The Business Case and the Scaling Challenge

Published: April 8, 2025
Author: Greg Wahlstrom, MBA, HCM
Focus: Economic viability, clinical governance, staffing, and strategic implications for scaling care at home.

Hospital-at-Home Hits the Tipping Point

The hospital-at-home (HaH) model has matured from novelty to necessity in 2025, driven by post-pandemic capacity limits, patient preferences, and payer interest. According to a 2024 MedPAC report, over 250 health systems now operate hospital-at-home programs—yet fewer than 15 have reached true scale. Despite $5 billion in private and federal investment, many programs remain pilots or fragmented service lines. The challenge is no longer proving concept efficacy; it’s scaling sustainably. As Dr. Stephen Parodi of Kaiser Permanente puts it, “We know this works clinically—we’re still figuring out if it works as a business.” Two examples illustrate the tension. At Mass General Brigham, patient outcomes have equaled or exceeded inpatient benchmarks, but staffing costs remain prohibitive. Meanwhile, AdventHealth in Florida has adopted a risk-sharing model with payers that funds HaH episodes at 90% of DRG rates. Undeniably, we’ve reached an inflection point.

At scale, HaH promises significant cost savings, better patient experience, and reduced hospital-acquired complications. Yet without systemwide alignment in financing, regulation, and technology, the model may remain elite and limited. In our own article, “Cost, Value, and Growth: What CFOs Are Watching in 2025”, we noted that payers and CFOs remain cautious about reimbursements for services outside traditional bricks-and-mortar facilities. That same hesitancy shows up in CMS’s temporary Acute Hospital Care at Home waiver, currently extended but not permanent. As such, executives must prepare for multiple reimbursement scenarios, from bundled payments to direct contracting. “Without payment parity, HaH won’t scale—it’ll stratify,” warned Dr. Bruce Leff, the model’s early architect at Johns Hopkins. Therefore, fiscal predictability must anchor the next phase of expansion.

The question isn’t just “Can it scale?”—it’s “Who will it leave behind if it does?” Equity and access challenges have already surfaced. In rural areas, broadband connectivity and workforce shortages limit HaH feasibility. For urban Medicaid patients, stable housing, caregiver support, and digital literacy remain barriers. Programs like Mount Sinai’s Mobile Acute Care Team and Atrium Health’s hospital-at-home pilots have had to adapt intake criteria and care pathways for underserved populations. According to a recent Commonwealth Fund brief, equity-focused HaH programs require 30% more upfront investment but deliver improved outcomes for vulnerable populations. Therefore, executives must pursue inclusive design from day one. Otherwise, hospital-at-home will become healthcare’s next great disparity. Thus, scale without equity is failure in disguise.

Economic Viability—From Pilot to Platform

For hospital-at-home to scale, it must evolve from a grant-funded initiative to a self-sustaining platform with durable returns. Executives need to rethink the financial model—not just add remote visits to traditional fee-for-service billing. According to a 2025 report by Health Affairs, systems that treat HaH as a service line lose margin, while those that treat it as a platform gain strategic leverage. Take Contessa Health, now a joint venture under Amedisys, which partners with health systems to create full risk-bearing HaH programs. Similarly, Mayo Clinic has embedded HaH into its digital infrastructure, treating it as a systemwide care model, not a niche product. “If we don’t redesign around the economics, we’re not scaling—we’re subsidizing,” said Dr. Margot Savoy of the American Academy of Family Physicians. Thus, viability requires integration, not just replication.

Many systems continue to face cost friction due to duplicative staffing, uneven logistics, and fragmented reimbursement. Traditional DRG-based models often fail to cover the ancillary costs of HaH—including courier diagnostics, remote monitoring devices, and home infusion services. At Northwell Health, leaders restructured budget lines to shift capital from brick-and-mortar expansion to home-based operations, aligning with value-based care priorities. One CFO noted that internal financial dashboards had to be rewritten entirely to track ROI by episode and geography. Revenue cycle leaders must now reconcile payer contracts, staffing ratios, and capacity shifts across virtual and physical infrastructure. In our article, “The CEO’s Guide to Value-Based Care in 2025”, we explored how risk-sharing arrangements can unlock sustainable scale for HaH. Accordingly, long-term viability demands internal redesign as much as external reform.

