PCORI has announced $208 million in funding awards for 17 clinical effectiveness research (CER) studies, as well as a separate, $2 million award for a project that aims to improve access to mental healthcare services for people undergoing dialysis.
The awards are part of a continuing program to apply new technologies and strategies to many of healthcare's common problems, such as chronic care management, palliative care, senior services and care for people living with rare diseases.
“These awards present significant opportunities to address urgent health challenges and empower patients and their families with actionable information about their health care choices,” PCORI Executive Director Nakela L. Cook, MD, MPH, said in a press release. “Facing a complex healthcare system and many care options, patients, caregivers, clinicians, and other health decision makers need reliable information to help them understand which care options will best meet individual patient needs and circumstances. PCORI-supported evidence will improve healthcare and outcomes for people across the nation.”
Included in the list of projects are three that use telehealth to improve care management for people living with multiple chronic conditions in primary care settings, with a focus specifically on COPD and sleep apnea, obesity and asthma in children, and care for medically fragile children.
Four large studies receiving PCORI funds will compare:
The treatment of coronary artery disease with either open-heart surgery or less invasive stent placement, with a focus on women and underserved populations.
Palliative care delivery for seriously Ill hospitalized patients by specialists against the same care delivered by trained general care practitioners.
Various medications as second-line treatment for the 25 percent of children with a severe form of juvenile idiopathic arthritis who do not get better taking a first-line biologic drug.
The impacts of annual wellness visits for older adults with complex healthcare needs against a program that adds integrated care involving interprofessional teams and at-home visits.
The $2 million award targets a project that will compare two treatments proven effective in a previous PCORI-funded project, medication and a cognitive behavioral therapy program delivered via telehealth, in dozens of dialysis units across several states.
“PCORI’s stewardship of patient-centered comparative clinical effectiveness research extends to ensuring useful findings can have a salutary impact in everyday clinical care, which is why we fund projects that encourage uptake of results,” Harv Feldman, MD, MSCE, PCORI’s deputy executive director for patient-centered research programs, said in the press release. “As a result of PCORI’s latest implementation funding awards, clinicians and patients confronting decisions about mental health while undergoing dialysis may experience better care and outcomes.”
A teledermatology clinic that was launched in a church is the model for a program aimed at creating new channels for underserved residents to access healthcare.
A DC-based health system has launched a grant program aimed at using telehealth to expand access to dermatology services in underserved neighborhoods.
The clinic offers access to care for treatment of inflammatory dermatoses, such as Atopic Dermatitis, which affects more than 30 million children and adults in the US.
“During the pandemic, the healthcare divide became even more apparent across many underserved areas,” Adam Friedman, MD, chair of dermatology and residency program director at the GW School of Medicine and Health Sciences, said in a press release. “However, as telemedicine enhanced access to dermatologic medical care for many, we also noticed that the divide itself was widened not just because there was a health desert, but now there’s also a technology desert.”
“Specific populations are at greatest risk for physical, emotional, and financial losses associated with inflammatory dermatoses," he added. "And it is well established that there are significant racial disparities in healthcare and disease burden. For example, those who identify as Black tend to have more Atopic Dermatitis [and] have more severe disease, but make up fewer of the appointments seen by a dermatologist for this condition. While finally receiving the attention it deserves, this disparity has been long-lived and pervasive in all areas of medicine.”
Friedman's program is one of many across the country aiming to address lack of access to healthcare by putting clinics and/or telehealth stations in areas where communities tend to gather, like churches, malls, pharmacies, salons, community centers, homeless clinics, and libraries.
"I appreciated that utilizing and partnering with a community lighthouse, so to speak, would engender a sense of trust and comfort for those potential patients in the area," Friedman said in an e-mail exchange with HealthLeaders. "Using a familiar location demystifies an unknown and unfamiliar program."
The grant program, offering grants of up to $250,000, aims to identify healthcare organizations that can take this model and expand to other underserved areas and communities. Applications are due by August 24, with programs expected to start by January 2024 and continue for as long as 18 months.
"First and foremost, I want applicants who are just as excited as I am to explore new ways and approaches to improving healthcare outcomes to those who need it most," Friedman told HealthLeaders. "I want to not only see how the applicant and their team will employ our telehealth help desk model within their community, but how they plan to sustain beyond the period of the grant. The funds can be used to support medical students interested in pursuing dermatology to dedicate, coordinate, and oversee the execution of the clinics; to compensate community partners for their time and investment in the project's success; [and] to purchase supplies and tools needed for a successful series of clinics and marketing/advertising to ensure a steady stream of patients."
