Today, the Centers for Medicare & Medicaid Services (CMS) outlined unprecedented comprehensive steps to increase the capacity of the American health care system to provide care to patients outside a traditional hospital setting amid a rising number of coronavirus disease 2019 (COVID-19) hospitalizations across the country. These flexibilities include allowances for safe hospital care for eligible patients in their homes and updated staffing flexibility designed to allow ambulatory surgical centers (ASCs) to provide greater inpatient care when needed. Building on CMS’s previous actions to expand the availability of telehealth across the nation, these actions are aimed at allowing health care services to be provided outside a hospital setting while maintaining capacity to continue critical non-COVID-19 care, allowing hospitals to focus on the increased need for care stemming from public health emergency (PHE).
“We’re at a new level of crisis response with COVID-19 and CMS is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” said CMS Administrator Seema Verma. “With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond.”
Acute Hospital Care at Home
In March 2020, CMS announced the Hospitals Without Walls program, which provides broad regulatory flexibility that allowed hospitals to provide services in locations beyond their existing walls. Today, CMS is expanding on this effort by executing an innovative Acute Hospital Care At Home program, providing eligible hospitals with unprecedented regulatory flexibilities to treat eligible patients in their homes. This program was developed to support models of at-home hospital care throughout the country that have seen prior success in several leading hospital institutions and networks, and reported in academic journals, including a major study funded by a Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI).
The development of this program was informed by extensive consultation with both academic and private sector industry leaders to ensure appropriate safeguards are in place to protect patients, and at no point will patient safety be compromised. CMS believes that treatment for more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols.
Participating hospitals will be required to have appropriate screening protocols before care at home begins to assess both medical and non-medical factors, including working utilities, assessment of physical barriers and screenings for domestic violence concerns. Beneficiaries will only be admitted from emergency departments and inpatient hospital beds, and an in-person physician evaluation is required prior to starting care at home. A registered nurse will evaluate each patient once daily either in person or remotely, and two in-person visits will occur daily by either registered nurses or mobile integrated health paramedics, based on the patient’s nursing plan and hospital policies.
CMS anticipates patients may value the ability to spend time with family and caregivers at home without the visitation restrictions that exist in traditional hospital settings. Additionally, patients and their families not diagnosed with COVID-19 may prefer to receive care in their homes if local hospitals are seeing a larger number of patients with COVID-19. It is the patient’s choice to receive these services in the home or the traditional hospital setting and patients who do not wish to receive them in the home will not be required to.
The program clearly differentiates the delivery of acute hospital care at home from more traditional home health services. While home health care provides important skilled nursing and other skilled care services, Acute Hospital Care at Home is for beneficiaries who require acute inpatient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis.
To support these efforts, CMS has launched an online portal https://qualitynet.cms.gov/acute-hospital-care-at-home to streamline the waiver request process and allow hospitals and healthcare systems to submit the necessary information to ensure they meet the program’s criteria to participate. CMS will also closely monitor the program to safeguard beneficiaries by requiring hospitals to report quality and safety data to CMS on a frequency that is based on their prior experience with the Hospital At Home model.
Six health systems with extensive experience providing acute hospital care at home are being approved today for the new waivers and include Brigham and Women’s Hospital (Massachusetts); Huntsman Cancer Institute (Utah); Massachusetts General Hospital (Massachusetts); Mount Sinai Health System (New York City); Presbyterian Healthcare Services (New Mexico); and UnityPoint Health (Iowa). This immediately expands the at-home care options for Medicare beneficiaries in the regions served by these organizations. CMS has been in discussions with other health care systems and expects new applications to be submitted.
Ambulatory Surgical Center Flexibility
As part of Hospital Without Walls, CMS also previously announced regulatory flexibility that allowed ASCs – facilities that normally provide same-day surgical care – the ability to be temporarily certified as hospitals and provide inpatient care for longer periods than normally allowed, with the appropriate staffing in place. ASCs are normally subject to a requirement that patients only remain in their care for less than 24 hours or require admission to a regular hospital.
Today, CMS is announcing an update to that regulatory flexibility, clarifying that participating ASCs need only provide 24-hour nursing services when there is actually one or more patient receiving care onsite. The program change provides ASCs enrolled as hospitals the ability to flex up their staffing when needed and provide an important relief valve in communities experiencing hospital capacity constraints, while not mandating nurses be present when no patients are in the ASC. The flexibility is available to any of the 5732 ASCs throughout the country seeking to participate and will be immediately effective for the 85 ASCs currently participating in the Hospital Without Walls initiative. CMS expects this flexibility will allow these and additional ASCs enrolled as hospitals to serve as an added access point that will allow communities to maintain surgical capacity and other life-saving non-COVID-19, like cancer surgeries. Allowing these types of treatments to occur in designated ASCs enrolled as hospitals while hospitals are managing any surges of COVID-19 would allow vulnerable patients to receive this needed care in settings without known COVID-19 cases.
Today’s announcement builds upon the critical work by CMS to expand telehealth coverage to keep beneficiaries safe and prevent the spread of COVID-19. CMS has expanded the scope of Medicare telehealth to allow Medicare beneficiaries across the country to receive telehealth services from any location, including their homes. CMS also added over 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid when delivered by telehealth. The flexibilities announced today, and the aggressive action taken by CMS to remove barriers to telehealth, ensure patients and providers have options when receiving and providing care given the challenges and additional stress placed on hospitals and the health care system during the COVID-19 PHE.
To view the Acute Hospital Care At Home initiative and application, please visit: CMS’: https://qualitynet.cms.gov/acute-hospital-care-at-home
For more on the ambulatory surgical center flexibilities, please see: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/guidance-processing-attestation-statements-ambulatory-surgical-centers-ascs-temporarily-enrolling
To view comments from health systems participating in the Acute Hospital Care at Home, please visit: https://www.cms.gov/files/document/what-are-they-saying-hospital-capacity.pdf