6 things the hospital-at-home model needs to scale up nationally

Earlier this year Congress extended CMS’s hospital-at-home waiver for five years via the Consolidated Appropriations Act of 2026. With that bold stroke, hospital-at-home (“HaH”) services became eligible for Medicare reimbursement through September of 2030. 

Supporters of the HaH model cheered the development as an opportunity to scale the program and, in doing so, to “catalyze transformation of healthcare outside of brick-and-mortar health facilities.”

The quote is from Bruce Leff, MD, of Johns Hopkins, David Levine, MD, MPH, of Harvard and co-authors whose article on the topic was published April 23 in JAMA. 

“HaH brings key elements of hospital care—physician, nursing and other clinical team members; diagnostics, therapeutics and technology—to patients’ homes,” they write. “Compared with brick-and-mortar care in multiple trials, HaH is associated with lower rates of hospital-associated complications, better patient and family member care experience, lower postacute health service utilization and lower costs.”

The team underscores that the waiver extension presents an opportunity, not a definitive solution. 

Leff, Levine and colleagues lay out six issues still outstanding before HaH can be scaled for the benefit of patients and family caregivers across the country. In their own words: 

1. The field needs to iterate on HaH practice standards, standardize quality metrics and develop new quality assessment instruments. 

• For example, the Hospital Consumer Assessment of Healthcare Providers and Systems is not fully compatible with HaH care. 
   

2. Workforce development is required to scale HaH. 

• Unlike early in its development when HaH care was delivered by geriatricians, hospitalists have assumed a paramount role in HaH care delivery, yet are not commonly trained in home-based care; focused training on home-based acute care competencies and processes is needed. Other professionals, including nurses, will also require training. 
   

3. The next generation of caregiver support approaches needs to be developed.

• Family caregivers often play critical roles in HaH care, and research suggests that family caregiver experience in HaH is comparable to or better than brick-and-mortar care. 
   

4. Better regulatory alignment is needed between state and federal rules.

• The alignment needs to harmonize rules on home-based nursing, best practices for mobile integrated health paramedics and  oversight of pharmacy regulations—just to name a few issues.  
   

5. Under the waiver, observation-status patients are not eligible for HaH. 

• Allowing observation-status patients to be admitted to HaH and applying the same rules for conversion to inpatient status would allow patients the benefits of HaH care. 
   

6. Technologies of various types, including remote patient monitoring, have emerged as a ubiquitous feature of HaH care.

• We need to continue to iterate on these technologies and understand how to best leverage them. Additionally, although AI has been used in many programs to help evaluate eligibility for HaH, other applications are in their early stages.
   

“While brick-and-mortar hospitals remain necessary, what we treat in those facilities has evolved over time,” Leff, Levine et al. remark. “The hospital of the future will comprise emergency departments, operating rooms, intensive care and other highly specialized units. Much else can and should move to the home. HaH can lead us toward this future.”

CMS’s list of approved HaH facilities and systems, updated April 13, shows 364 certified sites across 137 health systems in 37 states.