The telehealth help desk, established in a church with more than 15,000 members, offers resources and education on how to access and use telehealth and specific dermatologic diseases like Atopic Dermatitis and Alopecia Areata, and can link a visit to a specialist for a free virtual visit. Patients are registered through GW's EHR platform and can be scheduled for follow-up visits.
“The number of dermatologists/dermatology clinics in this area of the district is disproportionately low to serve the health needs of this large population," Friedman said in the press release. "In fact, there is not a single dermatologist practicing in this area of DC. Though the reasons for underutilizing telemedicine can vary from patient to patient, we believe that improving access to technology and increasing awareness of teledermatology will lead to more patients using this type of healthcare to seek diagnosis and treatment before symptoms become too severe.”
Friedman told HealthLeaders the process of finding partners to establish clinics and good locations for those clinics isn't easy. Good programs need high traffic and visibility and a steady base of volunteers.
He hopes to expand this model not only to other locations, but to address other chronic conditions.
"This grant program, even the telehealth help desk we established and can now continue thanks to [support from organizations like (Pfizer and Lilly] is an amazing example of how academic and pharmaceutical partnerships can be meaningful [and] productive and achieve the shared goal of improving patients’ lives," he said. "I am very grateful we have the opportunity to take the learnings and experience from our free clinic and support those we fund to launch this model in other cities to ensure success."
Liz Ashall-Payne, the founder and CEO of ORCHA, an international effort to establish digital health standards, explains why mHealth apps need a rigid rating system to gain widespread acceptance.
[Editor's Note: Liz Ashall-Payne is a trained clinician in the UK's National Health Service and the founder and CEO of the Organisation for the Review of Care and Health Apps (ORCHA), a global leader in digital health accreditation and distribution services.]
Twenty-five years ago I started my career as a speech language pathologist for the British National Health Service. And from day one I was frustrated that I could only see one patient at a time, especially with long waiting and treatment times.
When digital health and mobile health apps began to appear on the market, I realized that these scalable tools could help solve those problems. They can be given to one person or one million people, giving everybody access to help at the same time.
Back then, there were only around 35,000 digital health apps, but more importantly, nobody was using them.
With that in mind I founded the Organization for the Review of Care and Health Apps (ORCHA). Our mission was to be an arbiter between the tech-focused health app developers and the healthcare providers who wanted to use and/or prescribe these new tools, holding these health apps to the highest possible standards.
Liz Ashall-Payne, founder and CEO, ORCHA. Photo courtesy ORCHA.
On one hand, having this technology on our cellphones brings unparalleled possibilities for the future delivery of healthcare. Health apps can help us manage chronic conditions such as cancer or diabetes, remind us to take meds, encourage us to eat well and exercise more, flag potential skin cancers or help support us with our mental health.
On the other, this market still is largely unregulated, and poor-quality apps can present a significant risk to IT security and patient safety. Unlike the tightly controlled medication marketplace, the health apps available to consumers on Google and Apple app libraries are subject only to light oversight.
Yet when these apps are put through an ORCHA assessment, we consistently fail around 80 percent of them. They fail due to poor performance in data privacy, professional assurance, or usability, or a combination of the three.
In contrast, when the federal right to abortion was overturned last year, we were all jolted by the unexpected consequences to digital technology. Users of period tracker apps who had felt safe and private found that their most sensitive data was being shared with third parties--and that, in the wrong hands, this data could be used against them. Our own research found that 84% of period tracker apps were sharing data with third parties and half showed poor compliance with privacy laws.
Our team has identified several apps that are popular on app stores but offer little or no evidence of support from a healthcare expert or any published trials or studies. These include a substance abuse app with more than 100,000 downloads and an AI chatbot with 10 million downloads.
So here we are, on the cusp of a healthcare revolution that offers unlimited potential for every demographic in the US, and with citizens increasingly ready to use these tools (5 million are downloaded each day) but with significant issues still to be addressed.
In 2020 an open source and multi-organization steering group was set up to tackle this problem. Working together, and in the interests of the public good, the American Telemedicine Association, the American College of Physicians and ORCHA developed the nation's first health app assessment framework – a nationwide effort to raise the quality of health apps.
