The Growth Imperative, Part 1: The CEO’s Perspective (Why Hospital-at-Home is a Strategic Necessity)

Part of a Series on "The Growth Imperative for Hospital-at-Home"

In the high-stakes arena of hospital administration, CEOs navigate an array of complex- and sometimes competing- priorities. Success as a Hospital CEO is gauged on measures like 3%+ operating margins, 30-day readmissions below 15%, top 25% HCAHPS scores, and nurse turnover less than 20%. These objectives are, as one CEO put it to me, “[the] numbers that dictate our strategy and determine my survival.”

Amidst these pressures (and the strain of a global pandemic), hospital-at-home emerged as an innovative care model with the potential to deliver big results across each of these dimensions. But it also requires big investments- of time, money, energy, and political capital. Over the course of my conversations with four hospital Presidents/CEOs, they painted a picture for me of the hospital of the future. A hospital with bricks and mortar but also with telehealth, rapid logistics, and other capabilities to extend out into the community. Hospital-at-home has the potential to significantly advance core objectives but achieving the potential requires a clear-eyed approach to overcoming innovation hurdles and the perseverance to grow into a core component of the hospital's services.

Financial Performance and Defending Margins in a Shifting Economy

The financial vise on hospitals tightens daily as they manage headwinds from multiple directions. An aging Baby Boomer generation saddled with chronic diseases requires resource-intensive and capacity-straining treatments. In parallel, disruptive threats looms as new entrants aggressively explore ways to further unbundle hospitals and eat into their revenue streams. “Payers spend more on inpatient care than anything else and they are looking for openings to chip away at that,” observed one system President, underscoring this threat. Hospital-at-Home presents a strategic countermeasure. By shifting acute care delivery to the home—a setting where early data suggests per-episode costs can be 20-30% lower—Hospital-at-Home offers a potential lever to retain patients in a way that may not be easily replicated by new entrants.

“Payers spend more on inpatient care than anything else and they are looking for openings to chip away at that."

But the potential alone doesn’t pay the bills and the gap between investment and return can be stark. “We committed eight figures to launch this initiative,” one CEO said, “but we’re seeing an average daily census of eight patients—that math doesn’t work.” Growing the program is essential to recoup those upfront costs. By scaling patient volume—say, from a census of eight up to 25 patients daily—hospitals can spread fixed costs like technology and training over more cases, dropping the per-patient overhead. Higher utilization also maximizes staffing and equipment investments, pushing the program past breakeven to profitability. Only through this kind of expansion can the promise of lower per-episode expenses deliver a sustainable return, transforming a financial sinkhole into a viable business case.

Hospital-at-Home also plays a role in value-based care arrangements, which more hospitals are being pressured to enter into with payers. By managing acute care in the home, it strengthens a hospital’s ability to meet pay-for-performance metrics- like reducing readmissions- by tailoring care plans and easing the transition post-discharge. Hospital-at-Home also preserves the patient relationship by meeting patients where they are, countering payers’ direct-to-consumer pushes that threaten to cut hospitals out. “They see an angle to bypass us, and they’re moving,” one system President warned, highlighting recent payer acquisitions of home health agencies and physician practices. As another CEO put it, “In a value-based world, if we can’t manage the full spectrum of care, these deals become all sticks and no carrots,” reinforcing how hospital-at-home secures both patient loyalty and strategic leverage in a competitive market.

The Bottom Line: If hospital-at-home remains niche or boutique, the financial consequences are clear. Hospitals risk being saddled with the escalating costs on their inpatient infrastructure while simultaneously losing volume—and revenue—as payers and patients migrate to lower-cost alternatives. Margins erode further, negotiating power with payers diminishes, and CEOs are left wrestling with shrinking budgets and a weakened competitive posture.

Quality and Clinical Outcomes Beyond Hospital Walls

Hospital-at-home elevates clinical quality by delivering personalized, home-based care that can improve patient outcomes. Through continuous monitoring, seamless follow-up in the patient’s home environment, and addressing social determinants, hospital-at-home tackles key metrics like 30-day readmission rates. Studies suggest Hospital-at-Home can reduce readmissions by up to 25%, thanks to fewer hospital-acquired infections (like MRSA), more ambulation, and lower stress levels that speed recovery. “It’s simple: patients recover better at home, and they feel better about their care,” a CEO explained. By alleviating pressure on inpatient beds, hospital-at-home also indirectly supports quality initiatives across the hospital, freeing resources for other critical cases.

However, demonstrating quality improvement hinges on the breadth and depth of impact. Small-scale efforts, like a pilot to improve discharge planning for 50 heart failure patients, might modestly lower readmissions by impacting a small subset of the patient base. In contrast, hospital-at-home holds the potential for significant and broad impact across 30%+ of a hospital’s inpatient population. “We have many quality-focused 'experiments' in play, and many show promise. But they’re usually small and incremental...nothing on the same scale as a brand new home hospital”, said one leader. Realizing the full benefit requires planning on a similarly large scale which can include standardizing equipment, thoroughly training staff for remote care delivery, and carefully coordinating logistics. True transformation requires moving hospital-at-home from the periphery to the core, and determining for which patients home-based care should be the standard.