Examples of economic redesign are gaining traction. Emory at Home partnered with DispatchHealth to create a shared-services HaH model across Georgia, centralizing logistics and reducing per-episode costs by 17%. Meanwhile, UnityPoint Health reallocated unused inpatient capital to fund HaH transition units and mobile command centers. Both examples show that smart financial engineering can outperform grant dependency. “The question isn’t whether it works—it’s whether we’ve made room for it to work,” said Dr. Patrick Conway, former CMS Innovation Center director. In other words, platform thinking—not patchwork budgeting—defines the next phase of HaH expansion.

Staffing the New Clinical Frontier

Even with economic alignment, hospital-at-home will collapse without scalable staffing models. The labor needed to operate HaH programs is distinct—not just fewer people, but different people with new skills. HaH requires clinicians trained in both acute care and autonomous in-home decision-making. In 2025, there’s no such thing as a “hospital-at-home nurse” pipeline. Monmouth Medical Center reported onboarding times for HaH clinicians averaging 4.5 months, due to limited cross-training in home-based diagnostics, portable EHRs, and teletriage workflows. Similarly, Michigan Medicine emphasized that remote rounding requires clinical judgment shaped by mobile constraints. “We’re not just sending nurses home—we’re sending hospitals home,” said Dr. David Levine of Brigham Health. Therefore, staffing is not just deployment—it’s reinvention.

To address the gap, some systems have created dedicated clinical career ladders for HaH. UCHealth introduced a hospital-at-home certification pathway with stepwise competency modules in home oxygen titration, virtual rounding, and asynchronous communication. Similarly, Mount Sinai collaborated with nursing schools to create simulation-based rotations in HaH protocols. These initiatives build not only capacity but commitment. “HaH careers won’t happen by accident—they must be architected,” noted Dr. Linda Aiken. Internal flexibility is also critical: respiratory therapists, dietitians, and pharmacists must be HaH-literate and available through centralized dispatch systems. Therefore, talent strategy must evolve from shift coverage to skill reconfiguration.

Examples from outside health systems offer additional insight. Medically Home, which now powers dozens of HaH programs nationwide, leverages virtual command centers staffed by nurse navigators and hospitalists across time zones to provide 24/7 oversight. Similarly, Heal, a consumer-facing platform, uses algorithm-driven routing to optimize physician dispatch based on acuity and geography. These hybrid models demonstrate that staffing at scale requires both human adaptability and tech infrastructure. As we noted in “From Burnout to Belonging: Redesigning the Healthcare Workplace in 2025”, workforce satisfaction and innovation are intertwined. Consequently, HaH staffing strategy must become a cornerstone of leadership—not an afterthought.

Clinical Governance in a Decentralized Model

As hospital-at-home expands, one of the most pressing challenges is how to govern clinical quality and patient safety across decentralized environments. Traditional hospital governance relies on centralized oversight—physical rounds, unit-based policies, and real-time incident reporting. HaH disrupts this model by fragmenting oversight across homes, vendors, and virtual platforms. “It’s like managing an ICU with invisible walls,” said Dr. Meena Seshamani, Director of CMS’s Center for Medicare. At Cedars-Sinai, governance teams had to redesign escalation protocols for patients receiving remote telemetry monitored by nurses in a different zip code. Likewise, Atrium Health embedded clinical governance liaisons into their HaH command center to maintain practice consistency. These structural adaptations are essential, as decentralized care can dilute accountability if not governed proactively. Thus, decentralized care must be matched with distributed accountability.

Standardization of care protocols is essential for governance. Leading systems are adapting acute care guidelines to fit home-based constraints, such as smaller physical assessments, fewer labs, and reliance on real-time vital sign streaming. At Intermountain Health, clinicians follow a “home rounds matrix” that dictates triage thresholds, home visit frequency, and escalation criteria. Cleveland Clinic developed a multidisciplinary HaH oversight committee that includes ethics, safety, pharmacy, and infection control. These governance bodies meet weekly to audit deviations, review clinical pathways, and recommend policy updates. As we emphasized in “Developing Effective Leadership Skills for Healthcare Executives”, shared governance structures must evolve with care models. Accordingly, clinical governance must migrate with the patient—not remain confined to campus.

