CMS-10752 AHCAH waiver

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Acute Hospital Care at Home

Please note: Each hospital certified to provide care to Medicare patients has a unique CMS Certification
Number (CCN). Each hospital seeking to provide acute hospital care at home must submit its own waiver
request under its unique CCN. For example, if a hospital system has seven hospitals, but only two of the
hospitals admit patients who use acute hospital care at home services, two separate waiver requests
must be submitted.
If your hospital is seeking Medicaid reimbursement, please contact your state Medicaid agencies as soon
as possible; there may be other state law requirements that need to be met.
This waiver is only in effect through December 31, 2024 under authority from the 2023 Consolidated
Appropriations Act.
All fields marked with an asterisk (*) are required.

Hospital Information
CMS Certification Number (CCN) *

CCN is required
Hospital Name *

Hospital Phone Number

Hospital Name is required
Hospital Address Line 1 *

Hospital Address Line 2

Hospital Address Line 1 is required
City *

State *

City is required

State is required

ZIP Code *

ZIP Code is required

Point of Contact
Name *

Name is required
Email Address *

Confirm Email Address *

Email Address is required

Confirm Email Address is required

Phone Number *

Phone Extension

Phone Number is required

Acute Hospital Care at Home Waiver Request
Has your hospital provided acute hospital care at home services to at least 25 patients since the
program's inception? *
Yes
No
How many patients has your Acute Hospital Care at Home hospital treated who qualified for inpatient
hospital admissions since its inception? *

This field is required

1/5

Can your hospital provide acute care services at home? You are required to provide or contract for the
following services: *
Pharmacy
Infusion
Respiratory care including oxygen delivery
Diagnostics (labs, radiology)
Monitoring with at least 2 sets of patient vitals daily
Transportation
Food services including meal availability as needed by the patient
Durable Medical Equipment
Physical, Occupational, and Speech Therapy
Social work and care coordination

Yes
No
Explain how you are able to meet the pharmacy needs of each beneficiary. *

This field is required
Detail your processes and protocols for performing IV push and IV Piggyback infusions. *

This field is required
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. *

This field is required
What diagnostic studies are available to patients while hospitalized in acute hospital care at home?
Include which laboratory studies, radiology tests, or other diagnostics are available and the expected time
between the order placement and results. For services unavailable in home, how will these be provided
via the hospital? *

This field is required
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. *

This field is required
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, non-ambulance medical
transport, or other means. *

This field is required
How does your hospital plan to provide meal services to patients to ensure the availability of meals as
needed by the patient? *

This field is required
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. *

This field is required
Please describe your plan to deliver physical, occupational, and speech therapists to the home, including
availability of these services and ability to provide on same-day basis and during the course of an Acute
Hospital Care at Home admission. *

This field is required
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. *

This field is required
To be eligible for this waiver, a hospital must guarantee that each patient is admitted to Acute Hospital
Care at Home from an Emergency Room or Inpatient Hospital, and that an admitting MD/APP performing
a History and Physical Exam sees each patient in-person initially. After this first in-person visit, an MD or
Advanced Practice Provider must visit and examine each patient at least daily – this can be done remotely
if appropriate based on the provider’s evaluation of the patient’s condition and course.
Explain your staffing model to ensure that this minimum level of oversight and care can be provided to
each patient. *

This field is required
To be eligible for this waiver, a hospital must guarantee that there are at least two in-person visits by
clinicians each day. There must be at least one in-person or remote visit with a Registered Nurse (RN) who
develops a nursing plan consistent with hospital policies. If the RN determines it is clinically appropriate,
the in-person visits can be with a Mobile Integrated Health (MIH) paramedics without RN on-site care.
Explain your staffing model, including whether you are able to ensure each patient is seen in-person or
remotely by an RN at least daily. If your hospital plans to use MIH members on your team, explain their
role in the team structure. *

This field is required
Can your hospital meet the following minimum emergency response times for each patient: *
Immediate, on-demand remote audio connection with an Acute Hospital Care at Home team
member who can immediately connect either an RN or MD to the patient
In-home appropriate emergency personnel team to the patient’s home within 30 minutes. This can
be provided by 911 or emergency paramedics

Yes
No
This field is required
Explain how you ensure each patient can be remotely connected to a hospital team member immediately
at all times. Describe technology and device use (e.g. telephone, personnel emergency response system,
remote telemetry), staffing, and any limitations based on time of day or weekend. *

This field is required
Explain how you will meet the requirement of a 30 minute in-person response time with appropriate
emergency personnel (this may include use of the 911 emergency response system). Detail the algorithm
and timing of each step in the process and describe which personnel will travel to the home. Describe any
partnerships with local paramedic groups or other professionals who will improve this response time.
Detail equipment that will travel with this team. *

This field is required
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? Please give
complete details including all inclusion and exclusion criteria. *

This field is required
Will you agree to track the following 3 metrics, report them to the Chief Medical Officer, Chief Nursing
Officer, or Chief Executive Officer of your hospital, and report them to CMS on a weekly basis? CMS will
contact this executive directly with any concerns about reporting or quality. *
1. Unanticipated mortality during the acute episode of care
2. Escalation rate (transfer back to the traditional hospital setting during the acute episode)
3. Volume of patients treated in this program

Yes
No
This field is required

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? *
Yes
No
This field is required
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? *

This field is required
Describe the process to address advanced care planning, including code status updates and possible
palliative care consultation prior to patient admissions? *

This field is required
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? *

This field is required
Describe the process for patient informed consent, including communication of patient expectations for
care? *

This field is required
Describe the emergency response plan in the event the patient does not respond to remote
communication or is unable to be reached for in-person visits? *

This field is required
Additional Information

Attestation
By submitting information within this form, I attest that I have personally reviewed the information above for
accuracy. I have also received consent from the represented hospital and any individuals whose information
(name, email, and phone number) has been included in this request.
The email addresses provided will receive a verification email from CMS within 24 hours.

Attesting Name *

Attesting Name is required
Attesting Email Address *

Attesting Email Address is required
Attesting Phone Number *

Attesting Phone Number is required
Attesting Title *

Attesting Title is required
(Must be C-suite level of hospital system, including Chief Medical Officer/Chief Nursing Officer)
CMS will utilize the information collected to communicate eligibility with you or your authorized representative(s). In addition, we may
perform oversight and quality control activities, combat fraud, andrespond to any concerns about the security or confidentiality of the
information. You may find additional information regarding this site’s Privacy Policy here.
Section 3087 of the 21st Century Cures Act, signed into law in December 2016, added subsection (f) to section 319 of the Public Health
Service Act. This new subsection gives the HHS Secretary the authority to waive Paperwork Reduction Act (PRA) (44 USC 3501 et seq.)
requirements with respect to voluntary collection of information during a public health emergency (PHE), as declared by the Secretary, or
when a disease or disorder is significantly likely to become a public health emergency (SLPHE). Under this new authority, the HHS Secretary

may waive PRA requirements for the voluntary collection of information if the Secretary determines that: (1) a PHE exists according to
section 319(a) of the PHS Act or determines that a disease or disorder, including a novel and emerging public health threat, is a SLPHE under
section 319(f) of the PHS Act; and (2) the PHE/SLPHE, including the specific preparation for and response to it, necessitates a waiver of the
PRA requirements. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has been designated as the office that will
coordinate the process for the Secretary to approve or reject each request.
The information collection requirements contained in this information collection request have been submitted and approved under a PRA
Waiver granted by the Secretary of Health and Human Services. The waiver can be viewed at https://aspe.hhs.gov/public-health-emergencydeclaration-pra-waivers .

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