Hospitals’ New Push: Treating Patients in Their Homes

Institutions say it is safe and opens hospital beds, but policymakers fear it’s too pricey and lacks strict standards

Paramedic Elizabeth Kinch speaks with patient Herbert Irvine about his knee.

In a suburb just outside Boston, Herbert Irvine sat in his recliner on a July morning as he got a visit from paramedic Elizabeth Kinch. She wasn’t there responding to a 911 call, but instead to provide at-home care.

His prognosis after a fall was good: No fever, chills or some other troubling symptoms of worsening infection in his knee, the paramedic told nurse practitioner Michele Kelley, who was examining Irvine virtually via video. 

But the 85-year-old’s knee was still red and swollen, requiring at least one more day of monitoring. “I just want to make sure the redness doesn’t progress, or the swelling or the pain gets any worse,” said Kelley of Mass General Brigham.

Around the country, more than 300 hospitals are deploying or preparing to dispatch paramedics, nurse practitioners and other medical staff to treat patients at home instead of in hospital settings, a service widely referred to as hospital at home. 

The efforts are part of a nationwide experiment that began with the pandemic, when hospitals were overcrowded and under financial strain. Federal regulators proposed a fix: Hospitals could temporarily take care of Medicare patients at home, but still get paid the same hospital-stay rate. The pandemic-era program was open to patients in fee-for-service Medicare. 

Many hospitals are deploying medical staff to treat patients at home.
Elizabeth Kinch holds up a phone for patient Herbert Irvine to speak with nurse practitioner Michele Kelley during the visit.

The idea outlasted the public health crisis and hospital finances rebounded, attracting investment from medical centers and technology companies eager to capture a piece of the emerging market. 

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But policymakers say they fear hospitals are overpaid and will overuse the home-based services, raising spending unnecessarily. As more health systems adopt these models, clinicians and regulators also grow concerned about the quality and safety of these programs. Patients, too, question the risks they face. 

Medicare won’t pay for at-home care after December, unless Congress votes to continue the program. Despite this, home services have grown under the federal insurer for the elderly and disabled. Some commercial insurers, including Medicare Advantage, also cover hospital-at-home services, according to hospitals and insurers. 

Getting at-home care

Not everyone is eligible for these programs. Hospitals limit their selection to patients who are stable enough to be at home, but sick enough to need hospital-level care. 

Hospitals also evaluate patients’ ability to move independently, whether they live alone and how much support they have from family and friends. Patients who live alone can be treated at home, but may be provided an aide, in some cases. 

At Mass General Brigham, 250 employees work with patients via home-hospital care. The patients commonly include those with infections and chronic conditions, such as congestive heart failure. 

Dwayne Thomas receives medication during a home hospital visit.

Dwayne Thomas was first offered at-home care via Mass General Brigham in July after he was treated at Newton-Wellesley Hospital for a kidney condition that had caused dangerous fluid buildup and swelling throughout his body.

Thomas felt uneasy about the quality of care.

“I knew whatever I was going to be getting was not going to be as good as in the hospital,” he said.

He eventually came around after learning more. As a professor of sports management, Thomas was also curious to see how it worked. 

Patients who are eligible for these programs receive home visits twice a day from staff who deliver prescriptions, draw blood and outfit homes with equipment to remotely monitor patients’ vital signs and movement. 

Some hospitals have started to send home some patients after surgery who normally remain in recovery on site for some days.

In emergencies, hospitals must be able to reach patients in 30 minutes, under federal requirements. Medical staff also pre-emptively send patients back if they are concerned. 

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On a recent visit, Mass General Brigham paramedic Kinch used a hand-held laboratory kit to run a rapid test of his electrolytes that helped decide Thomas’s daily treatment with medication to reduce fluid swelling. 

Elizabeth Kinch works in her vehicle, preparing for a day of home visits.

His condition had dramatically improved as his swelling lessened, Thomas said in late July. He had begun taking walks again after roughly a week of home-hospital care. It was a heartening sign of progress for the 62-year-old pickleball player and coach.

“It’s phenomenal,” he said.

Growing concerns

Policymakers and some medical professionals aren’t sold on it.

Hospitals must meet basic requirements to treat patients at home. Beyond that, they have leeway to decide on the technology used to monitor patients and the combination of virtual house calls and in-person visits they will employ in addition to what’s mandated, Medicare’s advisory group has said. That latitude makes it hard to know when it is best to see patients in-person or whether remote monitoring affects the quality of care. 