Technology can enhance governance when embedded intentionally. At Providence, AI-assisted rounding software flags outliers in vitals, medication adherence, and patient-reported symptoms. At OSF Healthcare, remote patient monitoring tools are integrated into the EHR for real-time quality dashboards visible to the CMO. These tech-enabled layers allow governance teams to see HaH trends across hundreds of patients without being physically present. “We don’t need more policies—we need smarter visibility,” said Dr. Neil Calman, CEO of the Institute for Family Health. Governance, therefore, must evolve from static compliance to dynamic surveillance rooted in trust, data, and human judgment.

Technology Infrastructure as the New Bedrock

Hospital-at-home programs rise or fall based on technology infrastructure. From broadband availability to device integration, the tech stack is no longer supportive—it is foundational. In many cases, the home becomes a virtual ward with multiple device endpoints: pulse oximeters, EKGs, IV infusion pumps, and video triage tablets. Systems like Viz.ai and Butterfly iQ have made portable diagnostics viable—but they require interoperability, training, and broadband bandwidth. “Connectivity is now as important as clinical staffing,” said Dr. Christine Cassel of the National Academy of Medicine. This is especially urgent in underserved communities, where digital redlining compounds health disparities. As outlined in “Green Hospitals: Leading the Way in Climate-Conscious Healthcare”, sustainability and digital equity must intersect in modern infrastructure planning. Therefore, tech strategy must be written into capital plans—not bolted on after launch.

Cloud-based command centers now anchor the operational spine of HaH. These virtual hubs coordinate logistics, monitor clinical status, communicate across care teams, and escalate emergencies. At Trinity Health, the command center functions as a 24/7 digital unit with its own nurse manager, respiratory therapist, and pharmacist—staffed similarly to an inpatient telemetry floor. Medically Home’s model incorporates cloud-based physician dispatching, automated patient risk scoring, and device integration for over 30 conditions. These systems reduce failure-to-monitor events and increase response time by 28%, according to internal audits. Technology must be designed for care continuity—not just surveillance. Consequently, digital architecture must be treated as clinical infrastructure.

Security and data governance must also mature alongside scale. HIPAA compliance is no longer enough; HaH requires end-to-end encryption, secure telemetry, consent management, and user authentication across patient-facing devices. At Mass General Brigham, patients receive individualized digital onboarding sessions covering privacy, navigation, and escalation. Hackensack Meridian Health partnered with a cybersecurity firm to conduct simulated attacks on its HaH tech stack, identifying vulnerabilities in Bluetooth-connected peripherals. As discussed in “Securing the System: What Executives Need to Know About Healthcare Cyber Threats”, cyber readiness is now an executive function. Therefore, tech leadership must sit at the strategy table—not in the basement.

Regulatory Risk and Policy Volatility

Despite its growth, hospital-at-home remains tethered to fragile policy scaffolding. The CMS Acute Hospital Care at Home waiver, first introduced in 2020, has been extended multiple times but remains temporary. In 2025, over 120 HaH programs operate under the waiver with no guarantee of permanency. “We’re innovating on a rug that could be pulled out at any moment,” said Dr. Kavita Patel of Brookings. This precarious footing deters investment and complicates long-term planning. The AHA and AMA have both lobbied for permanent authorization and expanded reimbursement models. At Mercy, executives report delaying capital upgrades due to regulatory uncertainty. Policy volatility isn’t just a barrier—it’s a destabilizer. Therefore, healthcare leaders must advocate aggressively to solidify regulatory foundations.

State policy also varies widely. While Arizona and Utah have passed HaH reimbursement parity laws, many states lack any regulatory framework. At UCHealth, cross-county HaH deployment was delayed by inconsistent credentialing and telehealth rules. Similarly, BayCare Health faced zoning and transportation issues that prevented home-based IV services in some municipalities. Policy fragmentation results in service deserts—even within the same state. Systems need public affairs teams to monitor and shape state-level rulemaking proactively. As discussed in “The 2025 Regulatory Roadmap”, regulatory strategy must be owned by the executive team—not outsourced to compliance. Accordingly, systems must treat policy risk as a strategic variable—not a footnote.

