Kansas City, Mo.-based Saint Luke's Health System plans to grow its hospital-at-home, already one of the biggest in the country, once more payers get on board with the care model, a leader told Becker's.

Becker's caught up with Michael Nassif, MD, medical director of Saint Luke's Hospital in Your Home, about what has changed about the program over the past year. The conversation has been lightly edited for clarity and brevity.

Q: In late 2023, we talked about census numbers. Your average daily census for hospital at home was about 10 patients, and now it's up to 12. Have you grown steadily?

MN: Yes, 2022 had 30 admissions per month, 2023 had 50, and 2024 reached 68 per month. We ended 2024 with daily censuses of 11-12. For 2025, the goal is 80 monthly admissions and a census closer to 15. Most of our admissions (97%) are Medicare or Medicare Advantage. We've had a promising UnitedHealthcare pilot with 80 to 90 patients but need a better payer mix. Talks with payers, including Missouri Medicaid, are ongoing.

The government's 90-day extension for CMS to cover hospital at home was crucial. We're hoping for a five-year extension to secure private contracts and expand services.

The Congressional Budget Office rated hospital-at-home as budget-neutral, making it favorable for extension. However, previous extensions were tied to less neutral programs like telemedicine. A five-year extension would help us negotiate contracts with payers and grow sustainably.

Q: For your health system, is the program budget-neutral?

MN: Not yet, but we aim for it by reaching a census of 15 to 16. It's labor-intensive, requiring three RNs and several paramedics daily. For St. Luke's hospitals, the goal is to free up bed capacity rather than generate profit.

Q: Are startup costs the main factor there?

MN: Yes, replacing hospital infrastructure with labor is costly. For example, nurse practitioners see fewer patients daily because of travel and longer visits. Home-based care reveals social challenges, like patients using gas stoves for heat. Addressing these adds complexity but improves outcomes.

Q: What was the initial investment for the program?

MN: It's in the millions. The program involves significant logistics, such as delivering IV antibiotics during snowstorms. We recently adjusted admissions during severe weather to prioritize patient safety.

Q: Do staff operate centrally or at hospital campuses?

MN: Staff are geographically focused, with hubs on hospital campuses. Cross-border logistics between Kansas and Missouri complicate centralization due to pharmacy regulations.

Q: Would a more diverse payer mix allow for growth?

MN: Yes. Currently, only 7-8% of eligible patients are admitted. Commercial payers could increase growth by 70-80%. Medicaid patients, despite complexities, would benefit significantly from this program.

Q: Are all your patients getting inpatient-level care under the CMS waiver?

MN: Yes, acute inpatient criteria. We previously piloted 30-day bundled care but paused due to insurance challenges.

Q: Is congestive heart failure still your most common diagnosis?

MN: Yes, followed by respiratory illnesses like COPD. We've expanded to perioperative patients and post-procedure monitoring.

Q: Has the technology used for the program changed?

MN: We've transitioned to Biofourmis for more customization, including telemetry patches and patient communication on personal devices.

Q: What's planned for this year?

MN: We aim to grow by 10% and expand to more assisted living and memory care facilities. Partnerships with private payers and VA plans are key for future growth.

Assisted living is ideal for hospital at home, but liability concerns and administrative barriers complicate partnerships.