Home hospital programs in rural areas see good results

In recent years, health systems have launched hospital-at-home programs, but they’re typically in urban or suburban areas.

But a new study of hospital-at-home programs in rural areas finds encouraging results. Researchers say the findings suggest expanding programs to deliver acute care at home can aid rural communities, where hospitals have struggled mightily in recent years.

Researchers from Mass General Brigham and Ariadne Labs performed the study, which was published this morning by Jama Network Open. They say it’s the first study to examine hospital-at-home programs in rural communities.

Researchers looked at patients with three rural hospitals and found those receiving care at home fared as well as those who were treated in brick-and-mortar hospitals.

David Levine, MD, clinical director of research & development at Mass General Brigham Healthcare at Home, tells Chief Healthcare Executive® that the study indicates hospital-at-home programs can be effective in rural areas. He says that’s important since most home hospital programs have been launched in cities and suburbs.

“That is the big reason we wanted to do this trial, and this study was to show the viability of home hospital in rural communities, in rural areas,” Levine says. “Because the vast majority of home hospital is urban. The research has been done in urban areas, the implementation has been done in urban areas for the most part.

“Of course, there's a few existing rural programs, but they are, by far, the outlier. And I think, part of that is because we don't have as much evidence in rural areas. And this will be the first randomized control trial to show that home hospital works in rural areas,” he says.

• Read more: Lawmakers push to expand hospital-at-home programs

Similarities in outcomes

Researchers looked at 161 adults who required inpatient care for conditions such as heart failure, chronic obstructive pulmonary disease, or asthma. They looked at patients at Blessing Hospital (IL), Hazard Appalachian Regional Healthcare Regional Medical Center (KY), and Wetaskiwin Hospital and Care Centre (Canada).

Some patients received acute care solely within the hospital, while others were moved into hospital-at-home programs after spending a short time in the hospital.

For those in hospital-at-home programs, nurses and paramedics visited patients in person twice a day, while a doctor or advanced practice provider saw the patients virtually once a day.

Those at home wore wireless stickers on their chests for monitoring, and some were given intravenous infusions.

Researchers said there were no significant differences in patient safety between the two groups, and readmission rates were similar between those who stayed in the hospital and those who received care at home.

Patients who were transferred from the hospital to treatment at home fared even better, Levine says.

In the study, some patients were transferred to the home hospital programs later, and Levine says it’s harder to see the benefits of treatment at home if someone has spent four days in a brick-and-mortar facility.

“When we looked at the patients who transferred earlier, we saw even better outcomes for those patients than we did among the entire cohort,” Levine says.

Patients at home showed more mobility, taking an average of 700 steps per day more than those in the hospital, the study found.

Levine says it makes sense that those living in homes with yards, or farms, would be more likely to want to move around a bit.

“In rural areas, we had some extraordinary anecdotes about patients being in just their gorgeous, gorgeous farms … and that goes a long way for healing,” Levine says. “Somebody's used to being out on their tractor or being with their horses, or, being in their beautiful rural area, versus having to be cooped up in a hospital room where you can sometimes be lucky to have a window. That's just miles apart.”

• Read more: Hospital-at-home and improving health equity

High patient satisfaction

Patients who received acute care at home demonstrated significantly more satisfaction, and Levine calls that a key finding in the study.

Using the net promoter score, home hospital patients provided a rating of 88.4, compared to 45.5 for patients in the hospital, according to the study.

“This honestly blew me away,” Levine says.

In previous research of home hospital programs in urban settings, patient satisfaction was comparable with those getting treated in brick-and-mortar facilities, Levine says. But there was much higher satisfaction for patients in rural home hospital programs.

“To me, that again, speaks to the cultural aspects of care in rural communities. It speaks to how we can use home hospital to tailor care to what a patient needs,” Levine says.

Researchers also found costs were 27% lower for those who received acute care at home, if they were transferred from the hospital after spending less than three days in the facility.

For those who were transferred to home hospital programs later, the costs were comparable. Levine says with later transfers, health systems tend to see less savings.

“It’s a good lesson for existing programs, for new startup programs, frankly, rural or urban, that transferring patients early should be a really big paradigm for programs,” Levine says. “It leads to better clinical outcomes. It leads to better cost outcomes. And so I think I wasn't surprised that patients who transfer early had savings. And honestly, I think it's a great lesson for our field.”

The rural hospitals running home hospital programs were challenged by limited staffing, which Levine says is also a challenge for urban health systems.

But Levine says the smaller teams operating rural home hospital programs worked extremely well together. He says the small rural teams, by necessity, communicate very well together and know how to craft innovative solutions to problems.

“It was such a tight-knit community,” Levine says. “And I think we saw that in how the teams worked together. I think we saw that on how the teams worked with patients. It was, it was definitely an aspect there.”

Other studies have found hospital-at-home programs have seen good results in patient safety. Researchers found low mortality and complications among home hospital patients, according to a study published by Annals of Internal Medicine in January 2024.

Hoping to spur more programs

Health systems in rural areas have faced severe financial hardships in recent years. More than 150 rural hospitals have closed since 2010, according to the American Hospital Association, and analysts have said hundreds more are at risk of shutting their doors.

Levine says he hopes more health systems, including those in rural areas, will look to develop hospital-at-home programs. He says expanding acute care into the home could help address the healthcare crisis in rural communities.

“I really do think the data support that, really, this can be a big game changer for rural communities, particularly rural communities that may have lost their brick-and-mortar hospital,” Levine says.

“I think the data here speak for themselves on the quality and the safety that was delivered, and the costs of the care as well,” he says. “And so I really do think that taken all together, this does demonstrate the viability of rural home hospital.”

Nationwide, 147 health systems, and a total of 419 hospitals, are approved to provide acute care at home, and those programs are operating in 39 states, according to federal data.

However, some health systems that have considered establishing hospital-at-home programs haven’t moved forward because of concerns about federal support, the American Hospital Association says.

Telehealth and hospital-at-home programs were disrupted during the federal government shutdown, since short-term waivers for such programs expired. They were extended as part of the short-term spending package to reopen the government, but they only last until Jan. 30, when the spending legislation expires.

Kyle Zebley, senior vice president of public policy for the American Telemedicine Association, told Chief Healthcare Executive® in an October interview that the lack of predictability in telehealth policy has deterred health systems from setting up hospital-at-home programs.

The association and other healthcare groups have been pressing President Trump and Congress for permanent reforms, at least multi-year extensions of telehealth waivers.

“Large healthcare systems, small ones, large hospitals, rural and local hospitals, alongside Medicare providers in their practices and provider groups, they want to make wise choices with the limited dollars they have, and you want to make those investments in areas that will be around for a while,” Zebley said.

Levine says he’s seen strong legislative support for hospital-at-home and telehealth programs. He says he hopes that Congress and the Trump administration will sign off on lasting reforms.

“I completely understand some of my colleagues on the other end who don't have a program yet, or are really challenged when this thing starts and stops,” Levine says. “And so I totally get that. It is a big, big big issue preventing others from entering into the field.”

However, Levine also points to the development of the federal government's new $50 billion Rural Health Transformation Program. The government will distribute the money to states over the next five years, and Levine said the study could offer some guidance to states in creating new programs.

"States could probably use the data to help inform building out the rural home hospital infrastructure in their state, especially states that have lost lots of hospitals," Levine says.