The Digital Health Assessment Framework (DHAF) offers a universal benchmark, testing each health app against 400 standards, including the Health Insurance Portability and Accountability Act (HIPAA). The framework has been developed based on existing and emerging global digital health assessment models, including those used by UK's National Health Service, the German Federal Ministry’s DiGA and emerging standards used in Scandinavia, New Zealand, and Canada.
To meet the DHAF standards, digital health products need to score 65% or better in three criteria: Data privacy, professional assurance, and usability.
The objective is twofold: To help digital health app developers produce better products, and to collate the high-quality apps which pass the DHAF review into digital health app libraries. Physicians can then use these online libraries to recommend top quality health apps to their patients.
As an example, the ThyForLife app helps more than 30,000 people cope with thyroid cancer.
“I find the DHAF to be the necessity in this field because the lack of regulation means the barrier of entry is very low," the app's developer, Natalia Lumen, says.
“It has been difficult for professionals to know which tools are reliable and they don’t have the capacity to do the due diligence to find the resources available," she adds. "Having a standard approach that collectively everyone agrees is the right benchmark helps create more transparency and enables professionals to feel more at ease. Without the framework the healthcare professional cannot recommend digital tools. It also benefits the patients themselves, as they now have access to the best tools and assurance that the tools are top quality.”
A year on from launch, the DHAF team has reviewed hundreds of health apps and is working with organizations across the country to set up safe and trustworthy health app libraries.
While the DHAF, which remains an open-source program, gathers steam, the message needs to get out get out that people should be asking their healthcare providers for health app recommendations, and those providers should be familiarizing themselves with apps, where they can, and to begin telling patients about them.
What we are all trying to achieve here is to get better healthcare to more people, so that consumers can learn to manage their health better from their homes. It's not going to be easy, but considering that are now more cellphones on this planet than toilets and toothbrushes, it is achievable.
The chief innovation and transformation officer at Israel's largest hospital talks about the ARC innovation model and efforts to forge international partnerships.
One of the world's most innovative healthcare organizations is Sheba Medical Center, located near Tel Aviv in Israel. In 2019, the hospital launched the ARC innovation model, and set its sights on guiding the evolution of healthcare across the globe. Earlier this year Sheba signed an agreement with Deloitte Consulting to facilitate adoption of the ARC model in other countries.
To explore the global implications of the ARC model, HealthLeaders sat down, virtually, with Eyal Zimlichman, MD, MSc (MHCM), chief transformation officer and chief innovation officer at Sheba Medical Center. Prior to joining Sheba, he was lead researcher at Boston-based Partners Healthcare, now part of Mass General Brigham, and conducted research for Brigham and Women's Hospital and the Harvard-affiliated Center for Patient Safety Research and Practice on using technology to improve quality and patient safety.
Q. What is the ARC innovation model and how does it benefit healthcare organizations?
Zimlichman: ARC is short for accelerate, redesign, and collaborate. The ARC innovation model allows healthcare institutions to accelerate transformation efforts to answer the many challenges that healthcare systems currently face while also turning healthcare innovation into an engine of economic growth.
Based on our experience at Sheba Medical Center, we were able to build a model that can really move the needle on both aspects simultaneously. The model was built in a way that is very structured, enabling it to be implemented successfully anywhere in the world not just specifically at Sheba. To our knowledge, it is the only model of its kind in the world.
Q. Several large health systems in the US have created their own innovation centers and programs. How does the ARC model differ from those programs?
Zimlichman: ARC is not really an innovation center; it's much broader because it has a global aim. ARC aims to transform healthcare around the world, and to do so by the year 2030. This goal requires a very specific strategy that will enable us to reach the global standard we've set for ourselves.
To achieve this goal, ARC has built a global ecosystem that now includes more than 140 members in almost 30 countries. These members are all working together to lead transformation efforts for themselves, but also drive this as a global effort. This is unique because other hospitals typically focus internally to create solutions to be deployed only in their institutions.
Our partners include leading medical centers such as Mayo Clinic, Mass General, and Cedars Sinai, in addition to many international industry partners, governments, academia, startups, and more.
Q. What are the challenges or barriers to healthcare innovation that ARC addresses?
Zimlichman: ARC is looking to address the most critical challenges facing healthcare.
One of these challenges, for example, is quality and patient safety. There are huge gaps in quality and patient safety around the world which we've not been able to address over the last 30 years.
