"We don't want to wait for symptoms. We can be proactive, before a full exacerbation of a chronic disease," says one ACO executive.
Editor's note: This article is part of HealthLeaders' Mind the Gap series, a three-part exploration of how healthcare is bringing information, patients, care, and payment closer together. Read the other articles on automated prior authorizations and real-time drug benefits checks.
Yet another benefit of the pandemic's telehealth expansion is more hospital-at-home (HAH) and remote patient monitoring (RPM) programs. Integra Community Care Network, the accountable care organization (ACO) for Care New England Health System, is launching both in partnership with tech company Biofourmis. And with the Centers for Medicare & Medicaid Services (CMS) expanding HAH waiver eligibility and reimbursement parity beyond the COVID personal health emergency, look for more payviders and health systems to deliver at-home solutions.
Two programs for at-home care
The Integra HAH waiver program, per the Biofourmis press release, will " 'admit' patients to their homes instead of a medical facility for inpatient-level care." Data from wearable sensors connects with the company's FDA-cleared Biovitals Analytics Engine to monitor the status of Medicare patients, who will also be connected via tablets, video, and in-person home visits as needed.
"This enables us to be just so much more connected to patients and better able to help people feel comfortable 24/7," says Ana Tuya Fulton, MD, MBA, chief medical officer at Integra and executive chief of Geriatrics & Palliative Care at Care New England.
Integra's second program for remote monitoring applies to its entire ACO population—Medicare, Medicare Advantage, Medicaid, and commercial—with a focus on patients with congestive heart failure, COPD, asthma, and other chronic conditions.
"Integra ACO has remote monitoring for multiple populations," says Fulton "with a focus on improving outcomes, decreasing costs, and improving patient/member satisfaction." From the Biofourmis release, Fulton added: “From a clinical and cost standpoint, safely keeping patients out of the hospital is certainly one of our goals as a risk-bearing ACO …"
A little help from CMS
The HAH program from Integra/Care New England and a growing list of hospitals was made possible by CMS' Acute Hospital Care at Home waiver. Announced in November 2020, the program is part of the agency's broader Hospital Without Walls initiative. While the program is strictly for Medicare beneficiaries, Fulton notes that some states may be working toward a similar solution for people enrolled in Medicaid. In December 2021, CMS issued a revised Fact Sheet to help state and local governments develop "alternate care sites with information on how to seek payments through CMS programs."
Fulton cites Integra ACO's foundations as a strong one for their current work. "We've been learning the care pathway with our patients," she says. "We started as an early ACO in community-based, complex care management with interdisciplinary teams taking care of the highest need, typically older patients. Noting that "we wanted to build a continuum to give options," Integra expanded from nurse practitioner and nurse care manager home visits to a
Community Care Medicine program in 2018 that added rapid-response acute care to the home. In 2021, Fulton says that Integra added to their remote-monitoring capacity with one goal: "We don't want to wait for symptoms. We can be proactive, before a full exacerbation of a chronic disease."
The role of patient identification
As to the other ways that an ACO can grow itself operationally? "Correct patient identification is everything," says Fulton, adding: "No one has it nailed down 100% and everyone is looking for the secret recipe. Utilization and cost data to stratify risk is not enough."
Fulton continues: "We spend a good chunk of our time digesting data from claims-based payer reports, including Medicare. Who are our patients, what are their conditions, what claims do they have?" She adds: "We look at their clinical needs, our medical programing, community resources, social determinants of health. We spend a great deal of time in an ACO analyzing data, honing programs—and it changes every year. I spend so much time living in the patient EHR."
While Fulton is living the patient's EHR, she is helping to create a situation where more patients can do their living at home. Integra's HAH and RPM programs seek to transfer elements of care from a hospital setting to one where convenience and familiarity may help speed healing.
Laura Beerman is a contributing writer for HealthLeaders.
One Northeastern ACO is building off its complex-care roots to advance design of its hospital at home and remote patient monitoring programs.
A combination of wearable sensors, tablets, video, and in-home visits will aid a variety of patients with chronic conditions.
The ACO cites the critical role of accurate patient identification, continuous data analysis, and program refinement.