Health systems now have a five-year reimbursement runway for the federal Acute Hospital Care at Home waiver, ending years of uncertainty. That stability shifts the conversation from whether to adopt the model to how to build and scale it effectively.
The Five-Year Runway Changes the Conversation
Dr. David Levine, an associate professor of medicine at Harvard Medical School and clinical director of research and development for Mass General Brigham Health Care at Home, moderated a webinar discussing this shift. He said health systems that previously stayed on the sidelines because they could not justify building a substantial program without knowing how long reimbursement would last are now asking practical questions about vendors, staffing models, and technology infrastructure.
Levine noted that building a Hospital at Home program can take six to 12 months, particularly for organizations without existing home-based care infrastructure. The five-year reimbursement horizon provides more than financial stability; it gives organizations time to make the investments required to build a real service line. This distinction matters because Hospital at Home requires an operational model, a clinical workforce, and technology infrastructure rather than being a simple technology toggle.
Workforce May Be the Biggest Scaling Challenge
Healthcare professionals generally are not trained for hospital-level care in the home. Hospital at Home requires clinicians who can work more independently and bring a broad set of generalist skills into the home. The challenge involves recruitment, but it also requires developing new skills for this model of care.
Levine said his team is working on studies to develop specific curricula for clinicians who have never been trained in Hospital at Home. Some organizations are already treating it as a core service line, rotating physicians, nurse practitioners, and physician assistants between traditional hospital care and home care. If Hospital at Home becomes part of the mainstream delivery model, it also needs to become part of the mainstream healthcare workforce.
The Technology Has to Work for the Patient
Technology is central to Hospital at Home, but the goal is not to deploy more technology. Programs may use remote patient monitoring, virtual visits, communications capabilities, and connections to the electronic health record, but those tools must be designed around patients using them.
Levine offered a simple example of a usability failure. Some programs send a blood pressure cuff into the home but require an older patient to take the reading and manually enter the result into a tablet. For an 80- or 90-year-old patient, that can become a significant barrier. He sees greater potential in passive data capture, where devices transmit information directly to the clinical team, but truly usable passive systems designed for older adults and people with lower digital health literacy remain limited. The technology must connect with the EHR, clinicians, pharmacy, laboratory, and imaging, which can require custom interfaces, testing, and cybersecurity work.
Don’t Start With the Technology
Levine emphasized that the proportion of patients who can be cared for safely at home is often overstated. He estimated that perhaps 25% of all-comers to a medical unit could be appropriate for Hospital at Home today, with that figure potentially reaching 50% in the next few years, but not 100%. He recommended starting with the patient population rather than the technology. “Hotspotting” can help leaders understand where patients live, how far they are from the hospital, their acuity, transfer rates, and other characteristics. The basic question should be: What problem are we trying to solve, and which patients would benefit most?
Despite the challenges, the evidence base is substantial, with dozens of randomized controlled trials. But evidence that a model works does not automatically tell health systems how to implement it successfully. Implementation science becomes increasingly important to explain why some programs grow while others remain small.
Quality and Safety Concerns
Questions from the webinar audience focused on practical concerns. One audience member asked why staffing would remain an issue if a hospital uses a vendor. Levine noted that vendors can provide services such as remote patient monitoring or delivering food, but those services do not eliminate the underlying clinical workforce requirements.
Another audience member raised a quality and safety question: If a hospital is already struggling with physician and nurse vacancies or operational backlogs, why should patients trust that organization to deliver hospital-level care safely at home? Levine emphasized that under the Acute Hospital Care at Home waiver, care delivered at home falls under the same quality and safety monitoring jurisdiction as brick-and-mortar hospital-level care. The larger point is that Hospital at Home needs to be treated as hospital-level care, not a lesser version of it.
Liability was another concern. Could greater reliance on technology and virtual interactions create additional litigation risk? Levine said that to date, malpractice insurers have covered Hospital at Home care in the same way they cover brick-and-mortar hospital care and have not seen an increase in liability. The fundamentals of clinical judgment still apply: the right level of care for the right patient at the right time.