Form CMS-10752 Acute Hospital at Home

CCN:
Type:
Reporter:
Hospital Name:
Has your
hospital provided
acute hospital
care at home
services to at
least 25 patients
since the
program's
inception:
How many
patients has your
Acute Hospital
Care at Home
hospital treated
who qualified for
inpatient hospital
admissions since
its inception:
Can your
hospital provide
acute care
services at home:
Explain how you
are able to meet
the pharmacy
needs of each
beneficiary.:
Detail your
processes and
protocols for
performing IV
push and IV
Piggyback
infusions.:

Explain how
respiratory care
will be delivered
to patients in
your hospital.
Please include
response times
and details
regarding the
availability of
oxygen delivery
and treatment,
nebulizer
treatment, and
any other
respiratory
services.:
What diagnostic
studies are
available to
patients while
hospitalized in
acute hospital
care at home:
Explain how you
will obtain and
deliver at least 2
sets of patient
vital signs daily
to a credentialed
provider of the
hospital team.
These include, at
a minimum,
Heart Rate,
Blood Pressure,
Respiratory
Rate, Oxygen
Saturation, and
Temperature.:

How will your
hospital
transport
patients between
the Emergency
Department and
their homes, and
back to the
hospital if
needed? Include
whether
transport is
provided by
ambulance, nonambulance
medical
transport, or
other means.:
How does your
hospital plan to
provide meal
services to
patients to
ensure the
availability of
meals as needed
by the patient:
Please describe
your plan for
being able to
deliver the range
of DME that may
be required
during an Acute
Hospital Care at
Home admission,
e.g. commode
chair, walker,
cane, hospital
bed, etc.:
Please describe
your plan to
deliver physical,
occupational,
and speech

therapists to the
home, including
availability of
these services
and ability to
provide on sameday basis and
during the course
of an Acute
Hospital Care at
Home
admission.:
How will the
social work and
care coordination
teams interact
with patients,
including
discharge? Please
describe, in
detail, your
Acute Hospital
Care at Home
discharge process
and processes to
ensure seamless
patient
discharges.:
Explain your
staffing model to
ensure that this
minimum level of
oversight and
care can be
provided to each
patient.:
Explain your
staffing model,
including
whether you are
able to ensure
each patient is
seen in-person by
an RN at least
daily. If your

hospital plans to
use MIH
members on your
team, explain
their role in the
team structure.:
Can your
hospital meet the
following
minimum
emergency
response times
for each patient:
Explain how you
ensure each
patient can be
remotely
connected to a
hospital team
member
immediately at
all times:
Explain how you
will meet the
requirement of a
30 minute inperson response
time with
appropriate
emergency
personnel (this
may include use
of the 911
emergency
response
system).:
Please describe
the criteria you
use to select
patients for acute
hospital care at
home. Do you use
or have you
adapted
published

selection criteria
or do you use
criteria
developed on
your own:
Will you agree to
track the
following 3
metrics and
report them to
the Chief
Medical Officer,
Chief Nursing
Officer, or Chief
Executive Officer
of your hospital?
CMS will contact
this executive
directly with any
concerns about
reporting or
quality`:
Will you agree to
establish a local
safety committee
review (similar to
a Mortality and
Morbidity team,
but dedicated to
this program)
which will review
the metrics listed
above prior to
weekly
submission to
CMS? :
Which accepted
patient leveling
process
(InterQual,
Milliman, etc.)
will your hospital
use to ensure that
only patients
requiring an

acute level of
care are treated
in this program:
Describe the
process to
address
advanced care
planning,
including code
status updates
and possible
palliative care
consultation
prior to patient
admissions?:
Describe the
process for
communicating
with the patient
support person
that the hospital
is responsible for
providing all
patient care
needs, including
medication
administration,
transportation,
treatments,
meals, and
patient hygiene?:
Describe the
process for
patient informed
consent,
including
communication
of patient
expectations for
care?:
Describe the
emergency
response plan in
the event the
patient does not

respond to
remote
communication
or is unable to be
reached for inperson visits?:
CCN:
Hospital Address
1:
Hospital Phone:
City:
State:
ZIP Code:
POC Name:
POC Email:
POC Telephone:
Attesting Name:
Attesting Title:
Attesting Email:
Attesting
Telephone:
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