Thousands of COVID-19-positive patients cared for safely via hospital at-home programs. Food insecurities for a thousand patients solved for, in conjunction with payers. Hundreds of emergency department visits averted. Millions of masks provided to communities.
Yes, COVID-19 presented once-in-a-century challenges – but it has also served as a catalyst for positive and broad transformation in the U.S. health system. For care providers and patients, these new realities – from broader adoption of telehealth to increased inclination toward alternative payment models (APMs) – will outlive the pandemic.
In short: Reverting to yesterday’s health system is not an option. The call now is for providers and payers to carry their learnings and innovations forward.
Two integrated health systems that are members of Premier’s Population Health Management Collaborative (PHMC) are embodying this creed. Both Atrium Health, based in Charlotte, NC, and Detroit-based Henry Ford Health System joined the PHMC in 2017, and they have leveraged their existing population health capabilities and technology infrastructure to meet critical care delivery needs during COVID-19.
Of course, these capabilities didn’t pop up overnight. First, they had to lay the foundation for population health progress.
The Groundwork for Innovation
Providers that are leading the way in COVID-19 innovations have been working in the population health space for years. Some of the capacities they’ve built to enable success include:
- Using claims-based population health analytics and peer-to-peer benchmarking to strategize care for at-risk populations
- Operating value-based payment models and structures such as accountable care organizations (ACOs), clinically integrated networks (CINs) and bundled payments, which incentivize and operationalize proactive care in low-cost settings
- Identifying and addressing physical, behavioral and social needs of patients by engaging with community-based partnerships with schools, food banks and local nonprofits
- Utilizing disease and care management programs and cross-continuum care coordination models, as well as home care and remote monitoring, to optimize care for patients in a timely manner and reduce high-cost, acute episodes and exacerbated chronic conditions
A key to effective, timely and financially prudent deployment of these capabilities is a safe space in which providers across the nation can network, share lessons learned and leverage guidance from industry experts. As an example, Premier’s PHMC, which has nearly 70 member health systems, offers ongoing support, networking and peer-to-peer learning opportunities for its members, including Atrium Health and Henry Ford, enabling them to learn best practices, avoid mistakes and accelerate progress related to value-based care.
The PHMC, which enabled 75 percent of participants to generate savings for Medicare in 2019, not only helps direct providers’ value-based strategy and capability development, it also supports performance improvement across payer segments.
Hospital at Home
There are many flavors of “hospital at home” but the core objective is consistent: enable providers to effectively monitor and care for patients as they recover in the comfort of their own homes. This can include remote monitoring capabilities, in-home provider visits, telehealth, medication management and many other care strategies. Patient selection criteria and scale also vary.
With COVID-19 as the springboard, Henry Ford and Atrium Health have embraced this concept and have tailored their programs to meet specific patient and organizational objectives.
The impetus: In May, Premier reported survey findings that illuminated how experience in population health and APMs put providers a step ahead in their response to the pandemic. This holds true for Atrium Health and Henry Ford, both of which participate in numerous value-based payment arrangements that cover approximately 300,000 and 350,000 beneficiaries, respectively. Atrium Health participates in the Medicare Shared Savings Program (MSSP) and Henry Ford in the Next Generation ACO (NGACO), and both have value-based commercial and Medicare Advantage agreements in place.
Both systems leveraged the capabilities and infrastructure that have enabled their success in these payment models to bolster their pandemic response efforts. They had each planned to launch a hospital at-home program for some time and found that COVID-19 was the critical accelerant to formalize and rapidly scale their offerings.
Response and structure: There are similarities and differences amongst each organization’s program, which support their distinct objectives. Both models facilitate in-person visits in the patient’s home through paramedics, with physicians (primary care and hospitalists) conducting telehealth visits as needed.
To quickly scale its program, Atrium Health leveraged its Triage Call Center and Mobile Integrated Health (MIH) program. The MIH program deploys paramedics and nurses to patients’ homes and conducts daily virtual visits through physicians and advanced practice providers as needed. MIH clinicians conduct home visits based on protocols and direct provider orders. Ruth Krystopolski, SVP of Population Health at Atrium Health, shared that its program is currently geared toward COVID-19 patients and contains two virtual “floors”: a virtual “acute” floor and an “observation” floor.
