Home Health Care Redesign/Reform Moving toward the hospital of the future

Moving toward the hospital of the future

The godfather of hospital at home weighs in

January 2021
medicare-dollar-maze

ASK BRUCE LEFF, MD, about his decades of both working in and championing hospital at home programs, and he credits the John A. Hartford Foundation, a New York-based nonprofit that funds programs to improve the care of older Americans.

“It was the original funder of my hospital at home research in 1994,” says Dr. Leff, a geriatrician at Johns Hopkins and director of the Center for Transformative Geriatric Research there, “and it has funded hospital at home pretty much continuously ever since. But for the Hartford Foundation, there would be no hospital at home now in the U.S.” Many proponents of the model might add: But for Dr. Leff and other hospital at home pioneers, the CMS may not have green-lit reimbursement for the model for fee-for-service beneficiaries.


For a look at how four health systems are building—or modifying—programs to make the most of CMS’s decision to pay for hospital at home services, read our “Building hospital at home” article.


There have been some auspicious breakthroughs along the way. In 2017, for instance, the Physician-Focused Payment Model Technical Advisory Committee unanimously recommended that the CMS create a bundled payment for hospital at home services. While the HHS secretary at the time didn’t adopt that proposal, CMS personnel began taking an interest. An August 2018 study in JAMA Internal Medicine from New York’s Mount Sinai on a hospital at home demonstration found markedly better outcomes vs. inpatient admissions in terms of LOS, 30-day readmissions, and ED visits and SNF admissions.

“Actual bricks-and-mortar hospitals will be large EDs, ORs and ICUs. Most everything else will be provided at home or in the community.”

Bruce Leff, MD

~ Bruce Leff, MD
Johns Hopkins

A growing list of organizations looking for ways to provide value-based care began launching hospital at home programs, including Utah’s Intermountain. And Dr. Leff and other members of a voluntary consortium—the Hospital at Home Users Group, funded by the Hartford Foundation—have for much of the past two years been forming work groups.

“We wanted to create more of a foundation for the model to be implemented at scale,” he says. Work groups have mapped out program standards, quality indicators, and solutions to payment and regulatory issues. They also were available for the occasional phone call from the CMS.

Then the pandemic hit. According to Dr. Leff, “the enduring legacy” of the pandemic might be how differently now the general population views hospitals and facility-based care.

“People are more hesitant to go to the hospital since covid,” he says. With that shift, hospitals and health systems immediately “started to think about hospital at home,” he says. “Health systems started to understand the risks to their delivery and business model when all health care is tightly linked to facility-based care.”

As operating rooms and clinics shut down last spring, telemedicine was rapidly implemented. “That was the answer to phase one of this pandemic,” he points out. And with CMS staring down this winter’s surge, the agency went into “overdrive,” he says, and put the waiver program in place.

“That literally happened over eight or nine days,” he says. “It’s pretty amazing to see government at its best.” Now his own and his fellow proponents’ inboxes are full of messages from interested hospitals and health systems, exploring their options.

Right now, the waiver is intended to last only through the current public health emergency. That is both “an incentive and a disincentive,” says Dr. Leff. “Some hospitals won’t get involved because no one knows with certainty how long it will last.” And after close to 30 years of advocacy, it is “a little bittersweet that it took a pandemic to get it going.”

But what New York hospitals looked like last spring—other than elective surgeries being suspended—is close to Dr. Leff’s vision of what the hospital of the future will look like.

“I don’t know if it’s 10, 30 or 50 years from now, but I am certain that actual bricks-and-mortar hospitals will be large EDs, ORs and ICUs,” he predicts. “Most everything else will be provided at home or in the community.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the January/February 2021 issue of Today’s Hospitalist

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