Another challenge we're facing is the workforce shortage and burnout, which is a critical problem right now, especially post-pandemic. ARC is focused on finding solutions to address this by taking the load off clinical teams and creating solutions that can replace some tasks that today are carried out by humans.
A third challenge is the rising cost of healthcare. Healthcare costs are on the rise in every developed country around the world and they are reaching unsustainable levels. It requires innovation to be able to provide a high level of care at a lower cost.
Finally, how do we build a system that will be more focused on the patient's needs and expectations and have the patient play a critical role within the system? This is another barrier that current healthcare systems have not been able to bridge. ARC is working on solutions to try and solve that.
Q. How are new or emerging technologies integrated into the ARC model?
Zimlichman: To really see the vision for the future of health come alive and make these transformations a reality, technology needs to play a central role in disrupting how we're delivering healthcare today.
We need to focus on two avenues to create these technological solutions. One is organic innovation, and the other is open innovation.
Organic innovation is technologies we develop in-house, based on the needs that we realize in the market. We then find the right teams to create solutions that we can implement and take to market, to have large-scale implementations across multiple institutions.
However, organic innovation is never enough to create meaningful transformation. For that, you also need to have open innovation, which is the ability to look outside of your own walls. We find the best technology outside and bring it in, so that we can create impact for our patients.
This is a central component of ARC as well. We've built an open innovation platform that constantly allows us to find the right technology, prove that it works, and take it to large-scale implementation.
Q. Would you say that's like a venture arm within ARC? Is that a good way to describe it?
Zimlichman: There is also a venture arm within ARC. The funds work to recognize the right technology, give it the support needed to grow, and get to a point where it can impact many patients.
In 2019, we identified the need for capital within ARC and established our first fund, Triventures. This was followed by two more funds, including Shoni Health Ventures. They are critical as well to ensure we get great ideas and great technologies to scale up.
Q. How do you measure success in the program?
Zimlichman: There are several metrics that we use. Some specifically look at the impact on our patients. For example, clinical outcomes or cost reduction. For technology solutions, we generally measure how much we're able to improve efficiency as well as effectiveness. That's one angle.
The other angle, of course, is financial. Are we able to really drive the economy and make this a successful and sustainable commercial model? We measure how many companies are born out of ARC. How much money have they raised? What are their accumulated valuations? How much are they selling on the market? These are all metrics that we've been following since the launch of ARC three and a half years ago.
Q. Could you point to a specific pain point in the healthcare industry that the ARC model has already helped to address?
Zimlichman: One example is our focus on technologies specifically related to artificial intelligence, which allows us to help clinicians improve decision-making and efficiency. A company called AI Doc that started at Sheba and is now deployed in 1,200 hospitals around the world, and is transformative in the way that it helps radiologists in the emergency department read the scans in a much more efficient manner. That has led to an improvement in patient outcomes--reducing mortality rates, for example, but also creating a reduction in cost for the hospitals due to the increased efficiency of radiologists. This is an example of where we could help in terms of being more sustainable, both in terms of trying to reduce our dependency on the human factor and improving quality and patient safety.
Q. What are the biggest challenges that healthcare organizations face in adopting the ARC model?
Zimlichman: One significant aspect is the culture. It requires a culture of innovation, a culture of being open to change. That is not always existent from the get-go, but part of the ARC model is about improving the culture.
We firmly believe that culture can be transformed and become a culture that's more open to innovation and change. This is part of the model of implementing ARC. Of course, it's always a challenge, especially when you start, and there's a lot of reluctance to change from your own staff. That's challenge number one.
Challenge number two is funding. Innovation is costly in many ways, especially if you want to build something robust and big enough to have a long-lasting impact. There are many opportunities for funding, such as government support, competitive grant funding, or even philanthropy, that will allow academic medical centers to build this much-needed infrastructure. But it is a challenge. Finding the source of funding, as we all know, is a challenge.
Q. How will the Deloitte partnership help this program?
Zimlichman: After spending three years building the ARC model, we started implementing it in different sites around the world. We very quickly understood that this was not our business; we're not consultants, we're a hospital. In addition, we don't have the capacity to do this for more than three or four institutions a year.