Public-private partnerships may hold the key to stabilization. Moving Health Home, a national coalition, has aligned over 50 organizations—including Amazon Care and Humana—to lobby for HaH as a core Medicare benefit. The Commonwealth Fund has called for CMS to create an Innovation Pathway that accelerates reimbursement for virtual-first care models. These partnerships can amplify executive voice and reduce isolation. “We need to speak with one industry voice or we’ll be ruled by a patchwork chorus,” said Seema Verma, former CMS administrator. Trust, scale, and permanence go hand in hand. Therefore, regulatory strategy must evolve from defensive posture to policy entrepreneurship.

Redefining Patient and Family Experience

Hospital-at-home fundamentally reorients the patient experience—from institutional dependence to domestic empowerment. Yet this transition is not universally positive. While many patients prefer recovery at home, others report anxiety over reduced in-person interaction and unclear escalation pathways. A 2024 Joint Commission survey found that 23% of HaH patients were uncertain whom to contact during complications. At Mount Sinai, clinicians redesigned discharge instructions and implemented 24-hour hotline support staffed by hospitalists. Sutter Health introduced a “virtual whiteboard” accessible via tablet, displaying team names, scheduled visits, vitals, and medication reminders. “We must treat homes like clinical ecosystems—complete with transparency and tools,” said Dr. Adrienne Boissy, Chief Medical Officer at Qualtrics. Therefore, patient-centered design must extend to domestic environments.

Family caregivers also experience mixed outcomes. While some appreciate the continuity and flexibility of HaH, others report burnout from additional responsibilities like medication administration and symptom tracking. At Cedars-Sinai, caregiver satisfaction scores lagged 18 points behind patient scores, prompting the addition of remote caregiver coaching sessions and respite referrals. Johns Hopkins incorporated structured daily debriefs between caregivers and HaH coordinators. As highlighted in “Trust as a Strategic Asset”, engaging caregivers proactively enhances transparency and loyalty. Ultimately, the HaH experience must be co-designed with families, not delivered to them. Thus, empathy must shape every interface.

Examples of high-impact patient experience innovation abound. Boston Medical Center introduced social determinants assessments at HaH admission and embedded social workers into virtual rounds. Health Leaders reports that this model reduced emergency transfers by 12% among high-risk patients. Similarly, Northwell Health launched a post-HaH “transition coach” program that guides patients through follow-up, medication reconciliation, and home safety assessments. “Trust is built not only by who shows up—but who stays connected,” noted Dr. Toyin Ajayi of Cityblock Health. Therefore, patient and caregiver experience is not peripheral—it is the core outcome of HaH success.

Capital Planning and Facility Transformation

Scaling hospital-at-home requires a reallocation of capital from buildings to platforms. Many hospital boards still view growth through a traditional lens—new towers, expanded wings, and upgraded ICUs. Yet in 2025, some of the most strategic capital investments are digital: logistics platforms, command centers, virtual care architecture, and mobile diagnostics. At Rush University Medical Center, leadership paused a $120 million expansion to reallocate $18 million toward HaH infrastructure. OSF Healthcare launched a “digital-first” facility planning committee that ranks ROI not only by square footage but by operational elasticity. “HaH isn’t a threat to brick-and-mortar—it’s a release valve,” said Dr. Sachin Jain of SCAN Group. Thus, capital planning must become clinically agnostic and operationally agile.

HaH also creates new demands for supply chain strategy. Portable equipment, medication kits, wearable monitors, and mobile lab units must be ordered, maintained, and delivered within tight windows. At Providence, the supply chain team redesigned delivery routes and vendor contracts for same-day dispatch. Trinity Health added warehouse-based HaH staging units to support high-volume hubs. These innovations blur the line between logistics and clinical care. In “AI in the C-Suite”, we explored how automation tools can drive smarter capital allocation and route optimization. Accordingly, facility strategy must integrate mobility, modularity, and measurable care transformation.

