National Daily Hospital News
Executive Briefing Monday November 17th, 2025
Global & Health Sector Headlines – Hospital-at-Home, Telehealth Cliff, and Capacity
News – Medicare Hospital-at-Home waivers lapse amid shutdown, threatening capacity.
Congress allowed key health care “extenders” to expire on September 30, 2025, including Medicare’s Acute Hospital Care at Home (AHCAH) initiative, forcing CMS to instruct hospitals to discharge or bring patients back to brick-and-mortar beds and stop new waiver admissions — raising the risk of crowding as flu/RSV/COVID volumes build. Politico+2Axios+2
https://bipartisanpolicy.org/article/medicares-acute-hospital-care-at-home-initiative-lapses-amid-shutdown/News – Hospital-at-Home and telehealth face a looming “policy cliff.”
The National Consortium of Telehealth Resource Centers warns that without Congressional action, key flexibilities for Medicare telehealth and Hospital-at-Home will expire (or remain lapsed), rolling back home-based acute and virtual care and re-imposing pre-pandemic rural and originating-site limits that reduce access and strain hospitals. Telehealth Resource Centers+1
News – CMS national AHCAH study: hospital-at-home delivers lower mortality and strong quality.
CMS’s 2024 Report to Congress on the Acute Hospital Care at Home initiative found that Medicare beneficiaries treated at home had lower mortality than similar inpatients, comparable or better quality outcomes, and positive patient and caregiver experience, reinforcing Hospital-at-Home as a safe, high-value capacity strategy. Centers for Medicare & Medicaid Services+1
https://www.cms.gov/newsroom/fact-sheets/fact-sheet-report-study-acute-hospital-care-home-initiativeNews – AHA presses for a five-year Hospital-at-Home extension.
The American Hospital Association’s July 2025 fact sheet calls for passing the Hospital Inpatient Services Modernization Act (H.R. 4313 / S. 2237) to extend the Hospital-at-Home waiver through 2030, emphasizing that H@H has been extended three times already and is now scheduled to expire Sept. 30, 2025 without further Congressional action. American Hospital Association
https://www.aha.org/fact-sheets/2024-08-06-fact-sheet-extending-hospital-home-programCase Study – Medicaid-focused evidence roundup highlights Hospital-at-Home gains and patchy uptake.
A July 2025 Center for Health Care Strategies evidence roundup reports that as of April 2025, 398 hospitals in 39 states held AHCAH waivers, but only 12 state Medicaid agencies were paying for Hospital-at-Home, even as evidence shows lower mortality, similar or better outcomes for Medicaid and dually eligible enrollees, and strong patient experience. Community Health Center Network
https://www.chcs.org/resource/hospital-at-home-for-medicaid-enrollees/Case Study – Hospital-at-Home saves lives and lowers post-discharge spending.
An AMA summary of the CMS AHCAH evaluation reports that Hospital-at-Home patients had lower mortality across all top 25 MS-DRGs, lower post-discharge Medicare spending, and fewer hospital-acquired infections than matched inpatients, with mixed but generally favorable 30-day readmission patterns. American Medical Association+1
https://www.ama-assn.org/public-health/population-health/hospital-home-saves-lives-and-money-cms-reportRecommendation – Treat Hospital-at-Home as core surge capacity, not a side project.
Taken together, AHA advocacy, CMS evaluation, and state/Medicaid experience suggest that Hospital-at-Home should be integrated into core capacity and safety planning — not treated as a temporary pandemic one-off — with hospitals actively planning for payer mix shifts if Medicare fee-for-service support remains unstable. American Hospital Association+2Community Health Center Network+2
Hospital Transitional Care and Post-Stay Follow-Up – TCM, Clinics, and Telehealth
News – Transitional Care Management (TCM) visits cut 30-day readmissions.
A 2025 PLOS One study from Northwell Health found that patients receiving transitional care management visits within two weeks of discharge had 26% lower 30-day unplanned readmissions (HR 0.74; 95% CI 0.63–0.88) compared with non-TCM follow-ups, and that providers who frequently use TCM codes see additional reductions in readmissions. PLOS
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0316892News – Outpatient follow-up visits reduce readmissions for high-risk conditions.
A 2024 CDC “Preventing Chronic Disease” meta-analysis of U.S. studies found that timely outpatient follow-up after hospitalization for heart failure, COPD, MI, or stroke was associated with a 21% relative reduction in 30-day all-cause readmissions (pooled OR/HR 0.79; 95% CI 0.69–0.91), with particularly strong benefits in heart failure. CDC
https://www.cdc.gov/pcd/issues/2024/24_0138.htmCase Study – Transitional care clinics for patients without primary care (New Case Study).
