As Mayo Clinic rolls out its hospital-at-home program in Arizona, John Halamka, M.D., president of the Mayo Clinic Platform, described the organization’s experience creating a centralized command center and scaling up the service.
Speaking at a panel session at the recent Tech Forum of the Office of the National Coordinator for Health IT, Halamka said Mayo Clinic has worked through practical issues around making hospital at home a reality. For instance, what is the user experience like? What is the redundancy and disaster recovery? What is the provider experience? And how do you integrate all of these components into work flow?
Early in 2020, Mayo Clinic asked how it could take serious and complex care — Mayo quality care with Mayo safety and Mayo outcomes and move it to non-traditional settings, Halamka said. “Of course, a lot of logistical questions had to be asked: How do you organize to do that? Do you have a single command center for the country? Who staffs it? What's the division of labor between specialists, nurses, supply chain experts, community paramedics?”
Mayo Clinic wanted there to be almost no discernible difference between admitting someone to the Mayo Clinic hospital in Minnesota, Florida or Arizona, or admitting them to their living room. “The data flows, the care planning, the way that the documentation and billing is done would be so integrated that it would almost be indistinguishable for our providers throughout the system,” he explained. “But of course, it would require in-home personnel, nursing visits, and blood draws and imaging; it would require a supply chain to the home. Also, we would have new classes of service: community paramedics helping with the delivery and installation of some of the equipment that is necessary, and some of the physicality of care.”
He stressed that this is not a model where Mayo Clinic is employing every person who's delivering a service. “Mayo may oversee quality or do training or certification, but especially in rural settings, where there are EMTs, let's upskill them, and make them now home health caregivers. And that's a model that will work in scale.”
He said that after researching the topic extensively, Mayo Clinic determined that if done with centralized care planning, command center oversight and operations, 24x7staffing, a cloud-hosted delivery mechanism, it would work. “But, of course, there were certainly questions that were left to early experience — such as how can you ensure that regulatory requirements are being met? Licensure of individuals, given a state has variation on who can practice delivering what service? Where might you run into issues? If you have a centralized command center and virtual delivery of these serious and complex services, how might you get reimbursed from private insurers, Medicare and Medicaid?”
Mayo Clinic has a notion of start small, think big, and move fast, Halamka said. “In July 2020, we started with one patient. We learned what the issue were; we then went to 10. We then went to 50. Between Mayo Clinic and work that we have done with partners, we've experienced over 1,000 patient discharges, and done so with extraordinary safety, quality and patient satisfaction, refining our processes, our care planning and our software integration along the way.”
A singular command center, currently in Jacksonville, Fla., is staffed 24x7. “We did have to negotiate some 300 payer agreements to make sure that as there was regional variation or payer-to-payer variation, that there would be a methodology, maybe a bundle, or maybe this idea that we are going to offer this set of services where we ultimately experience less cost with the same outcomes that made it very attractive for a payer to reimburse.”
Mayo Clinic had to figure out staffing numbers — how many nurses and how many doctors — and what alerts and reminders needed immediate action. “These are things that our command center today is mastering in a highly scalable model, increasing our rollout to the point where from Jacksonville we are overseeing the Florida geography, the Wisconsin geography and this week, we're rolling out in the Arizona geography."
Speaking about the interoperability of remote patient monitoring solutions, Halamka said that unfortunately, many devices that are on the market today don't follow widely accepted standards. “You have the challenge of getting these high-velocity continuous signals from the home into a standard form and then transmitting them robustly into the social platform. Mayo Clinic is working with Medically Home, a Boston-based technology-enabled services company, as its implementation partner. He said Mayo seamlessly and bidirectionally integrated Epic with the platform for selected data elements, “so that there was not a lot of having to hunt in two different places and having to manually re-key information.”
What has been the result? “We have been able to see a very large number of patients and achieve the same outcomes, the same safety, same quality, reduce readmission rates, and have Net Promoter scores that are higher than anything that has actually been achieved in a bricks and mortar facility,” Halamka said. “Part of the reason, he suggested is because you're taking a look at the whole patient and the whole family and bringing them back to health.
“About 30 percent of hospitalized patients, by our experience, will do just fine in a nontraditional setting,” Halamka said, “and they will do so with a great attention to social determinants of health, because as you enter the home, you have to immediately understand things such as their internet connection and the safety of the home and what is the capacity of a community to reach that home.”
He told a story of an 87-year-old patient with hyponatremia. “Typically, this would be a serious and complex illness you'd see in a bricks-and-mortar facility. We found that the 87-year-old husband was a cancer patient, not acutely ill but undergoing treatment," Halamka said. "We found that in order to bring that family back to health, we had to feed the entire family. We ensured the patient did well and the family was supported, and that resulted in a return to wellness sooner with less complications and greater satisfaction.”