As the demand for ARC increased around the world and we realized that we don't have the capacity to teach organizations how to build ARC, it was evident we needed to find a partner in the consulting space to help us scale up the ARC model. As a result of an RFP that was put out, with five consulting firms applying, Deloitte emerged as the winner. Now we're at a stage where we're putting together a joint product that Deloitte will take the lead in implementing around the world, with ARC's help to make sure it accurately encompasses what ARC is about.
We believe Deloitte is a critical partner to deliver a more professional product and enables us to scale up. Instead of doing just three or four implementations each year, we will be able to do 40 a year, which is our ultimate aim, to be able to scale up significantly.
Q. How do you see this program evolving?
Zimlichman: We see the ARC ecosystem growing, becoming stronger, and building better ways to collaborate. It's always a journey that we're on. ARC will have a substantial impact on what healthcare around the world will look like, accelerating transformation efforts through creating new solutions that will be able to answer the many challenges that we are facing.
Eventually we see ARC as a global force that will lead to two key outcomes that we're focused on. The first is improving the health of populations around the world through transformation. The second is driving the economy, within the local ecosystems, through investments, job creation, growth in businesses and so on.
Regarding our partnership with Deloitte, I personally am very excited about the possibilities. We found a great partner in Deloitte, with a very similar way of thinking.
We're confident that the Deloitte-ARC joint product will be the leading model around the world to drive transformations and growth in the healthcare sector and the economy. I would like to relay the dedication and excitement of the entire team on this new journey we're taking together with our partners.
Stacy Taylor, CFO at Nemaha County Hospital, chats with Associate Content Manager Amanda Norris about innovative ways Nemaha County Hospital has worked to optimize its workforce, provide revenue cycle education, and ensure financial stability as a small, critical access hospital.
The initiative, which has received support from close to a dozen healthcare organizations, is the latest in a string of programs aimed at supporting nationwide interoperability.
The Data Usability Taking Root Movement is designed to "make health data more useful" by encouraging organizations to follow guidance posted by the Sequoia Project Interoperability Matters Data Usability Workgroup.
“Over three years, more than 260 health organizations worked together through The Sequoia Project to develop practical guidance to make health data more useful for healthcare providers, health IT vendors, public health, health information exchanges, and patients,” Mariann Yeager, the Sequoia Project's CEO, said in a press release. “It’s time to put this guidance into action for the public good.”
“Implementers choose to work on areas that matter most to them,” added Didi Davis, the group's vice president of informatics, conformance, and interoperability. “For some, this could mean working on data provenance and traceability of change, data integrity and trust, or data tagging and searchability. For others, it could mean effective use of codes, reducing the impact of duplicates, effective use of narrative, or any combination they choose.”
Close to a dozen healthcare groups have pledged to support the initiative, including the HIMSS Electronic Health Record Association (EHRA), Epic, HCA, Health Gorilla, and Optum.
Several virtual events are planned this summer, leading up to a Data Usability Taking Root Summit on September 6 in Washington DC.
“Data usability is part of the DNA of the health information profession," AHIMA Chief Executive Officer Amy Mosser said in the press release. "We support this work not only because the public and private sectors together have made significant strides in health data interoperability, but because for over 96 years, AHIMA has been laser-focused on ensuring the completeness and usefulness of health data. Implementation of data usability guidance on a national scale will promote consistency across technologies that share data, at a time when more data are available and shared than ever before.”
The effort is the latest in a series of projects aimed at establishing a nationwide health information
Researchers have developed algorithms that can scrub EHR notes for references to specific social factors, giving providers the data they need to improve care management and treatment.
Researchers have developed natural language processing tools to pull data from clinical notes that will help address social drivers of health.
The technology aims to help healthcare providers address SDOH in care management and treatment plans for patients.
“Health and well-being are not just about medical care," Joshua Vest, PhD, a faculty member at both the Regenstrief Institute and Fairbanks School of Public Health and the study leader, said in a recent press release. "Mostly, they are about our behaviors, our environment, our social connections. More and more healthcare organizations are having to deal with social determinants because it is factors like financial resources, housing, and employment status that really drive costs that make people unhealthy. The challenge for healthcare organizations is effectively measuring and identifying patients with social risks so that they can intervene.”
Vest and his team developed three rule-based NLP algorithms and scanned notes from two different Indiana-based health systems, targeting keywords specific to three social factors.
"The demand from payers, policy-makers, and advocates for information on patients’ social factors and needs is substantial and multiple approaches are requested to obtain this information," they noted in their study. "In recent years, coding standards for recording social risks as structured data within EHRs using ICD-10 or LOINC codes have advanced substantially. Nevertheless, these structured data are very underutilized in practice."