An August 2024 NEJM Journal Watch review of transitional care clinics for recently discharged patients without an established PCP reports that these clinics may prevent ED visits and readmissions in high-risk populations by providing short-interval access, medication reconciliation, and linkages to longitudinal primary care. JWatch
https://www.jwatch.org/na57807/2024/08/29/do-transitional-care-clinics-patients-without-primary-careCase Study – Telehealth-focused transition-of-care programs (New Case Study).
A 2025 protocol published in JMIR Research Protocols describes a telehealth-enabled transition-of-care model for multimorbid patients, designed to reduce 3-month readmissions by combining remote monitoring, virtual visits, and structured handoffs between inpatient and ambulatory teams — highlighting how virtual tools can be systematically embedded into transitions rather than used ad hoc. Research Protocols+1
https://www.researchprotocols.org/2025/1/e71847/Recommendation – Standardize TCM and early follow-up as a default for high-risk discharges.
The emerging evidence base supports institutional policies that default high-risk discharges (e.g., sepsis, HF, COPD, frail older adults, complex multimorbidity) into a TCM or transitional care clinic pathway with scheduled follow-up within 7–14 days, supported by telehealth when in-person visits are not feasible. Research Protocols+3PLOS+3CDC+3https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0316892Recommendation – Align Hospital-at-Home, TCM, and telehealth policy strategies.
Given the simultaneous uncertainty about AHCAH waivers and telehealth reimbursement, hospitals and health systems should explicitly connect their Hospital-at-Home, telehealth, and transitional care programs into a single strategy and advocacy agenda, rather than letting each program fight for survival separately. CDC+4Telehealth Resource Centers+4Bipartisan Policy Center+4 https://telehealthresourcecenter.org/resources/the-telehealth-policy-cliff-preparing-for-october-1-2025/
Early Morning Briefing Highlights
Hospital-at-Home is a proven capacity and quality strategy with lower mortality and strong patient experience, but Medicare’s AHCAH waiver has lapsed amid the federal shutdown, injecting major uncertainty into hospitals’ home-based acute care programs.
Telehealth and Hospital-at-Home sit on a “policy cliff,” with expiring flexibilities that could sharply curtail home-based and virtual care access for Medicare beneficiaries if Congress does not act.
Transitional Care Management and structured outpatient follow-up are now backed by solid evidence showing meaningful reductions in 30-day readmissions for high-risk conditions.
Transitional care clinics and telehealth-enabled transition programs are emerging as practical, scalable models to protect access and reduce readmissions for patients without strong primary care linkages or with complex multimorbidity.
Strategic leaders should treat Hospital-at-Home, TCM, and telehealth as one integrated “post-discharge platform,” not as isolated pilots, and align governance, metrics, and advocacy accordingly.
Strategic Implications for Leadership
Capacity and LOS management:
With AHCAH waivers lapsed, hospitals may lose a flexible “safety valve” for medical inpatients just as respiratory season peaks; leaders should model how many inpatient days were shifted to home settings and identify contingency plans if that volume returns to the bricks-and-mortar hospital. Bipartisan Policy Center+1Financial risk and payer mix:
AHCAH and telehealth policy uncertainty particularly affects Medicare FFS and Medicaid patients, while many hospitals continue Hospital-at-Home via Medicare Advantage and commercial payers — potentially worsening equity and payer-mix gaps if public programs are not stabilized. Community Health Center Network+2Bipartisan Policy Center+2Readmissions, penalties, and margins:
Strengthening TCM and early follow-up directly supports Hospital Readmissions Reduction Program performance and can protect margin by preventing high-cost readmissions in heart failure, COPD, MI, stroke, and sepsis survivors. PLOS+2CDC+2Equity and access for patients without primary care:
Transitional care clinics and telehealth transitions can help close gaps for patients who are uninsured, under-insured, or disconnected from primary care, reducing avoidable ED visits and readmissions that disproportionately affect marginalized populations. JWatch+2PMC+2Advocacy and external relations:
Hospital and health system leaders have a narrow window to influence federal and state policy on Hospital-at-Home and telehealth; joining AHA and state hospital association advocacy around H@H extensions and telehealth flexibilities is now a core operational strategy, not just a policy “nice to have.” Politico+3American Hospital Association+3Telehealth Resource Centers+3
Quality Metrics to Share with Your Team (≤ 7)
398 hospitals, 39 states in AHCAH (as of April 2025).
