After several years of uncertainty around the federal Acute Hospital Care at Home waiver and a series of short-term funding extensions, health systems now have something they haven't had before: a five-year runway.

That changes the conversation. The question is no longer simply whether Hospital at Home is something health systems should explore. Increasingly, it is how they should build and scale it well.

That was the focus of the first webinar in Healthcare Innovation's Digital Health Intelligence Series, which I had the opportunity to moderate with Dr. David Levine, associate professor of medicine at Harvard Medical School and clinical director of research and development for Mass General Brigham Health Care at Home.

Our conversation, Hospital at Home at Scale: What 5-Year Stability Means for Health Systems, explored what the longer reimbursement horizon means for health systems, where the biggest challenges to scaling remain and what leaders need to think about before making the leap. One thing became clear: More certainty around reimbursement does not make Hospital at Home simple. It gives health systems the opportunity to take the model more seriously as a long-term part of their care delivery strategy.

The Five-Year Runway Changes the Conversation

Levine said he is hearing from health systems that had been interested in Hospital at Home for years but remained on the sidelines because they couldn't justify building a substantial program without knowing how long reimbursement would be available. Now, those organizations are asking more practical questions: Which vendors should they work with? What staffing model will they need? What technology infrastructure is required? And those aren't small questions.

Levine noted that building a Hospital at Home program can take six to 12 months, particularly for organizations that don't already have a strong home-based care infrastructure. The five-year reimbursement horizon therefore provides more than financial stability. It gives organizations time to make the investments required to build a real service line.

That distinction matters. Hospital at Home isn't simply another technology-enabled program that can be turned on. It requires an operational model, clinical workforce, technology infrastructure and connections to the broader health system.

Workforce May Be the Biggest Scaling Challenge

Of all the issues we discussed, workforce may have been the most striking. Healthcare professionals generally aren't trained for hospital-level care in the home. Hospital at Home requires clinicians who can work more independently and bring a broad set of generalist skills into the home.

The challenge isn't simply recruitment. Health systems also have to develop the skills required for this model of care. Levine said his team is working on studies to develop specific curricula for clinicians who have never been trained in Hospital at Home, something that could become increasingly important as programs grow.

Some organizations are already treating Hospital at Home as a core service line rather than a niche program, with physicians, nurse practitioners and physician assistants rotating between traditional hospital care and care in the home. If Hospital at Home becomes part of the mainstream delivery model, it also needs to become part of the mainstream healthcare workforce.

The Technology Has to Work for the Patient

Technology is central to Hospital at Home, but our conversation reinforced an important point: The goal isn't to deploy more technology. It is to make the care model work.

Programs may use remote patient monitoring, virtual visits, communications capabilities and connections to the electronic health record. But those tools have to be designed around the patients using them.

Levine offered a simple example. Some programs send a blood pressure cuff into the home but require an older patient to take the reading and manually enter the result into a tablet. For an 80- or 90-year-old patient, that can become a significant barrier.

He sees greater potential in passive data capture, where devices can transmit information directly to the clinical team. But truly usable passive systems designed for older adults and people with lower digital health literacy remain limited. Also, the technology can't operate in isolation. Hospital at Home also has to connect with the EHR, clinicians, pharmacy, laboratory and imaging. Those integrations can require custom interfaces, testing and cybersecurity work and may take six to 12 months to bring online. In other words, Hospital at Home technology isn't a standalone investment. It has to fit into the clinical and operational infrastructure that already exists.

The Evidence Is Strong. The Implementation Questions Are Growing.

Hospital at Home is not a new concept, and Levine emphasized that the evidence base is now substantial. He pointed to dozens of randomized controlled trials and described it as one of the most evidence-based care delivery innovations available.

But evidence that a model works doesn't automatically tell health systems how to implement it successfully. That is where implementation science becomes increasingly important. Why do some programs grow to serve large numbers of patients while others remain small years after launch? What organizational, workforce and operational factors explain those differences?

Those may ultimately be some of the most important questions as Hospital at Home moves from proving the concept to scaling it.

