Hospital at Home Leaders Map Three Paths to Equitable Care

Hospital at home, the model that delivers acute hospital-level care in a patient’s own living room rather than on a hospital ward, has moved from a promising experiment to one of the fastest-growing innovations in American health care. Yet as programs multiply across the country, a quieter and more consequential question has been building behind the scenes: who actually gets to be treated at home, and who is left out? A new qualitative study published in the Journal of General Internal Medicine offers the most detailed picture to date of how the people running these programs think about equity, and the answer turns out to be more layered than a simple commitment to fairness. Researchers from the Icahn School of Medicine at Mount Sinai, along with collaborators at Brigham and Women’s Hospital, Harvard Medical School, Ariadne Labs, Johns Hopkins, and Dispatch Health, interviewed the leaders of hospital at home programs and found that equity means distinctly different things depending on where a program stands in its evolution.

The research team, led by Abigail Baim-Lance and including veteran hospital at home researchers Linda DeCherrie, David Levine, Bruce Leff, and Albert Siu, purposively sampled programs to capture diversity in size, geography, and safety-net status. Between the interviews, they conducted 18 conversations with 28 leaders representing 15 hospital-based programs and three commercial operations, with roughly half of the participants coming from safety-net hospitals that serve disproportionately high shares of low-income and medically complex patients. Rather than relying on lengthy transcription-based coding, the team used rapid qualitative analysis, employing structured debrief templates and summaries with targeted coding to develop themes, a method increasingly validated for fast-moving health services research. They then organized the findings into a frame analysis, an approach borrowed from social science that examines how people conceptually structure a problem, because framing shapes what solutions seem possible.

What emerged were three complementary and non-mutually exclusive frames through which program leaders conceptualize equity in hospital at home. The first frame, which the researchers call Broaden HaH Access, focuses on the factors that limit or enable the establishment of programs in the first place, with the goal of reaching the broadest possible population. Leaders in this frame talked about the structural geography of the model itself: a hospital at home program that operates only in wealthy urban zip codes may deliver excellent care, but it reproduces the access gaps that already plague American medicine. Extending programs into rural areas, where the nearest hospital may be an hour away and where randomized trial evidence for home-based hospital care has only recently begun to accumulate, was described as a central equity strategy. In this view, equity begins with the map, not the bedside.

The second frame, Remove Barriers to HaH Enrollment, shifts attention from whether a program exists to who actually gets enrolled once it does. Here the leaders identified a cluster of socio-demographic factors that determine access in practice: insurance coverage, geographic reach, home safety and suitability, and the preferences of patients and their caregivers. Each factor comes with its own set of operational obstacles and its own targeted remedies. Payer mix emerged as a recurring concern, since programs dependent on commercial insurance or fee-for-service reimbursement can inadvertently filter out Medicaid beneficiaries and the uninsured. Leaders described strategies such as expanding payer mix to widen the door. Home environment posed another practical barrier, because hospital-level care at home presumes a home that can support it, complete with reliable utilities, space for equipment, and often a caregiver. Patient and caregiver preferences matter too; prior studies have documented that some patients decline hospital at home because they feel safer within hospital walls or worry about burdening family members, and leaders recognized that addressing those concerns is part of equitable enrollment rather than a marketing problem.

The third frame, Add Value by Addressing Disparities, is the most ambitious of the three. Rather than treating equity as a matter of spreading the model or fixing enrollment filters, leaders in this frame described hospital at home as an intervention that can actively mitigate pre-existing health and social challenges and improve longer-term outcomes for disadvantaged patients. This framing inverts a common criticism of home-based care, namely that it benefits the privileged who have stable housing and engaged families, and instead positions the model as a tool for reducing disparities themselves. The distinction matters analytically: broadening access and removing barriers aim to give disadvantaged patients the same opportunity to use hospital at home as everyone else, while the value frame aims to make the model work harder for those patients once they are enrolled, potentially narrowing gaps in readmissions, complications, and patient experience that traditional hospital care has not closed.

