A National Qualitative Study of Hospital-at-home Implementation Under the CMS Acute Hospital Care at Home Waiver

Ksenia Gorbenko PhD; Abigail Baim-Lance PhD; Emily Franzosa DrPH; Heather Wurtz PhD; Gabrielle Schiller MPH; Sybil Masse MPH; Katherine A. Ornstein PhD; Alex Federman MD; David M. Levine MD, MPH, MA; Linda V. DeCherrie MD; Bruce Leff MD; Albert Siu MD, MSPH


J Am Geriatr Soc. 2023;71(1):245-258. 

In This Article

Abstract and Introduction


Background: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements.

Methods: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding.

Principal Findings: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits.

Conclusions: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.


In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) initiated several waivers to alleviate pressure on hospital capacity. The CMS Acute Hospital Care at Home (AHCaH) waiver aimed to incentivize implementation of Hospital-at-Home (HaH) care. HaH provides hospital-level acute care in patients' homes as a substitute for care traditionally provided in the hospital. HaH was developed to reduce complications associated with traditional hospital care[1,2] and honor patients' preferences to recover at home, particularly older adults with medically complex conditions such as congestive heart failure and chronic obstructive pulmonary disorder exacerbations. Given the higher risk of serious complications and death from COVID-19 among older adults, HaH also maintained access to care while keeping older patients out of medical and congregate settings where they may have been at higher risk for exposure and associated morbidity and mortality. HaH has been demonstrated to provide high quality, safe, equitable, effective care. Compared with traditional hospital care, patient and family care experience is better, while complications and costs are lower.[3–10] Despite such benefits, prior to COVID-19 HaH programs were not widely implemented in the US, largely due to lack of fee-for-service Medicare reimbursement and regulatory limitations.[11,12]

The AHCaH waiver provided a fee-for-service payment for HaH care in Medicare for the first time. The waiver removed CMS' hospital requirement to provide 24-hour on-site nursing, but otherwise required programs to adhere to all other hospital conditions of participation, including providing or contracting pharmacy, infusion, oxygen, transportation, food delivery, durable medical equipment, skilled therapies, and social work services; performing a history and physical exam (H&P) in the hospital or emergency department (ED); and making at least one visit by a physician or advanced care provider (remote or in-person), and at least two in-person nursing or mobile integrated health (MIH) visits daily. Patients also needed access to in-home emergency services by personnel located within 30 min from their domicile.[13] Programs submitted data on their program outcomes to CMS at least monthly.

The CMS AHCaH waiver accelerated uptake of HaH by offering full diagnosis-related group (DRG) reimbursement through Medicare Fee-for-Service and non-managed Medicaid beneficiaries.[13] As of July 27, 2022, 245 hospitals in 110 health systems in 36 states had obtained the waiver and CMS reported early positive outcomes.[13–15] With this expansion, we conducted an exploratory qualitative interview study with program leaders to examine processes of uptake and implementation of AHCaH in a national sample using the Exploration, Preparation, Implementation, and Sustainment Framework.[16] Our goals in this qualitative study were to: 1) examine barriers and facilitators of AHCaH implementation across implementation stages and 2) describe strategies used to address these barriers and/or best practices.