The study noted that this technology would work best as part of an overall social health measurement strategy.
"It is important to not discard clinical text in favor of screening or other structured methods for data collection," the researchers noted. "However, social factors extracted via NLP could be utilized to impute missing survey results, augment survey data, or—given the ability to apply retrospectively—provide a longitudinal description of social factors. As products of a clinical encounter, these patient interactions and the information within clinical notes are important. However, it is also critical to remember that the text is, by nature, selective, filtered, and containing omissions (either left unrecorded by the provider or never volunteered by the patient). A comprehensive health measurement strategy will include formalized screening as well as information garnered from clinical documentation."
Vest said the study is one of the first to apply NLP tools to SDOH collection, and it points to the value of using a "relatively simplistic" tool to collect data from notes rather than more sophisticated AI tools that many health systems can't use or afford.
“We purposely designed a system that could run in the background, read all the notes and create tags or indicators that says this patient’s record contains data suggesting possible concern about a social indicator related to health," he said in the press release.
"Our overall goal is to measure social determinants well enough for researchers to develop risk models and for clinicians and healthcare systems to be able to use these factors—housing challenges, financial security and employment status—in routine practice to help individuals and to provide a better understanding of the overall characteristics and needs of their patient population.”
Payer scrutiny won't be letting up anytime soon, in fact, expect it to intensify.
The COVID-19 public health emergency has come to an end, which means more audits will be coming your way.
To prepare for a potential increase in payer audit activity, especially from CMS, it’s essential for revenue cycle leaders to examine upcoming trends so they can best protect an organizations’ bottom line.
In fact, organizations should expect heavier scrutiny from Medicare risk adjustment data validation (RADV) auditors in the near future, Rose Dunn, chief operating officer of First Class Solutions Inc. in Maryland Heights, Missouri, told NAHRI. “We are definitely going to see an uptick in activity because the RADV auditors have a few years to catch up on,” she said.
Telehealth will be looked at more intensely moving forward, Sandy Giangreco Brown, director of coding and revenue integrity at CliftonLarsonAllen LLP in Minneapolis, Minnesota, said in the same article. “I’ve done a fair number of audits for telehealth over the last three years and identified some things,” she says. Now that the public health emergency is over, leaders need to determine what will and won’t be allowed by different payers, she said.
To help with telehealth policy compliance and avoid potential payer audits, Brown suggests conducting internal audits as soon as possible. “I think we’re going to have to do our due diligence and make sure we are following who is allowing what,” she says.
Telehealth audits will likely focus on whether provider organizations were billing appropriately based on what rule was in place at that point in time, Dunn says. Auditors will look for documentation issues, as well as whether it was appropriate to treat a patient via telehealth. “I think this area is ripe for audits,” she says.
Going forward, Dunn emphasized to NAHRI that the need for national rules that preempt state requirements, especially for providers who are located near state borders.
Providers should also expect heavier scrutiny on reimbursement for COVID-19 claims, according to Brown. “We’ve seen some really sick patients who had COVID-19 on top of comorbidities,” she says. “And those are some long lengths of stay with very complex patients.”
Responding to COVID-19 audit requests shouldn’t be different than responding to any other audit requests based on diagnosis, such as sepsis or malnutrition, Brown noted to NAHRI. As long as the documentation is thorough and the audit response is complete and timely, there shouldn’t be any surprises.
Interwell Health CEO Bobby Sepucha joins HealthLeaders editor Jay Asser in this week's episode to share how the physician-centered organization is utilizing value-based care to set the standard in kidney care. Sepucha also discusses Interwell Health's strategic partnerships, the future of value-based care, and the operational challenges he deals with at the helm of the company.
With a Medicare-supported model as a blueprint, health systems are finding a lot to like in an acute care at home strategy. But they also have plenty of room to be creative.
Healthcare is embracing the trend of shifting care from the hospital to the home, and forward-thinking health leaders are finding there's plenty of room for flexibility.
Hundreds of hospitals across the country have launched an acute care at home program, focused on treating patients at home versus in a hospital bed. Many of those hospitals are following the Acute Hospital Care at Home model developed by the Centers for Medicare & Medicaid Services (CMS), which sets strict guidelines for in-person care to qualify for Medicare reimbursement.
