A $4.6 million grant from Massachusetts will help Mass General Brigham evaluate short-term skilled nursing in the home and could help payers determine whether the service is worth the expense.
Hospital-at-home technology and a small number of health systems offer home-based skilled nursing programs as a way to move patients more quickly into post-acute care, cut costs and reduce hospital readmissions. Those health systems include Cleveland Clinic, Mount Sinai, Allina Health and Marshfield Clinic.
Only a small number of private insurers cover the service under Medicare Advantage. Getting other payers on board, including fee-for service Medicare, has been a tough sell. Part of the problem is evidence to support such programs is not conclusive, according to researchers at Mass General Brigham. Depending on how its study of patients goes, that could change.
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In most at-home skilled nursing programs, nurses or paramedics make house calls once a day or just a few times over a period that lasts between five days and two weeks. They may provide wound care, draw blood or administer intravenous medication. Physical, occupational and speech therapists visit up to five times a week. Some programs supplement care with telehealth visits and remote patient monitoring through partnerships with hospital-at-home technology companies such as Medically Home, Contessa and Inbound Health.
Skilled nursing-at-home providers say expanding the programs hinges on payer reimbursement, but some researchers say more comprehensive evidence is needed to prove the programs are worthwhile.
Mass General Brigham piloted a skilled rehab-at-home program in 2019 with 10 patients. The pilot was popular with patients, but the Boston-based health system wanted wanted more proof the concept worked before expanding it, said Dr. David Levine, clinical director for research and development at Mass General Brigham’s Healthcare at Home program.
“That’s why I think this study is so important because we really don’t know if we should be doing this for patients,” said Levine, the study's principal researcher.
Mass General Brigham’s two-year evaluation will enroll 300 patients who need skilled nursing care after being discharged from five Boston-area hospitals. Patients will be split into two groups — half will receive short-term rehabilitation care at home and the other half will receive care in a skilled nursing facility. The grant will pay for the at-home skilled care and evaluate the overall cost, quality, safety and experience of delivering the care where they live.
“My big hope is that this trial is able to create the evidence base that then pushes the payment environment for rehab at home," Levine said.
Traditional fee-for-service Medicare won’t reimburse for the service and only a handful of Medicare Advantage plans and commercial plans will cover it through negotiated value-based contracts. Inbound Health, for example, negotiates contracts that reimburse at a fixed rate that is lower than the cost of a 30-day episode of care at a skilled nursing facility.
“It is essentially a rate that is traditionally somewhere between a traditional home health episode and what a traditional brick-and-mortar [skilled nursing] episode is,” said Inbound CEO Dave Kerwar.
Aetna does not reimburse for skilled nursing-at-home. In an email, a spokesperson said the company regularly evaluates its clinical policies regarding patient care. Other large health insurers, including UnitedHealthcare, Cigna and Centene did not respond to requests for comment on whether they reimburse for the service or are considering coverage.
Moving Health Home, a trade group that represents home-based care providers, is pushing for legislation that would cover the service under traditional Medicare.
“[Skilled nursing-at-home] is urgent because we have so many patients in hospital beds that don’t need to be there,” said Krista Drobac, the group's founder.
Some hospital systems with short-term rehabilitation programs said the initiatives have proven to be cost-effective and better for patients. Cleveland Clinic launched its Home Care Plus program in 2019 for patients enrolled in its accountable care organization. Some patients who received skilled nursing care at home recovered quicker than those who received care in a nursing home, said Dr. Jessica Hohman, accountable care president. A 30-day episode of home-based care costs about $5,000 less than a similar stay in a skilled nursing facility, she said.
Minneapolis-based Allina Health launched its Elevated Care at Home program in 2020 and has provided short-term rehabilitation care to more than 6,000 patients, said Dr. Emily Downing, the health system’s clinical officer for population health and continuing care. The hospital has seen a 60% reduction in emergency department visits among patients who received skilled nursing care at home compared with those who received facility-based care.
"We are seeing no signs that this is negative for patients and only signs that this is potentially positive for them," Downing said.
