During a March 15 Permanente Medicine webinar, a group of physicians leading acute hospital-at-home programs tackled issues ranging from new legislation to extend CMS payment and equity concerns to quality measurement frameworks and the challenges of scaling up.
Mary Giswold, M.D., is chief operating officer at Northwest Permanente. She leads operations for this physician-led, self-governed, multispecialty group practice, which provides care to more than 620,000 members of Kaiser Permanente in Oregon and southwestern Washington. Throughout the COVID-19 pandemic, she co-led the regional response leadership team for Kaiser Permanente of the Northwest and represented the Kaiser Permanente Advanced Care at Home program for a group of regional hospital chief medical officers.
Among the many benefits of the program, “we find that being in the home virtually and physically allows a real in-depth understanding of the social needs of our patients. It increases that opportunity to connect with patients and their families, so that we can address social needs and connect them to community resources,” Giswold said. “As an integrated system, we think the program also will bring value to our members because as these programs scale, they potentially will offer more affordable options for hospitalization than building brick-and-mortar facilities.”
Sarita Mohanty, M.D., is president and chief executive officer of The SCAN Foundation, one of the largest foundations in the United States focused on improving the quality of health and life for older adults. She previously served as vice president of care coordination for Medicaid and vulnerable populations at Kaiser Permanente. “Hospital-at-home programs are uniquely positioned to address social determinant of health issues, because they're personalized care models based on a person's needs and particular experiences throughout their life,” she said. In acute hospital at home, transportation burdens are less and there is less time off for family members who can see their loved ones in the home versus having to visit a hospital setting. You can do assessments on things like food insecurity. “One statistic I heard is that 16.3 percent of Californians over age 60 are food-insecure. We have an opportunity to really look at this more carefully to help vulnerable populations close health equity gaps.”
Mohanty added, however, that it is important to measure the impact and outcomes of the hospital-at-home models on vulnerable subpopulations. “Are we seeing differences in access to the hospital-at-home programs across racial and ethnic groups? What about those in rural communities? Are we able to avail them the same level of access to these types of programs? We must ensure that it is provided to all who are eligible. We don't want to make disparities and inequities worse by instituting these important models. As we work to scale these models, we’ve got to be mindful not just of the clinical, but the social and behavioral factors that really influence one's total health.”
Michael Maniaci, M.D., is enterprise physician lead for the Mayo Clinic’s Advanced Care at Home program as well as current medical director of Mayo Clinic Hospital in Florida. He said Mayo Clinic’s program, which now operates in three states, has had to look at the regulatory framework at both the federal and state levels, because the rules are different everywhere. It also partners with other similar programs in the Hospital at Home Users Group on establishing quality metrics. “We know what to do for brick-and-mortar hospital for quality metrics,” he said. “How does that pertain to hospital at home? How do we build this properly to look at the right metrics and feed that back to CMS and the commercial payers and everybody else? How do we build that regulatory environment? That’s why we built this coalition together — to say how do we do this from a medical standpoint to keep our patients safe and happy?”
David Levine, M.D., is a practicing general internist and clinician-investigator at Brigham Health and Harvard Medical School. He is medical director for strategy and innovation of the Brigham Health Home Hospital and co-chair of the Hospital at Home Users Group. He said that with the waiver, CMS struck the balance pretty well during the pandemic of making sure that people are providing great care and at the same time not overburdening systems with too much quality reporting. “There's legislation right now in the House and Senate to essentially extend this waiver for two years so that more systems can get experienced with this, we can get more data to see how these programs exist outside of pandemic-type situations,” he said. “I am extremely enthusiastic about that. On the quality metrics side of things, in the Hospital at Home Users Group, we have an entire set of quality metrics that all of the users from around the country and Canada have essentially helped to create together. That's going to form an entire national network, where systems will have the opportunity to report in and to start to benchmark themselves on that quality. I think we'll see CMS start to write some additional rules, set some regulatory guidance around additional metrics that we want to start looking at. But I don’t think we need hundreds and hundreds of quality measures to deliver good care. I think we need to measure the right things for our patients.”
Concerning the murky payment landscape, Maniaci says, “I always say do what's right for the patient and the quality metrics and payment would follow.” He said that if you look at what it costs normally for the hospital stay, post-recovery SNF, remote patient monitoring and care afterwards, multiple visits, readmissions — taking a fraction of that and using that as a bundled payment. If we build this longitudinal ownership of patients or if institutions share resources, in order to keep costs down, I think that's a payment model that both commercial and government payers can get after. Do what's right for the patient, keep them out of the hospital, keep them healthy, drive down costs — that's what we should be reimbursed for, not just the quantity, but the quality of care we give.”
Under the current waiver, patients can only be admitted out of emergency departments and the med/surge units. But for a fully integrated healthcare system like Kaiser Permanente, and probably for other systems, too, Giswold said they can move this further upstream. “We are starting now in our Southwest Washington area to admit patients directly out of urgent cares and clinics. It saves the patients the hassle, the discomfort, the pain of going to an emergency department, just to check a regulatory box to then be admitted to their home,” she said. “I think that really could help our ED utilization, the traffic to the emergency department so that emergency department can focus on those, very critically ill patients who need very timely care.”
Giswold spoke about some opportunities for scaling KP’s program up. “In Oregon and Washington, we have the lowest beds per 1,000 in the country. During the pandemic, we admitted over 1,200 patients to our program, which created bed capacity for other people,” she explained.
“Southern Oregon was hit very hard by Delta, and we do not have a lot of bed capacity down there in the more rural parts of the state,” Giswold added. “We were able to put patients in our Portland metro area in our program, and we created that capacity in the metro area so that patients who needed higher level of care transfers could be cared for in the Portland metro area. We are starting to experiment with bringing this program to more rural areas of our service delivery area. Certainly, it can be done. It takes some creative problem-solving with our supply chain partners. It just requires a lot of infrastructure and planning.
Also, in terms of scaling up, this does allow for a more flexible creation of hospital beds than building brick and mortar in the Portland metro area, she added. “We now have multiple health systems that are creating these programs, because we are really under-bedded in our area, and we can do this a lot faster than someone can go through a certificate-of-need process, and actually build new construction these days.”