Don't Start With the Technology

One of the questions I wanted to ask Levine was what he thought might be getting overstated in the current enthusiasm around Hospital at Home. His answer was refreshingly direct: the proportion of patients who can actually be cared for safely at home.

There is a tendency to talk about Hospital at Home as though every medical patient could eventually be treated outside the hospital. Levine doesn't see it that way. He estimated that perhaps 25% of all-comers to a medical unit could be appropriate for Hospital at Home today, with that figure potentially reaching 50% in the next few years. But he stressed that it will not be 100%.

That is an important reality check. The opportunity isn't to eliminate the hospital. It is to give health systems another way to deliver hospital-level care when the home is the better setting for the patient.

For organizations considering a program, Levine recommended starting with the patient population rather than the technology. "Hotspotting" can help leaders understand where patients live, how far they are from the hospital, their acuity, transfer rates and other characteristics that may determine whether Hospital at Home is a good fit. The basic question should be: What problem are we trying to solve, and which patients would benefit most? And in return, the answer should shape the program.

Our Audience Had Questions, Too

The questions submitted during the webinar underscored just how practical the conversation around Hospital at Home has become.

One audience member asked why staffing would remain an issue if a hospital uses a vendor. Levine noted that vendors can provide services such as remote patient monitoring or delivering food to patients' homes, but those services don't eliminate the underlying clinical workforce requirements.

Another audience member raised an important quality and safety question: If a hospital is already struggling with physician and nurse vacancies or operational backlogs, why should patients trust that organization to deliver hospital-level care safely at home?

Levine emphasized that, under the Acute Hospital Care at Home waiver, care delivered at home falls under the same quality and safety monitoring jurisdiction as brick-and-mortar hospital-level care. The larger point is that Hospital at Home needs to be treated as hospital-level care, not as a lesser version of it.

Liability was another concern. Could greater reliance on technology and virtual interactions create additional litigation risk? Levine said that, to date, malpractice insurers have covered Hospital at Home care in the same way they cover brick-and-mortar hospital care, and he said they have not seen an increase in liability. The fundamentals of clinical judgment still apply: the right level of care for the right patient at the right time.

The business case also came up. For organizations facing reimbursement concerns, limited operational bandwidth and competing priorities, how do you justify the investment? Levine's answer was that there is no one-size-fits-all approach. Health systems should start by understanding their specific pain points and determining whether Hospital at Home actually addresses them. He also noted that many organizations have found the model to be a financially positive element of their overall strategy.

And finally, an audience member asked whether rehabilitation services such as PT, OT and speech therapy are part of the model. Levine said they are core capabilities because Hospital at Home needs to be able to provide the same services available to patients receiving hospital-level care in a traditional setting, even though not every patient will need those services.

What Will Separate the Health Systems That Scale?

Coming out of the conversation, I was struck by how little of the discussion was really about whether Hospital at Home "works." That question has largely been answered.

The harder questions are organizational. Can a health system build the workforce? Integrate the technology? Identify the right patients? Build the operational processes? Make the financial case? And do all of that without overselling what the model can realistically deliver? Those questions become even more important as the five-year reimbursement runway gives health systems permission to think longer term.

Levine expects many more programs to come online, particularly as organizations that had been waiting on the sidelines begin building. But he also sees a future in which Hospital at Home becomes less of an "innovation" and more of an expectation.

Looking toward 2028, he doesn't expect Hospital at Home to be the default treatment option yet. But he hopes the country will be approaching a tipping point where patients increasingly expect to have the option of receiving hospital-level care at home when it is appropriate for them.

That may be the bigger transformation underway. The future of Hospital at Home isn't about replacing the hospital. It's about expanding our definition of where hospital-level care can happen. And if health systems use the next five years wisely, the hospital may no longer be defined by a building.

Did you miss the webinar? You can view it on-demand here.

And be sure to sign up for the other webinars being offered through the Digital Health Intelligence Series.

Melinda Taschetta-Millane is Market Content Director of Healthcare Editorial, and Head of Content for Healthcare Innovation.