Care New England began its use of remote monitoring of patients in the home to support members of its accountable care organization’s complex care management program. Now the Rhode Island-based health system is launching an acute hospital-at-home program.
Care New England’s ACO, Integra Community Care Network, has 150,000 members covered by Medicare, Medicare Advantage, Medicaid and commercial plans. In a recent interview, Ana Tuya Fulton, M.D., M.B.A., chief medical officer at Integra and executive chief of geriatrics and palliative care at Care New England, described the evolution of their home-based care program.
The initiative was initially focused on ACO members who they were already following in their complex care programs. “Similar to many ACOs, we follow some of our most complex patients very closely,” Fulton said. “We entered into the acute care-at-home space back in late 2018, because we realized that we needed the ability to rapidly respond to the home and treat some of these chronic conditions in place.”
Since 2018, they have added different layers to the program. “We've added some continuity services, such as in-home nurse practitioner visits,” Fulton said, “and we do a little bit of home-based primary care for some of our frailest patients. Acute care at home was done as part of our ACO work, with a goal in mind to improve quality and reduce utilization for patients who otherwise would have ended up in the hospitals,” she added. “We are now actually a certified acute care home hospital through Medicare at Kent Hospital. We just got that certification at the beginning of this month, so we're now entering into that space as well. That's going to allow us to provide the same services to non-Integra ACO members, to other Medicare beneficiaries that we care for at Kent Hospital.”
This progression in home-based addresses quality concerns and fits with the patients’ goals of wanting to avoid hospitalizations, Fulton noted.
“As a geriatrician, I'll tell you that many of our older adults absolutely want to try to avoid hospitalization, for lots of reasons. Older adults are at higher risk for complications, such as falls, confusion, and delirium,” she said. “Our goal is to provide options for patients who would rather get their acute care at home. We know that hospital home programs prevent all of those complications of hospitalization, and patients remain more active and therefore don't need those rehab services, so it's really a quality improvement program, and it's definitely something that aligns with what our patients want, and what matters to them primarily.”
I asked Fulton what some of the biggest challenges were in terms of creating the teams and the processes to make that kind of care available in the home?
“Our biggest challenges have been sustaining the programs,” she responded. Prior to the Medicare waiver, many of these programs sustained themselves on traditional fee-for-service billing, which is limited to the provider-patient interactions. “You could not get reimbursed for things like remote monitoring that you need to be able to do acute care and to do 24/7 response,” she explained. “The Medicare waiver gives us an opportunity to have a much more stable funding stream to support the work and to allow us to expand.”
Traditionally, Fulton added, these programs have been fairly small, because they're not easy to sustain. “Unless you really make sure you're choosing the right patients and that you're really avoiding those high-cost episodes, it's a constant balance in terms of your return on investment. Now this new payment stream for Medicare gives you the opportunity to expand to more patients. I think the biggest challenge has been sustainability and getting up to scale. That's why we did it with the ACO. I think many programs who bought into this space did it as part of an ACO, using shared savings to sustain the programs.”
I asked her if there also were also workforce issues involved in scaling up this model.
“Yes. The workforce piece is becoming an increasingly difficult challenge for us,” she said. “You not only need nurses and providers, you need those who are comfortable and have experience with complex older adults with multiple medical conditions, and who are comfortable operating in a home setting and have an acute care background. You have to know how to do home care, but also manage an acute condition like hospitals, so it's a very small pool that we can recruit from, and I think many of us are learning that what we really have to do is recruit and then also build robust training programs to have a dedicated team that has the skill set to do this work well.”
Integra has just started partnering with a Boston-based company called Biofourmis on the remote monitoring aspect. I asked Fulton if they had clear ideas of the highest priority things to monitor and which things could be done remotely.
“We did,” she said. “We're really excited to have added Biofourmis. We are working with them on two projects. With our Integra population, we wanted to add remote monitoring for those patients with chronic diseases — patients with diabetes, congestive heart failure, chronic pulmonary disease. We wanted the ability to add the remote monitoring component so that we could provide disease education, as well as give them the tools to better monitor their conditions, so they would call us earlier. One of the challenges is getting your patients to call you in time so that you can respond to the home and intervene before things get really acute. Monitoring has helped us do that.”
