New Study Questions Lack of Rural Hospital at Home Programs

Researchers found that most health systems following the CMS Acute Hospital Care at Home model are large urban hospitals, and said the current model may not be sustainable for small or rural hospitals.

A new study of the Hospital at Home strategy questions whether it can stand up in rural areas and small hospitals, key markets for the innovative program’s growth and sustainability.

In a December 23 study posted in JAMA, researchers from UCLA and the University of Pennsylvania say almost all of the healthcare organizations participating in the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home (AHCAH) program are large, urban, not-for-profit and academic hospitals.

As of December 2024, 373 hospitals across 139 health systems in 39 states are following that CMS model, which includes a waiver enacted in 2020 to help participating hospitals receive Medicare reimbursement. The waiver was recently extended to March 31, 2025, and with CMS hinting that it will no longer grant extensions, supporters are lobbying Congress to make it permanent.

The implications of this latest study are that only large, well-resourced health systems can sustain a Hospital at Home program, leaving a significant percentage of the nation’s health systems and hospitals out in the cold. Yet advocates say this strategy, while complex, can save money and resources and improve clinical outcomes, all key metrics for any type of hospital.

“If CMS’ goal is to continue to expand hospital-at-home, these findings suggest that different incentives or outreach may be needed for smaller, rural, and non-teaching hospitals,” Hasham Zikry, MD, MS, an emergency medicine physician and clinical research fellow at UCLA Health and lead author of the study, said in a press release.

[Also read: No Going Home: Hospital at Home is a Hype Machine.]

(One notable exception is Sanford Health, which launched its CMS-approved AHCAH program in November 2024 targeting patients in rural communities around Fargo, North Dakota. The health system is currently targeting an annual daily census of five patients and hopes to bring that number up to 12 soon.)

Zikry and his fellow researchers, David Schriger, MD, of UCLA Health and Austin Kilaru, MD, MSHP, of the University of Pennsylvania’s Perelman School of Medicine, also cite two familiar criticisms of the Hospital at Home movement: That these programs haven’t yet proven their value, and that they don’t take into account the pressure put on patients and their caregivers at home.

“Are family members of these patients acting as unpaid caregivers during these admissions?” Zikry asked in the press release. “Could these patients do just as well in other care settings? Do patients actually prefer to be at home? And are health systems leveraging this program equitably?” 

In addition, he said: “Resources are being poured into these programs around the country, yet we still don’t have a comprehensive understanding of how the programs are functioning on the ground.” 

Many expect the Hospital at Home strategy to take a hit if Congress declines to extend the CMS waiver or make it permanent. Without Medicare reimbursement and a relaxation of certain telehealth rules, some health systems may end or cut back their programs.

That said, supporters are arguing for at least another extension so that participating health systems can gather the data needed to prove the concept’s value. The prevailing opinion among both supporters and critics is that the strategy needs more time to gather data to prove value.