“There are no standards for the frequency and intensity of these services,” said the advisers about the use of technology to keep tabs on patients, in a report released in June.

Caring for patients at home also creates logistical challenges for hospitals that create potential risks, said Dr. Sachin Jain, chief executive of the Long Beach, Calif.-based nonprofit SCAN Group and its health plan subsidiary, SCAN Health Plan, who has early experience with home-hospital care. 

In addition to sending medical workers out, hospitals must coordinate drop-offs of medications, monitoring and medical devices, laboratory work and other essentials, such as food. Gaps and delays could be harmful, he said.  

“In the era of Amazon and Uber we do a lot of hand waving about, ‘oh, we’ll just get these things delivered at home,’” he said. But it isn’t so simple for home-hospital care, he added. “Delivering services at home really requires a lot of things to go right and in a particular sequence.” 

Mass General Brigham says it makes cautious changes when necessary to improve its program. Photo: Lane Turner/The Boston Globe/Getty Images

Mass General Brigham says it makes cautious changes when necessary to address issues or make improvements in its program. It collects and analyzes quality and safety data for its home-hospital patients and compares results to similar patients treated in hospitals when possible, the system said.

Overall, participating hospitals say home-based medical care is safe and more comfortable for patients, and it opens hospital beds, helping to ease severe emergency-room crowding in some cities. 

By federal requirement, hospitals report unexpected deaths and the percentage of patients who return to hospitals, either because patients want to return voluntarily or their condition worsened at home. Additionally, the Centers for Medicare and Medicaid Services said it collects other safety and quality measures for any hospital patient, such as rates of infections and heart attacks.

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Hospitals say they track additional quality and safety metrics for home-hospital patients, including falls, infections and how frequently patients end up hospitalized twice within 30 days.

Medicare patients have had 23,000 home-based hospitalizations through April, with few unexpected deaths, based on early analyses of federal data. In federal fiscal 2022, around 0.36% of patients died unexpectedly among the 105 hospitals that treated at least one patient at home that year.

But missing from the reporting is how easily patients can reach medical staff when needed and tracking whether rates of patient falls and avoidable infections are different from those inside hospitals, advisers to Medicare said in the June report. Congress has asked for a study of home-hospital services from the agency that oversees Medicare, with the report due no later than September. 

Home sweet home 

Keepsakes and family photos in patient Mojisola Asere's living room.
Keepsakes and family photos in patient Mojisola Asere's living room.

The comfort of home also comes with trade-offs. Medicare patients at home were treated longer than those in hospitals, by about a day, federal data for fiscal 2022 show. 

Longer stays push costs higher. Medicare pays hospitals the same for patients who are hospitalized at home or in a hospital setting, raising concerns the insurer is overpaying and giving hospitals an incentive to overuse the service. Patients at home received fewer expensive laboratory and radiology services, the federal data found.

It isn’t clear whether they should be paid the same, advisers to Medicare said this year. 

Mass General Brigham says the hospital system loses money on patients in the program. Driving between patients is less efficient than moving between beds in a hospital unit. Medical staff who make house calls in home-hospital programs are highly trained, with higher wages.

These factors add expense, along with other investments to ensure patients are closely monitored and have the supplies and support they need, from internet service to food deliveries, Mass General Brigham says. 

It may be profitable in the long run for hospitals. The Boston-based system gains, for example, by adding more space to care for highly complex patients who are in its overcrowded emergency rooms and hospitals, further increasing revenue. 

For some patients, being able to get treatment at home is worth it.

Home hospital patient Mojisola Asere relaxes in her living room, speaking with family members.
Paramedic Kim DeWolf, right, speaks with patient Mojisola Asere at home as her daughter listens.

Mojisola Asere easily agreed to return home for medical care after a severe asthma flare-up brought her to Mass General Brigham’s Brigham and Women’s Hospital emergency room in mid-July. 

“Who doesn’t want to be home?” said Asere, 71, a retired nurse. Medical staff check on patients overnight, interrupting their sleep, she said. “It’s not a restful place.” 

Ahead of her daily morning visit by a paramedic, Asere fixed lemon water and chatted by phone with family. One of Asere’s children sat by her side playing music from a computer. 

“It’s amazing,” she said. “You’re in your house, your living room. You’re watching your TV. You’re interacting with your children and you are getting well.”

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Write to Melanie Evans at melanie.evans@wsj.com

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