Care New England is also starting to work with Biofourmis for the hospital-at-home program at Kent. “As we go live, we are using their hospital-at-home platform, which provides constant communication with our patients,” Fulton said. “They have wearable devices, so we know 24/7, what's going on with them in terms of heart rate, blood pressure, vital signs, all those pieces, and the same ability for our providers to see what's going on and to reach out to the patient and for the patient to reach out to us.”
Besides patients monitoring their health, the data also flows to the providers as well, so if there's something outside of a normal range, they get a notice. “We have the ability to log on to our dashboards to see all of our patients and we can check in to see what their vitals were in the morning,” Fulton explained. “We can also see if their devices are not connected, if their batteries are low, then we can reach out and say, let me work with you. We're constantly connected. It is not reliant on the patient transmitting information.”
Fulton said they are eager to work with an analytics engine that Biofourmis has created to predict clinical deterioration. “They have great deal of analysis to create a score that translates into a clinical risk for that patient,” she explained. “If the score is above a certain level, it gives the provider one more metric to look at to understand who might need to be seen first that day, for example, or who is a patient who could be deteriorating clinically. I'm excited to learn more about that. I think it's a really exciting thing that they've developed this. I know other programs are further along than we are, but we're looking forward to using it and then seeing how that plays into our day-to-day management of our patients.”
She spoke about the data required to report on the hospital-at-home program for CMS, as well as other kinds of data that they will be looking at to assess the program’s value.
“We're already beginning to submit those measures to CMS. They want to know who the patients were in this program and what diagnoses they had. And they want any information that we can share in terms of anything that occurred that we didn't anticipate occurring.”
Care New England is also creating a hospital-at-home quality team that will review each and every case. “We want to really understand every patient we took care of — what the diagnoses were, how long they were on that home program. What we want to see is when you compare length of stay, for someone with the same diagnosis in the brick-and-mortar hospital compared to hospital at home, what's the difference — is it longer or shorter? We're also going to track all of the indicators that we are concerned about in terms of falls, infections, rate of delirium or confusion. We'll do all the same quality metric expectations that you would have in a brick-and-mortar hospital applied to the hospital-at-home program as well.”
They will also be tracking referrals to rehab facilities and patient satisfaction measures, “One of the things we learned very early on as we started this work with Integra is that you really have to be attuned to your patient — what they're eating at home, what their activity level is; you also have to make sure that you're not adding additional stress to caregivers, who may have been already burned out prior to this acute episode,” Fulton said. “We really want to stay in touch with our patients and their family members and caregivers.”
I asked Fulton if it is challenging to identify which patients are the best candidates for the acute hospital at home program?
“We have benefited from the learnings we've had with Integra,” she said, “and I think we've also benefited greatly from some of the programs that have been doing this for quite some time. There are large hospital-at-home programs at Brigham, Sinai and Hopkins. The diagnoses that are best treated at home are pretty clear. We are going to follow the path of many programs before us and use those five or six key diagnoses. The hospital-at-home users group resources have been immensely helpful in terms of understanding what are the right exclusion and inclusion criteria that you need to think about. I think there's a lot of evidence base out there.”
Like other hospital-at-home leaders, she noted that there is uncertainty surrounding whether CMS will extend the waiver program beyond the public health emergency. “Given what we're living every day, clinically, it doesn't feel like COVID is over,” she said. “We hope that it'll get extended past the end of the year. I think many people are optimistic that because of the interest in this program, because of the rapid uptake, Medicare will continue it in some form or fashion. I think the other thing that's important is people have been advocating for this, even prior to the pandemic, there's good solid data that it has better quality, that it's something patients want. Our hope is that Medicare will take the learnings from all this data collected during the pandemic and apply that to a permanent benefit for acute care homes.”
To be successful, Fulton added, each program must modify to the setting that they're in and the kinds of patients that are in the partnerships. “There are a lot of consideration that go into building a program. It’s all about the interdisciplinary team, pulling the right partnerships together, and then learning from the experience of others, but then really modifying it to your specific setting, so that it can be as successful as possible.”