During a recent webinar hosted by the Hospital at Home Users Group, executives from three health systems described their experience creating skilled nursing facility (SNF)/rehab-at-home programs as adjuncts to their hospital-at-home offerings.
As the webinar hosts pointed out, there is interest in this model from several perspectives: patients prefer to be home and avoid extended SNF stays; health systems often have waits to transition patients to SNFs, impacting lengths of stay; and health plans pay significant amounts for SNF-level care.
Emily Downing, M.D., system clinical officer at Allina Health, coined a Dr. Seuss-like term, “Snospital at Home” to describe what Allina has done in filling the gap between acute care and SNF care.
Allina Health has approximately 1,600 hospital beds across the Minneapolis metropolitan area. This program was started in 2020 in response to COVID. So far, Allina has taken care of 5,200 patients within this model of care. An example of the type of patient in this program is someone who is on chemotherapy and doesn’t qualify for a SNF but does still have pretty significant medical management needs. “Typically, the model episode is around four and a half days, and most patients — about 70 percent — continue with some level of home health, skilled nursing and potentially therapy at the time of discharge,” Downing said.
The Allina model of care consists of the community paramedic transition visit that includes biometric setup, with 24/7 oversight, typically twice a day at minimum and then synchronous management alerts, and daily visits by a nurse or community paramedic for the first three days of the episode. They can continue daily, in addition to urgent visits from those same providers as needed daily for urgent tele-provider visits and urgent health provider visits, 24/7 centralized nursing and provider coverage and then all the ancillary services – DME, oxygen, lab, imaging, respiratory therapy as needed, pharmacy support, physical therapy, occupational speech and social work.
The program at Allina was built through the lens of discharging patients earlier from the hospital and being able to support higher complexity medical needs. “We really focused on the need of medical complexity in skilled nursing facility care as our primary gap to fill vs. the high needs for rehabilitative care,” Downing said.
Rehab-at-Home in Ohio
Cleveland Clinic created a program called Home Care Plus in 2019 with a goal of creating a safe home-based alternative to skilled nursing facility care for a subset of patients who traditionally go to SNFs with a focus on post-acute rehabilitative care. “Our Home Care Plus program was really designed in some ways to mimic elements of care that patients would receive in a skilled nursing facility, but in the home,” said Jessica Hohman, M.D., president and medical director of the Cleveland Clinic Medicare Accountable Care Organization and an investigator in its Center for Value-Based Care Research.
“Our program was actually front-loaded with higher intensity provider-to- patient contact in the first 14 days – getting on average about five hours a day of total patient contact times spread across service lines,” Hohman added. “In order to do this, we partnered with our internally owned home health agency to provide all skilled services. That included our home care nurses, physical therapists, occupational therapists, and social workers when needed.”
They also contracted with an external vendor to provide additional wraparound or custodial care, essentially private duty aids. for these patients. “We recognize that often a huge barrier to getting patients home is that ability to provide that additional tuck-in service, that non-skilled care, and we provided up to three hours a day of that for that first 14-day higher intensity period,” she said.
“We also wanted to create greater flexibility in terms of medical support, and we leveraged the excess capacity in our home-based primary care group to be able to flex into the home as needed to be able to provide visits for these patients,’ Hohman said.
To make things easy for the inpatient team to identify patients who were eligible, Cleveland Clinic developed an internal report that runs daily and is delivered first thing in the morning to all of the care teams in the hospital. It identifies the patients who meet the criteria who are currently on census. The goal is to make this as easy as possible to identify the patients who would meet those eligibility criteria so that they can be approached each day.
To begin this program, Cleveland Clinic selected a regional hospital that has an unusually high volume of skilled nursing facility utilization. They completed multiple cycles of education and workflow mapping of processes to get this program up and running. “From there we spread this program to our other regional hubs in our Northeast Ohio footprint, at the same time contracting with that external vendor and all of their offices in order to cover our whole geographic catchment area,” Hohman explained. “In order to get buy-in for this, we started to do direct patient engagement using our patient portal, as well as communication in the hospital to allow patients to know that this was an option that they could also begin to ask for as a way to start to boost patient engagement with this program.”
Joint Venture at Marshfield Clinic
Wisconsin-based Marshfield Clinic Health System’s hospital-at-home home Recovery Care Program is a joint venture initiative between Marshfield Clinic and a company called Contessa that delivers comprehensive care at home. The program delivers high-acuity inpatient-level care and SNF-level care at home for patients at reduced cost. “We started our program with our acute models in 2016, and in September 2019 we started with a SNF/rehab-at-home model,” said Swetha Gudibanda, M.D., medical director of the Hospital at Home/Home Recovery Care program.
Gudibanda described four different models: a direct to home model where they admit patients directly from the ER and the clinics; a high-acuity pathway model where they admit patients to the hospital one day and then take them the next day. They have a completing hospitalization-at-home model where they transfer the patient home to complete the hospitalization and the last is the SNF-at-home model.
The foundation for their program is the multidisciplinary care team providing comprehensive care at home. They have physician providers, acute care RNs, recovery care coordinators, virtual care coordinators who are RNs by training. They have CNAs, and personal care coordinators, physical, occupational speech, social workers and we have a pharmacy services as well as transportation services.
Gudibanda said this program helps hospitals reduce length of stay, which can be prolonged as they wait for nursing home beds to open up, especially in rural communities. ‘With our program, we easily transport them home and then we take care of them at home.”
In addition, she said, they have saved 15 to 30 percent per bundled payment episode and decreased readmission rates and increased patient satisfaction rates.
What About the Payment Models?
Moderator David Levine, M.D., M.P.H., clinical director for research and development at Mass General Brigham, asked about how the models are paid for and the perceived return on investment.
“This program was designed initially targeting our ACO and essentially our value-based patient population because that's where the incentives most align,” Cleveland Clinic’s Hohman said. “The ACO was the test kitchen. We use shared savings to pay for private duty aids for these patients because that was not reimbursable. all of our skilled front loaded care was built and reimbursed as part of skilled in-home care. Our goal as an organization was to break even on the scale of intermittent home care. And that's one of the luxuries of the fact that we have our own home care agency and we had a desire to partner as an organization to front-load higher intensity services and really design something that worked, knowing that in doing so we were able to substantially reduce our SNF utilization rates. Because we're in total cost of care contracts, on the back end, it's allowed us to generate revenue in terms of shared savings.”
Downing noted that Allina’s primary goal was capacity creation and throughput, especially during a time of limited SNF access. “So pulling these patients out of the hospital and especially when there is the opportunity to use your hospital capacity, such as during the pandemic and even now, is a is a big part of the value proposition.”
Gudibanda said the biggest plus for Marshfield is that it has its own health plan. “We get the bundled payment contracted through the joint venture. We're working with other payers to do the same.”