When scaled effectively, hospital-at-home positions hospitals as clinical quality leaders, enhancing reputation and market influence. High-quality outcomes—like top-quartile readmission rates or improved HCAHPS scores—align with value-based care goals, strengthening payer negotiations and patient trust. Unlike non-hospital competitors, who may lack the clinical rigor of a hospital-backed program, hospital-at-home cements hospitals as the quality leaders. “Launching is the easy part. The real work is in the execution—scaling it, integrating it, and demonstrating a tangible impact on overall quality,” one CEO stressed. Success here sets a hospital apart in a competitive, value-driven landscape, turning quality into a strategic edge.

“Launching is the easy part. The real work is in the execution—scaling it, integrating it, and demonstrating a tangible impact on overall quality,”

The Bottom Line: Hospital-at-home’s impact on clinical quality can be game-changing if the benefit reaches enough of the right patients. Persistently high readmission rates signal breakdowns in care transitions, risking payer penalties, regulatory scrutiny, and eroded trust. Failure to grow high-potential new offerings like hospital-at-home leaves CEOs managing quality gaps that jeopardize rankings, accreditation, and reputation.

Meeting Patient Expectations Head-On

High patient satisfaction, often captured by HCAHPS scores, serves as a differentiator for hospitals who can meet the needs of diverse patients. Hospital-at-home drives satisfaction among patients who desire receiving care at home. "The unifying theme is that patients mostly want to get out [of the hospital] whenever possible." one CEO noted, a desire cutting across aging Baby Boomers' trust in hands-on care and younger, digitally-native patients' push for tech-driven experiences. Hospital-at-home acts as a virtual hospital alongside the physical one, letting systems tailor the setting: inpatient for those needing more oversight, home with telehealth for those who don't. “It’s like we’re operating two hospitals under one roof,” a CEO said, and the optionality has boosted satisfaction scores to 80%+ by matching patients to their preferences and not forcing a single mold.

That satisfaction edge hinges on being able to absorb my patients as word gets out. Patients share their experiences and quicker recoveries with convenient, home-based care may fuel demand for hospital-at-home. Subscale programs or those with hard census caps may not keep up, leaving some stuck in brick-and-mortar when they’d rather be home. “We're betting on patients voting with their feet while the other hospitals around us are slower to move,” a CEO said. Hospitals slow to adopt and grow hospital-at-home could lose patients to competitors with more options, especially for frequent flyer conditions that fill well with this model. This drift risks dragging HCAHPS scores down, eroding loyalty, and fraying referral networks, all while demand outpaces supply.

The Bottom Line: For CEOs, the inability to scale Hospital-at-Home risks a diminished market position and a growing disconnect with evolving patient expectations, ultimately portraying the hospital as failing to keep pace in the delivery of patient-centered care.

Reimagining Roles to Stabilize the Workforce

Hospital-at-home offers a new option in the battle for talent, particularly nursing talent, where turnover rates hover around 20% amid persistent shortages. “We’re bleeding experienced nurses, and the pipeline isn’t refilling fast enough,” one CEO stated bluntly. By shifting care to the home, hospital-at-home creates roles that appeal to clinicians seeking less physically demanding work, greater autonomy, and chances to work at the top of their license. This flexibility draws both aging nurses looking for respite and younger, tech-savvy clinicians eager to leverage telehealth and remote monitoring. Hospitals can pitch this as a recruitment edge: promising variety and purpose to lure talent and stem the tide of departures.

Making this model a retention win hinges on scaling it thoughtfully to match staff enthusiasm. Nurses often relish the autonomy and patient connection of home-based care, but subscale programs limit how many can escape the inpatient grind. “For years, we’ve tried to solve the staffing crisis linearly: by just trying to get more nurses. That approach is failing,” one CEO reflected. “We must accept we’ll be doing more with potentially fewer, and definitely different, types of clinical teams”. Growing hospital-at-home lets nurses split time between high-acuity wards and the virtual ward, blending challenge with reward. Training for these dual roles fosters engagement, but without scale, hospitals risk overworking a small team as patient demand rises, undermining satisfaction. One system saw turnover for hospital-at-home nurses drop by half, proving the payoff of getting it right.

“For years, we’ve tried to solve the staffing crisis linearly: by just trying to get more nurses. That approach is failing”

A scaled Hospital-at-Home program stabilizes the workforce, bolstering resilience and care delivery. Lower turnover keeps seasoned staff in place and saves on recruitment costs which can be over $50k per FTE. Satisfied nurses become ambassadors, drawing peers to a hospital known for retention, while stability strengthens payer trust and referral networks. Without this, burnout accelerates, driving a vicious cycle of shortages and departures. “If we don’t create viable alternatives, we risk losing staff faster than we can replace them".

The Bottom Line: Hospital-at-home can turn the tide on workforce woes, but only if scaled effectively. A stagnant or subscale program leaves hospitals trapped in a losing battle—bleeding talent, inflating costs, and straining care delivery—while a robust one redefines roles, retains staff, and positions CEOs as leaders in a labor-scarce future.

Conclusion: The Imperative to Grow

In the messy trenches of hospital leadership, hospital-at-home represents a unique opportunity to reshape care delivery. It's a pathway to stronger finances, better outcomes, happier patients, and a steadier workforce. Hospital CEOs agree: acute care's future stretches beyond the hospital's four walls, into patients' homes and communities. The task isn't just seeing this potential, it's acting to make it real. For those who push hospital-at-home to grow, it becomes a tool to manage today's pressures and shape tomorrow's successes.