RNs say ‘Home All Alone’ schemes put patients in grave danger  

California Nurses Association (CNA) is calling on California lawmakers to continue to reject any moves to facilitate Home All Alone programs, which permit hospitals to treat patients at home for conditions that require hospitalization for acute inpatient-level care. On Tuesday, May 2, the Assembly Health Committee will hold an informational hearing on these schemes where CNA will present its deep concern about the grave danger they present to patients.

“Nurses know it is impossible to provide the equivalent quality of hospital care to patients in their homes as these programs falsely claim to do,” said Cokie Giles, RN and CNA President. “When a patient requires hospital care, they require ongoing, in-person assessment and treatment by licensed health care professionals. In a hospital, patients have a wide variety of health care professionals who are available 24 hours a day, including doctors, registered nurses, respiratory therapists, pharmacists, and more. There is absolutely no way to duplicate this kind of care or the timely response that happens in a hospital in a home setting. We oppose the implementation of these schemes because we know these programs put patients' health at risk and can easily lead to poor outcomes, including death.”

“We heard from one nurse who briefly worked in one of these programs but quit because she said the care was quote ‘unethical’ and ‘dangerous’,” said Chris Nielsen, CNA’s assistant director of education. “The nurse was alarmed to find out that acutely ill patients were sent home with nothing but a watch that served as a call button, and a small tablet set up in the room where the patient spent the majority of their day. Furthermore, the nurse said vital checks were carried out just twice a day, by either paramedics or EMTs, and that the first could happen as late as noon. Patients could go up to 17 hours without being remotely accessed by a nurse, and unless a patient hit the call button, nurses would have no way of knowing if they were alive or dead. The nurse told us that the majority of a nurse's time was spent arranging for delivery of medication and delivery of care. The experience was so upsetting, the nurse reached out to us to share their story as a warning.”

• What: Informational hearing in Assembly Health Committee concerning Home All Alone Programs
• When: May 2, 2023 1:30-3:30 pm
• Where: 1021 O Street, Room 1100, Sacramento, Calif.
• A live stream of the hearing can be accessed here.

Nurses know this redefining of “hospitalization” is not driven by a desire to increase the health and well-being of patients, but rather to dramatically increase the profit margins for the hospital industry. These programs are part of a decades-long trend, intended to maximize industry profits, which has led to the steady reduction in the availability of acute inpatient services and hospital beds available in California and across the country. If Home All Alone programs are allowed to operate in California, it will allow the healthcare industry to push even more patients out of the hospital and further reduce acute care capacity across the state, which we know will exacerbate already widening health inequity.

“We have heard proponents of Home All Alone say these schemes could come to replace hospitals so that ‘hospitals ultimately being reduced to ERs, ORs and ICUs’ with the remaining space being sold off for commercial gain,” said Nielsen. “Since 2005, 192 rural hospitals have closed across the country. Between 1990 - 2022, there have been 137 urban hospital closures in California. These closures disproportionately affect communities of color. If the pandemic taught us anything it is that we need more hospital capacity not less, and that our patients of color are particularly at risk. We know that these Home All Alone schemes will accelerate the trend of closures in communities of color or in areas where many patients are dependent on government insurance.”

The federal “Acute Care at Home” program that provides a path for these schemes was established by the Trump Administration under a waiver outside the normal rulemaking process. These programs allow the hospital industry to capture windfall savings in labor costs and overhead by providing bare-bones care, while receiving inpatient-level reimbursement rates.

Last year, CNA and other patient advocates warned against previously proposed legislation that would have laid the groundwork for Home All Alone programs in California. At that time, CNA sent a letter of objection delineating the nurses’ strong opposition to these schemes. The union has also authored a comprehensive report outlining the dangers of these programs, and produced a short video describing nurses’ concerns.

Registered nurses are extremely concerned that the proliferation of Home All Alone schemes will create an undue burden on patients’ caregivers and family, especially women. The burden of this unpaid labor may not only lead to an increase in poor patient outcomes, but familial stress that could force caregivers to stop working or work less outside of the home, creating economic stress and instability.

“The pandemic has laid bare what nurses have long known: corporate greed and consolidation have created a health care system that does not have the capacity to care for all those who need it in our country,” said Giles. “We must address this issue at its core, with a deep look at who is making decisions about our health care in this country. Now is not the time to deteriorate care by pushing people out of the hospitals when they need hospitalization, but by creating a more robust, more accountable system that puts patients’ needs at its center.”

California Nurses Association/National Nurses United is the largest and fastest-growing union and professional association of registered nurses in the nation with 100,000 members in more than 200 facilities throughout California and nearly 225,000 RNs nationwide.