The Hospital-at-Home (HaH) waiver enables U.S. hospitals to deliver acute care in patients’ homes with equal reimbursement to inpatient services. Despite strong outcomes, cost savings, and patient demand, program expansion faces uncertainty amid delayed federal reauthorization. Sustained policy support and flexible technology partnerships are key to HaH’s long-term viability.
The Hospital-at-Home waiver1 created a path for hospitals in the U.S. to deliver acute care in a patient’s home and receive the same reimbursement as if that care happened inside the hospital. But nearly five years in, the fate of the model is in limbo, coming to a head just as the government shutdown stalls key health policy decisions.
At the same time, patient demand is high, early results are strong, and health systems across the country are joining the list of hospitals bringing care into the home. Interest alone doesn’t make the model easy to adopt. While the waiver outlines specific requirements, many hospitals, especially regional systems and those that aren’t large academic centers, are weighing whether the investment makes sense amid ongoing reimbursement uncertainty.
U.S. health systems have piloted versions of HaH for decades, and it’s long been part of care models in other countries. When the COVID-19 pandemic strained hospital capacity, CMS introduced the Acute Hospital Care at Home (AHCAH) waiver to safely care for patients at home who didn’t require intensive hospital services but still required acute-level care.
Prior to the waiver, roughly two dozen HaH programs existed2 across the U.S. Today, over 4003 hospitals have been approved to offer at-home care under the waiver. The waiver provides hospitals with a means to deliver acute care at home without compromising inpatient reimbursement. If a patient qualifies, the hospital receives the same Medicare payment4 it would for treating that patient in the hospital, based on the diagnosis and the level of care required.
The waiver, already extended three times5, is in limbo amidst the ongoing government shutdown. Legislation has been introduced to prolong the initiative through 20306, and major healthcare groups have voiced their support7. But with Congress at a standstill amid the government shutdown, the proposal’s future is on pause and is adding another layer of uncertainty for hospitals trying to plan ahead. The extensions bought hospitals time, but not certainty, leaving many still evaluating how, or if, they can make a long-term investment in HaH work.
Before delivering care under the waiver, hospitals must meet specific requirements8, including Medicare certification and a formal application to CMS. The federal agency categorises applicants based on experience9.
According to CMS, hospitals that have already treated at least 25 acute care at-home patients may follow an expedited process and attest to established safety protocols. These hospitals must report monitoring data monthly. Hospitals with less or no prior experience must submit more detailed documentation demonstrating their readiness to deliver hospital-level care at home and are required to report data weekly.
There are two common approaches to delivering this care, according to MedPAC’s 2024 report on the program10. Some hospitals begin by transitioning eligible patients from a brick-and-mortar stay to continue treatment at home, which is often called early supported discharge.
Others bypass a hospital stay entirely by admitting patients straight into the HaH program from the emergency department. Many hospitals start with the former to build familiarity and operational capacity before expanding to direct admissions.
To deliver care safely, hospitals must have the right infrastructure in place. CMS requires hospitals to have screening protocols11 to assess both medical and non-medical factors before care begins.
While the AHCAH program waives some of Medicare’s traditional hospital conditions of participation, it adds new standards specific to home-based care12, including two in-person visits per day by clinical staff. These visits are typically delivered by a registered nurse or a paramedic13, depending on the patient’s care plan. Each patient must also receive a daily evaluation14 from a physician or advanced practice provider, which can be conducted virtually or in person. According to MedPAC, AHCAH programs generally use virtual visits15 to deliver physician services.
According to CMS, hospitals must be able to respond to changes16 in a patient’s condition within 30 minutes. To maintain oversight, CMS requires hospitals to track and report data17 on patient volume, unanticipated mortality, and escalation events. Each hospital must also establish a local safety committee18 to review these metrics on an ongoing basis.
Patient eligibility is just as important. The waiver is designed to support individuals who require hospital-level care but are stable enough to receive it safely at home. According to CMS, the most common conditions19 treated under the AHCAH initiative include respiratory illnesses, heart disease, kidney issues, and infections.
Before admission to a HaH program20, each patient must be evaluated by a physician and must provide informed consent21 to receive treatment at home rather than in a brick-and-mortar hospital. Hospitals must also confirm that the home environment is safe and, in CMS’s words, “conducive to the provision of hospital-level care.”
In the years since the waiver’s rollout, multiple studies, from both providers and CMS, have shown that at-home care can deliver strong outcomes and lower costs. Mass General Brigham, one of the largest systems participating in the program, analysed outcomes for over 5,800 patients22 treated under the waiver with complex conditions such as heart failure, COPD, cancer, and dementia. Fewer than 1% died during their at-home care, which is lower than the 2% mortality rate typically reported across U.S. inpatient stays, according to CDC data23. Only 7% of patients required a return to the hospital for a stay longer than 24 hours.
A CMS review echoed those results24. HaH patients had lower 30-day mortality rates than those treated in hospitals across respiratory illness, heart disease, kidney issues, and infections. Readmission rates varied. They were lower for pneumonia and COPD, but higher for sepsis. Overall, quality and safety remained consistently high.
Costs were also lower. CMS tracked Medicare spending25 from the time of admission through 30 days post-discharge and found that HaH patients cost significantly less. Although they spent slightly more time in the acute phase, by less than a day on average, overall Medicare spending was about 20% lower. For common conditions like pneumonia, heart attacks, and sepsis, Medicare spent $1,000 to $3,300 less per case in the 30 days after discharge compared to traditional hospital stays.
While HaH programs continue to grow, they’re not expanding evenly. Many of today’s HaH programs are shaped by the needs of top-tier academic institutions and high-capacity systems, which can absorb early costs and partner with national vendors. But most hospitals in the U.S. operate with tighter margins, smaller teams, and fewer beds.
Many of today’s models rely on third-party vendors that bundle remote monitoring, software, logistics, and clinical staff. These packaged solutions can work when patient volume is high, but they often come with steep upfront costs and little room for customization.
Outsourcing every component can also lock hospitals into rigid structures that don’t reflect their clinical priorities or capacity. In some cases, vendors can price services so high that they absorb most of the CMS reimbursement, which leaves mid-sized and regional hospitals with little margin to support internal teams or infrastructure.
HaH is a multi-phase model26 that includes technology, workflows, staffing, and patient experience, all of which need to work together. Instead of outsourcing all components, hospitals can partner with tech providers that offer modular tools, like remote patient monitoring, EHR integration, and care coordination dashboards, without requiring them to buy into services they don’t need. That lets hospitals build programs that reflect their capacity and evolve over time.
Patients are ready for care at home. In a national Vivalink survey27, 84% of adults over 40 said they’d choose HaH if it meant returning home sooner, and nearly as many said they would trust their provider’s recommendation to do so. Despite ongoing policy uncertainty, the path forward is clear for many hospitals. The waiver criteria are established, the technology is available, and patient demand is strong. With the right partners and technology services, hospitals can begin delivering hospital-level care at home on their own terms and at their own pace.
Jiang Li, PhD, is the founder and CEO of Vivalink, Inc., a Silicon Valley company developing digital health technology solutions for remote patient monitoring in healthcare and clinical research. Before founding Vivalink, Jiang held leadership positions including Vice President of Engineering at Thin Film Electronics, Kovio, and Spansion, as well as Director of Product Engineering at Advanced Micro Devices (AMD). He earned his Bachelor of Science in Chemical Engineering from Zhejiang University and his PhD in Chemical Engineering from the University of Wisconsin at Madison in 1998.
