A 68-year-old woman presents to your emergency department (ED) with increasing fatigue, shortness of breath, and swelling in her legs. Your work-up reveals a mild congestive heart failure exacerbation. Although you know what resources the patient needs—a few days of diuresis and monitoring—it is increasingly less clear where this should happen.

Traditionally, this patient would be an easy admission to medicine or cardiology, or in some places, a short stay in an observation unit. But new options for patients are emerging.

Currently, Congress is considering extending reimbursement mechanisms for a popular response to rising acute care demand—hospital-at-home.¹ Hospital-at-home programs seek to replicate inpatient medical admissions in the setting of a patient’s home, offering analogous in-person and virtual services.²

Originally launched decades ago but supercharged by the COVID-19 pandemic, hospital-at-home programs promise higher quality care at lower cost. ED benefits are often cited to justify these programs—including alleviating boarding by expanding hospital capacity.³ However, the ideal role of the ED in these programs has not been established, and the long-term implications for our specialty are unclear.

As hospital-at-home expands, emergency medicine must confront two critical questions: What role should it play, both in terms of shaping and operationalizing hospital-at-home? Can the hospital-at-home model relieve the ED boarding crisis plaguing hospitals nationwide?⁴ Emergency medicine has always adapted to the realities of the health care system, for better or worse. The emergence of hospital-at-home may require a more profound shift—not just in how we practice, but in how we define the specialty itself.

Emergency Medicine Implications

Successfully scaling hospital-at-home depends on thoughtful integration of the ED into the admission pathway. Although emergency medicine has traditionally focused on triage, diagnosis, stabilization, and short-term decision-making, this landscape is shifting.

Emergency physicians are increasingly expanding their scope beyond the ED, taking on leadership roles in observation units, virtual care settings, and intensive care units. Moreover, as experts in disposition and acute illness management, we are uniquely positioned to identify appropriate candidates for hospital-at-home—patients who would otherwise require hospitalization but are stable enough to recover at home with structured medical support.

Yet, currently, most hospital-at-home programs are led by hospitalists and internal medicine departments, with minimal input from emergency physicians. This risks marginalizing emergency physicians from a pivotal transformation in acute care, to the detriment of hospital-at-home’s long-term success. Integrating emergency physicians will improve the patient selection process and prevent hospital-at-home from becoming an expensive substitute for observation units.