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required to apply to CDPH for the waivers of state regulations gov- erning hospital care. The hospital industry frames Home All Alone programs as the sunny future of hospital care. Hospitals tout all the reasons unrelated to actual health care outcomes as justification for these programs: Patients like being at home, patients can stay with their families and pets, patients may be at lower risk of nosocomial infections. Nurses see it as simple patient dumping and depriving patients of our professional, 24/7 nursing care, with the most vulnerable, least-resourced, and often Black, Indigenous, Brown, and other patients of color and their households suffering the worst outcomes and perhaps death. If these programs are allowed to grow, hospitals as we know them may ultimately disappear—especially small-to-medium and more rural facilities. Already, overall hospital bed capacity nation- wide is declining, dropping from 1.5 million in 1975 to about 919,000 in 2019, according to the American Hospital Association and Statista. And as more and more patients are sent home, hospi- tals will use the lower patient census as justification to close inpatient beds and further cut RN staffing, leading to a self-fueling death spiral of community hospitals. Brick-and-mortar rural hospi- tals, already an endangered species, will certainly go extinct. "These programs are designed to make hospitals appear less relevant for our communities, and to make it easier to close down hospitals, espe- cially those that don't make money or serve patients who don't have private insurance," said Mahon. "If the pandemic has taught us anything at all, it is that we need more hospitals, and hospital beds, not fewer." According to the NEJM Catalyst article, hospitals treated only 1,878 patients as of Oct. 27, 2021 under the CMS waiver program, with 134 patients sent back to the brick-and-mortar hospital and eight unexpected mortalities. But market forces dictate that these programs must be adopted widely to make it worth the investment. Besides hospital systems themselves, private equity and venture cap- ital firms have also invested in these schemes, seeing the possibility of huge windfalls. "We know these programs are not cheap to start," said Mahon. "We know investors are chomping at the bit to see them expanded as quickly as possible and as widely as possible to recoup their investments and reap their profits." N urses' limited interactions with these fledgling Home All Alone programs already confirm that they are dangerous and untested for patients. Kalaveras said she saw patients who were "admitted" to their homes, but "failed" and then returned to her ER far sicker than they had been originally. Her hospital, Kaiser Vallejo, is one of two pilot sites for Kaiser's Advanced Care at Home initiative in Northern Cali- fornia and many more Kaiser is operating in the Pacific Northwest. "I have seen Covid patients who were sent home with an iPad return to the ER with their oxygen levels so low their lips were blue and they needed immediate lifesaving interventions," said Kalaveras. "I cared for another patient who was returned to hospital by ambu- lance. His fever was through the roof, and he had a raging infection and was nearly septic." Kalaveras said she tried to convince that patient to remain in the hospital after he was given antibiotics and his fever was brought down. She told him she feared if he went back home, his fever could shoot back up and his condition could deteriorate quickly. But a nurse and a physician assistant, who were both contract workers with the remote program, convinced the patient to go home. The patient returned home by ambulance. "I can only imagine the confusion a patient would feel when they are approached by a medical team, one wearing a white coat and so 14 N A T I O N A L N U R S E W W W . N A T I O N A L N U R S E S U N I T E D . O R G J A N U A R Y | F E B R U A R Y | M A R C H 2 0 2 2 "There is no substitute for human contact. You can feel the heat and cold of a person's body, you learn so much from touching a patient's abdomen. What does their breath smell like? Does it smell like juicy fruit gum? If so, you are already in trouble." CVS AMAZON HCA CARE HEALTH ADVENTIST HEALTH KAISER DIGNITY HEALTH BEST BUY