Two compelling examples show what facility transformation can look like. Cleveland Clinic converted a vacant outpatient pavilion into a centralized virtual hospital to anchor HaH operations, complete with teleICU pods and EMS coordination bays. Corewell Health (formerly Spectrum) redesigned unused urgent care space into HaH launch stations stocked with home diagnostic kits and dispatch vehicles. These conversions reduce overhead while increasing throughput. “Capital strategy should reflect care trends, not construction trends,” said Dr. Michael Apkon of Tufts Medicine. Therefore, facility transformation must follow clinical demand—not historical precedent.

Health Equity and Inclusion at Scale

Without intentional design, HaH could deepen existing disparities. Data from KFF shows that broadband access, housing stability, and home caregiving capacity are unequally distributed—precisely the infrastructure HaH depends on. Systems that ignore these disparities risk building a model that excludes the most medically vulnerable. At RWJBarnabas Health, eligibility screens for HaH now include social risk indicators, triggering resource referrals before enrollment. UCHealth provides mobile hotspot kits and multilingual orientation videos to ensure HaH isn’t biased toward the digitally fluent. “Equity is not a constraint—it’s a design principle,” said Dr. Kamillah Wood, Senior Fellow at Health Leads. Therefore, HaH expansion must include social architecture.

Culturally responsive staffing is equally critical. Language barriers, privacy concerns, and cultural norms can all impact the safety and acceptability of home-based care. At Children’s Hospital Los Angeles, bilingual HaH care teams are paired with patients based on language and geography. Montefiore employs CHWs as HaH liaisons, building trust in underserved neighborhoods. These models increase engagement and reduce escalation. As explored in “Inclusive Succession Planning Strategies”, leadership at all levels must reflect the communities served. Consequently, equity must be embedded—not appended.

Health systems are beginning to track equity KPIs in HaH reporting. Baystate Health publicly shares HaH outcome data by race, payer type, and ZIP code. Yale New Haven Health uses equity dashboards in weekly HaH governance meetings to review outreach, enrollment, and clinical outcomes. These practices allow leaders to course correct in real time. “Equity is a metric—not a metaphor,” said Dr. Rachel Hardeman, health equity researcher at the University of Minnesota. Therefore, scaling HaH must scale inclusion with it.

Executive Strategy for Scaling What’s Next

Hospital-at-home is not just a care delivery model—it’s a test of executive vision, infrastructure fluency, and moral leadership. Scaling HaH requires hospital CEOs and boards to think beyond episodic volume and embrace longitudinal value. It means redefining growth not by beds added but by admissions avoided, days at home gained, and disparities narrowed. At Mayo Clinic, hospital-at-home is now part of the system’s annual strategic roadmap, reviewed quarterly alongside margin and mortality metrics. At Sutter Health, the HaH expansion plan includes full P&L projections, policy risk modeling, and ROI by social determinant. “This isn’t a program—it’s a commitment,” said Dr. Bruce Leff. Therefore, leadership must treat HaH like an investment in the future of care—not a workaround for yesterday’s capacity.

System-wide integration is essential. From EHR alignment to workforce development, executives must scale HaH as part of the core business—not a bolt-on pilot. As discussed in “The Great Health System Shakeup”, successful health systems in 2025 are agile, tech-enabled, and partnership-driven. At Trinity Health, HaH is embedded into post-acute pathways, value-based care contracts, and staff promotion criteria. AdventHealth integrated HaH into its population health dashboard, with equity-weighted ROI metrics reported to the board. “You don’t scale services—you scale systems,” said Dr. Bob Wachter of UCSF. Therefore, scaling HaH must be a whole-organization commitment.

The $5 billion question is not whether hospital-at-home can scale—it’s whether executive leaders will choose to make it scale equitably, ethically, and sustainably. The answers will shape the next generation of hospital care—and determine whether health systems remain trusted, transformative anchors in the communities they serve. Because in the end, scaling care at home is not about disrupting hospitals—it’s about returning healing to where it began.