This strategy, which combines virtual care with in-person services, could be a mainstay in healthcare. But it's a complex process, with an ROI that may take years to show itself.
At a recent HealthLeaders NOW virtual summit, participants from eight different health systems said the future may lie in modifying the model to suit each organization's specific care needs and resources, even if that means bypassing Medicare reimbursement for now.
"We're constantly tweaking it," said Eve Dorfman, vice president of NYU Langone Health, which stood up an acute care at home program less than a year ago that focuses solely on acute care rather than post-acute care. "It's very much a hybrid model."
Dorfman said it took a while to iron out the wrinkles, including infection prevention at home and remote patient monitoring. The health system even used a simulation lab to help nurses "look at the healthcare delivery model differently."
"This is a collaboration," she said. "It is different."
While acute care at home programs have been around for more than a decade (one of the first was launched at Brigham and Women's), the strategy burst onto the mainstream during the pandemic, when health systems created programs to treat COVID-19 patients at home and reduce stress on overtaxed inpatient services.
The CMS Acute Hospital Care at Home program was launched in November 2020 to address those needs. The program sets rigid rules for Medicare reimbursement and requires hospitals to apply for a waiver of the Hospital Medicare Conditions of Participation, which mandate round-the-clock nursing coverage on the premises.
More than 270 hospitals in more than 120 health systems are currently following that model, with the CMS waivers remaining in place until the end of 2024. Lobbying efforts are underway to make those waivers permanent, but the uncertainty of continued Medicare support is affecting how health systems map out scalability and sustainability.
Because the concept is so new, some states haven't caught up to it yet. Eve Cunningham, MD, MBA, group vice president and chief of virtual care at Providence, said its program was almost shut down before it started because Washington state law has strict definitions on hospital-level care. And Penni Kyte, digital care strategy officer for Ballad Health, said her health system had more problems working with Tennessee state officials to OK a program than they did with CMS.
Lauren Hopkins, MPH, assistant vice president of virtual care and community engagement at Augusta University Health, said the health system started with an all-virtual platform to treat COVID-19 patients and has since pivoted to focus on the transition from acute care to post-acute care, including chronic care management. The health system hasn't applied for CMS waivers yet, she said, because Georgia hasn't amended its state laws to accommodate the care model.
With the uncertain policy and regulation landscape as a backdrop, health systems are developing their own acute care at home programs. Some are using their own nurses for home visits, while others are partnering with home health or mobile integrated health programs. Some are monitoring patients around the clock, while others are collecting data from patients at certain times of the day. Some are using wearables, and some are integrating pharmacists, physical rehab, even health and wellness services to address social drivers of health.
And not everyone is going with the CMS model. Cunningham says some programs are seeing success with bundled payment models and other services that payers are willing to reimburse.
In a separate interview with HealthLeaders, Tina Burbine, vice president of care innovation and enterprise analytics at HealthLink Advisors, which has advised many health systems—including negotiating with payers—to set up these types of programs, said there's no set definition of acute care at home.
"There are many different flavors of care at home," she said. "And hospitals are seeing a lot of success … as long as they mindful of incorporating their value-based care goals."
"There's so much learning that has to happen" with the CMS model, adds Burbine, who recommends that hospitals start small and build up their program slowly and incrementally with lesser-acuity patients, to see whether high-acuity care will work for them. "This has become such a competitive market that we're even seeing payers compete with health systems."
Some say the acute care at home model will evolve significantly as COVID-19 fades away and hospitals take back some of those inpatient services to bolster their bottom line. In that scenario, the platform shifts more toward post-acute care, including rehabilitation and chronic care management.
Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, said during the HealthLeaders virtual summit that acute care at home may eventually surpass inpatient care as the highest quality acute care platform. The challenge lies in navigating the complexities to create a program that fits well within the health system.
"Think of this as building another brick-and-mortar hospital," he added. "It is very challenging work, but it is so beneficial."
"They've really been helping to drive this," he said of KP's provider base. "There's a general excitement to do this."
Burbine says the model could someday replace the rehabilitation center as a better and more cost-effective post-acute care pathway and create better alternatives to skilled nursing facilities. It might also be used in prisons, substance abuse treatment programs, and for other populations where hospitalization is difficult.
"Ideally, we want our patients' care to be managed by their health system," she said. "And we're seeing new ideas [for] how that can be done. It changes not only the definition of a hospital, but the definition of a home."