CMS had approved 398 hospitals in 39 states for Acute Hospital Care at Home waivers, though participation varied, demonstrating substantial but uneven uptake of Hospital-at-Home nationwide.
https://www.chcs.org/resource/hospital-at-home-for-medicaid-enrollees/419 hospitals affected by AHCAH lapse.
By September 2025, 419 hospitals across 39 states had AHCAH waivers and were instructed to discharge or transfer Medicare/Medicaid FFS Hospital-at-Home patients back to brick-and-mortar care when the program lapsed on September 30, 2025.
https://bipartisanpolicy.org/article/medicares-acute-hospital-care-at-home-initiative-lapses-amid-shutdown/Hospital-at-Home mortality advantage.
The CMS AHCAH evaluation found that Hospital-at-Home patients had lower mortality than matched inpatients across all top 25 MS-DRGs, with statistically significant differences for 11 of those DRGs, and lower post-discharge spending.
https://www.cms.gov/newsroom/fact-sheets/fact-sheet-report-study-acute-hospital-care-home-initiativeTCM visit effect on 30-day readmissions.
In the Northwell Health PLOS One study, TCM follow-up visits were associated with a 26% reduction in 30-day unplanned readmissions (hazard ratio 0.74; 95% CI 0.63–0.88) compared with non-TCM visits.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0316892Outpatient follow-up meta-analysis effect size.
A CDC systematic review and meta-analysis found that timely outpatient follow-up after discharge for heart failure, COPD, MI, or stroke was associated with a 21% relative reduction in 30-day all-cause readmission (pooled OR/HR 0.79; 95% CI 0.69–0.91).
https://www.cdc.gov/pcd/issues/2024/24_0138.htmHeart failure subset: 27% readmission reduction with follow-up.
Within the same meta-analysis, heart failure–specific studies showed a 27% reduction in 30-day readmissions (OR/HR 0.73; 95% CI 0.55–0.95) with early outpatient follow-up.
https://www.cdc.gov/pcd/issues/2024/24_0138.htmPolicy timing risk – Telehealth and H@H “cliff” date.
Telehealth policy analysts highlight September 30, 2025 as the key date when pandemic-era telehealth flexibilities and Hospital-at-Home waivers either expired or risk expiring, creating a “policy cliff” that could sharply curtail home-based and virtual care without further Congressional action.
https://telehealthresourcecenter.org/resources/the-telehealth-policy-cliff-preparing-for-octorber-1-2025/
Leadership Call to Action (≤ 5)
Map your Hospital-at-Home exposure and contingency plan.
Build a one-page briefing for your C-suite and Board quantifying how many admissions, bed-days, and high-risk DRGs have been managed via Hospital-at-Home over the past 12–24 months, and model what happens to ED boarding, LOS, and diversion rates if those patients must return to inpatient beds.
https://www.cms.gov/newsroom/fact-sheets/fact-sheet-report-study-acute-hospital-care-home-initiativeIntegrate TCM into standard discharge workflows for high-risk patients.
Make TCM or equivalent structured follow-up the default for discharges with heart failure, COPD, MI, stroke, sepsis, and complex multimorbidity, with scheduling built before discharge and supported by telehealth where needed.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0316892
https://www.cdc.gov/pcd/issues/2024/24_0138.htmStand up or strengthen a Transitional Care Clinic model.
For patients without a reliable PCP or with fragmented care, develop a transitional care clinic that guarantees short-interval (7–14 day) follow-up after discharge, with a clear handoff protocol into long-term primary or specialty care.
https://www.jwatch.org/na57807/2024/08/29/do-transitional-care-clinics-patients-without-primary-careAlign advocacy with AHA and state hospital associations on H@H and telehealth.
Direct your government relations team to align with AHA and state associations in advocating for a multi-year Hospital-at-Home extension and preservation of telehealth flexibilities — emphasizing local data on bed capacity, ED boarding, readmissions, and patient experience.
https://www.aha.org/fact-sheets/2024-08-06-fact-sheet-extending-hospital-home-program
https://bipartisanpolicy.org/article/medicares-acute-hospital-care-at-home-initiative-lapses-amid-shutdown/Treat Hospital-at-Home, TCM, and telehealth as one integrated “post-discharge platform.”
Charge a cross-continuum steering group (CNO, CMO, CFO, CIO, ambulatory/ACO leaders) with designing a unified post-discharge platform that integrates Hospital-at-Home, telehealth, TCM, and transitional care clinics — with shared metrics, equity goals, and a common analytics dashboard.
https://www.chcs.org/resource/hospital-at-home-for-medicaid-enrollees/
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