IMPORTANCE: Contemporary data regarding the safety and quality of acute hospital care at home for heart failure (HF) are limited. OBJECTIVE: To compare safety and quality outcomes of an advanced medical care at home (AMCAH) program to brick-and-mortar (BAM) hospitalization for HF. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at 11 service areas within Kaiser Permanente Southern California. Participants were adult patients hospitalized with a principal diagnosis of HF between February 2023 and December 2024. Analysis included propensity score matching and both intra- and inter-service area comparisons. Data were analyzed from April 2025 through March 2026. EXPOSURE: KPSC's AMCAH program vs continued BAM hospitalization. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite outcome of all-cause escalation, readmission, or mortality at 30 days. Secondary outcomes included individual components of the composite outcome at 30 days, the composite outcome and its individual components at 60 days, days alive and out of hospital (DAOH) at 30 and 60 days, and guideline-directed medical therapy (GDMT) score at 30 and 60 days. RESULTS: In the intra-service area comparison, 307 pairs were matched (mean [SD] age, 75 [12.6] years; 374 [61%] male). By 30 days, there were 73 composite outcome events (24%) in the AMCAH group, including 18 (6%) escalations, compared with 80 events (26%) in the BAM group (odds ratio [OR], 0.89 [95% CI, 0.61 to 1.28]); individual components were directionally consistent. Participants in the AMCAH group had a mean (SD) of 28.2 (4.9) vs 28.3 (4.2) DAOH in the BAM group (β = -0.12 [95% CI, -0.85 to 0.60]). The mean (SD) GDMT score was 3.2 (2.2) in the AMCAH group vs 3.1 (2.5) in the BAM group (β = 0.13 [95% CI, -0.23 to 0.50]). In the inter-service area comparison, 239 pairs were matched. By 30 days, there were 53 composite outcome events (22%) in the AMCAH group, including 12 participants (5%) with escalations, vs 59 participants (25%) in the BAM group (OR, 0.87 [95% CI, 0.57 to 1.34]). Participants in the AMCAH group had a mean (SD) of 28.0 (5.6) DAOH vs 28.2 (4.5) DAOH in the BAM group (β = -0.21 [95% CI, -1.12 to 0.70]). The mean (SD) GDMT score was 3.0 (2.1) in the AMCAH group vs 2.9 (2.4) in the BAM group (β = 0.11 [95% CI, -0.29 to 0.51]). No significant differences were observed at 60 days in either comparison. CONCLUSIONS AND RELEVANCE: In this cohort study among patients hospitalized with HF, no differences in all-cause readmissions, mortality, DAOH, or GDMT scores were seen at 30 or 60 days after discharge among individuals who received AMCAH vs those who underwent continued BAM hospitalization, highlighting the safety and quality of an AMCAH program with clinician-determined eligibility.