The technical foundation for this optimism is real, though the leaders’ framing analysis makes clear it is not automatic. Meta-analytic evidence dating back more than a decade has shown that hospital-in-the-home models can match or exceed traditional inpatient care on mortality and other outcomes, and more recent randomized controlled trials in the United States, including trials of remote versus in-home physician visits and pragmatic comparisons of hybrid hospital at home against conventional admission, have reinforced the safety and quality case. Studies of bundled hospital at home with post-acute transitional care have shown improved clinical outcomes and patient experiences, and analyses of economically disadvantaged versus non-disadvantaged patients within a mature program found comparable outcomes, an early signal that the model can deliver equitably when designed to do so. At the same time, research on individual- and community-level predictors of hospital at home outcomes, and on racial and ethnic differences in care escalation among COVID-19 patients treated in a home-based hospital, shows that disparities can emerge within the model if programs do not monitor for them.

The policy backdrop amplifies the stakes. The Centers for Medicare and Medicaid Services’ Acute Hospital Care at Home waiver program, launched during the COVID-19 public health emergency, allowed hundreds of hospitals to count home-based stays as inpatient care for payment purposes, and the program has grown to encompass hundreds of approved facilities and systems. CMS has reported on the initiative’s early national experience, and the program’s future depends on congressional action to extend the waiver. That growth has occurred alongside persistent questions, raised in health policy journals and by multistakeholder analyses, about whether hospital at home will narrow or widen disparities depending on how programs are designed, staffed, and paid. The new study’s contribution is to show that the leaders running these programs are not passive with respect to those questions; they hold articulated, differentiated theories of what equitable hospital at home would look like.

The framing lens itself carries weight in the study’s argument. Drawing on a tradition of scholarship showing that how institutions frame a condition or a problem shapes the social patterning of health and the coping strategies of those affected, the authors argue that the three frames are not merely descriptive categories but operational commitments. A program that sees equity primarily through the access frame will invest in rural expansion and new market entry. One that sees it through the enrollment frame will audit its referral pathways, examine which patients decline and why, and adjust eligibility practices. One that sees it through the value frame will build in social work support, caregiver training, and post-discharge follow-up targeted to patients facing housing instability, food insecurity, or limited health literacy. The frames are complementary, and the authors suggest that clarifying and aligning them, then matching targeted improvements within and across frames, can enhance the ability to deliver comprehensive, equitable care as the model continues to grow.

The study arrives at a politically complicated moment. Federal executive action in early 2025 directed agencies to end diversity, equity, and inclusion programs, and health equity language has become contested terrain in American public life, even as government accountability reports continue to press the health system on reducing spending and enhancing value. The researchers note that the leaders they interviewed demonstrated a practical, operational understanding of equity-related issues regardless of the terminology used, focusing on concrete barriers like payer restrictions, geographic coverage, home safety assessment, and caregiver burden. That pragmatism may be the study’s most transferable lesson: equity in hospital at home, as its leaders describe it, is less a slogan than a set of engineering problems, each with identifiable constraints and testable solutions. As hospital at home scales toward mainstream status, the programs that thrive may be those that treat all three frames as simultaneous obligations, building the map, opening the door, and then making sure the care delivered on the other side of that door genuinely closes the gaps it was meant to address.

Subject of Research: How hospital at home program leaders conceptualize and operationalize health equity in acute home-based care

Article Title: Leadership Perspectives on Hospital at Home and Equity: Broadening Access, Removing Enrollment Barriers, and Adding Value by Addressing Disparities

Article References: Baim-Lance, A., Perez, S., Gorbenko, K., Nnemnbeng, J. F., Hart, J., Howard, B., DeCherrie, L. V., Levine, D. M., Leff, B., & Siu, A. L. (2026). Leadership Perspectives on Hospital at Home and Equity: Broadening Access, Removing Enrollment Barriers, and Adding Value by Addressing Disparities. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10841-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10841-5

Keywords: hospital at home, health equity, disparities, qualitative research, framing analysis, safety-net hospitals, health policy, acute care, enrollment barriers, rural access, value-based care, Journal of General Internal Medicine