directed at healthcare organizations struggling to care for a surge of infected patients with a stressed workforce. The concept of delivering hospital-level acute care services in the home offered relief, while testing the long-standing idea that patients would recover more quickly and effectively in their own homes.
Now health systems and hospitals are taking that idea to new levels. Hundreds have launched programs, both within and outside the confines of the CMS model, targeting new populations and care pathways.
In Massachusetts, Mass General Brigham and the University of Massachusetts have launched studies of the SNF at Home concept, supported by state grants. The models are testing the idea that many patients destined for an SNF can be better treated at home, not only saving thousands of dollars per patient but also leading to improved outcomes.
“If successful, this care model may lead to a complete transformation of how we deliver advanced rehab care to our patients,” David Levine, MD, MPH, MA, clinical director for research and development for Mass General Brigham’s Healthcare at Home program and principal investigator of the trial, said in a 2024 press release. “There are not enough rehab beds in Massachusetts, and if we can substitute facility-based care with home-based care, we will be able to help alleviate the capacity crisis that our healthcare systems have been experiencing across the state. This would have an immediate benefit for patients, family caregivers and clinicians.”
Constantinos “Taki” Michaelidis, MD, MBA, MS, Medical Director of the Hospital at Home program at UMass Memorial Medical Center, says it’s too early to say home-based care could replace the SNF. But it could weed out a lot of unnecessary and costly discharges and potentially improve clinical outcomes for a subset of patients who don’t really need all that an SNF provides.
“What we’re all concerned about is high-quality patient care,” says Michaelidis. A viable SNF at Home program, he says, would be “an absolute win for the most vulnerable facilities.”
Critics say the Hospital at Home movement aims to shift too many critical services to the home that can’t be supported by digital care and in-person visits. Simply put, some patients are too complex to be treated in the home. That’s especially true of patients transferring to SNFs, who often require structured and frequent services.
Michaelidis says the effort doesn’t aim to replace SNFs, noting “there are some very, very high-quality SNFs and we want them to be successful.” But a successful program can help hospitals better manage their inpatient population and make better choices about who should be discharged to SNFs.
Moreover, advances in telehealth programs and digital health tools, from remote patient monitoring platforms to wearable sensors and monitors, mean more clinical-grade services can be delivered in the home. And home, Michaelidis points out, “is where most patients want to be.”
“A lot of facility-based care tends to be bundled care,” he notes. And that can mean patients are discharged because they can be treated in that bundled program, rather than based on their individual needs. An SNF at Home program would tailor services around each patient’s care pathway.
One of the biggest barriers, of course, is payer support. So much of the Hospital at Home movement now is dependent upon Medicare reimbursement. Michaelidis notes studies have shown that a Hospital at Home program can eliminate 80% or more of SNF referrals, alongside improved clinical outcomes.
He says the industry is “well past the point” of proving the Hospital at Home model of care, and while the CMS’ AHCaH model is a good foundation, health systems and hospitals are now moving beyond that rigid construct and building their own models.
“I think the proof is going to be in the pudding,” he says. “We’re going to be able to show our payer partners ad our patients and their families that this is better care. And payers will say ‘This is what I prefer.’”
Beyond that, Michaelidis says emerging models like SNT at Home or Pediatric Care at Home could fundamentally change how hospitals discharge their patients. Hospital at Home programs have the potential to give health systems more of a say in where and how their patients are treated after the hospital stay, rather than just handing someone off to an entirely new entity.
“Perhaps the default for everything we do should be the home,” he says.