Henry Ford also leaned on its paramedic-based MIH program and extensive telehealth capabilities. In five weeks, Henry Ford procured the equipment and vehicles necessary to facilitate its hospital at-home program, and developed clinical protocols, a patient referral and identification process, a way to document the visit in the electronic health record and a 24-hour triage line.
Both have structured processes in place to identify patients who are a good match for their programs, but their selection criteria differ from one another. Atrium’s program automatically enrolls COVID-19-positive patients from across the system in its observation floor. Those patients as well as patients from Atrium’s acute care facilities and emergency departments (ED) are then escalated to the acute virtual floor as needed.
Henry Ford’s program initially focused on selecting patients to send home early from their flagship hospital and has since integrated patient identification processes in the ED, physician office and the patient’s home. This has enabled providers to appropriately divert more patients away from an inpatient stay if clinical guidelines suggest they can be appropriately and safely cared for at home.
Results: Since launching this spring, Henry Ford has cared for over 650 patients through more than 1,100 paramedic visits as of mid-November, and this number continues to increase as the hospital volumes rise with the second COVID-19 surge that began this fall. Atrium Health cared for nearly 1,500 patients at home from April-November 2020 through their virtual acute floor. Additionally, it virtually monitored nearly 37,000 COVID-19 positive patients with less acute symptoms via its observation floor during this timeframe.
This new avenue of care has freed up hospital capacity, offered a safe and effective method to care for COVID-19 patients, and reduced avoidable ED visits. Of the patients cared for through Henry Ford’s hospital at-home program, called Healing at Home, SVP of Population Health Susan Hawkins reports about one-third avoided an admission or readmission.
Sustaining innovation: Both organizations fully intend to carry their programs forward once the pandemic subsides, recognizing they will need to evolve their models and solve for new barriers that arise. In the 2021 Physician Fee Schedule Final Rule, Medicare permanently added additional services to the Medicare reimbursable telehealth list including group psychotherapy, neurobehavioral exams, care planning for patients with cognitive impairment and home visits. However, significant expansion of reimbursement is still needed through Medicare and other payer segments to broadly support hospital at-home programs post-pandemic.
Henry Ford’s participation in the Next Generation ACO model affords flexibility due to the waivers in the program, and they are providing hospital at home services to patients across payers and the uninsured. As providers await more information from the Centers for Medicare and Medicaid Services on telehealth regulations moving forward, Atrium Health and Henry Ford are working with their payer partners to help ensure providers are compensated for patient care in the most appropriate site, including the patient’s home.
In addition to addressing reimbursement, Henry Ford is actively budgeting to expand its program to other hospitals throughout their system and expanding the use of in-home skilled nursing for more acutely ill patients. Atrium Health is evaluating how to align its program with its existing population health and value-based models. Furthermore, Atrium is appraising unintended factors, such as the impact on readmission rates. For example, moving less complex patients to hospital at-home programs can superficially increase a hospital’s readmission rates due to the removal of those patients from the metric’s denominator, potentially harming performance in value-base programs.
Community Engagement and Care Inequalities
Atrium Health and Henry Ford both focus on community engagement and care inequality as a central element of their missions, and each organization already had partnerships with community organizations to address social needs they could build upon.
The impetus: COVID-19 presented a heightened need to enhance these efforts due to increased social determinant of health (SDOH) needs and additional socioeconomic, racial/ethnic, and health equity challenges.
- Atrium Health’s approach: Building upon its already robust social and economic impact strategy, Atrium Health used data to identify glaring care disparities. The organization found that a disproportionate number of patients from minority communities were using EDs for COVID-19 tests as opposed to Atrium’s drive-thru testing sites. Atrium Health’s data also unearthed that positive test rates were nearly twice as high within their vulnerable communities.
Response and results: Recognizing the primary driver of this disparity was a lack of transportation, Atrium revamped its testing services and dispatched several mobile testing units into the most vulnerable communities in the Charlotte area. In addition to testing access, given research shows that masks reduce the risk of COVID-19 by 65 percent, Atrium Health partnered with other Charlotte area organizations to launch the Million Mask Initiative.
As of mid-October, Atrium Health had conducted more than 18,000 COVID-19 tests at its mobile testing sites and given away nearly 1.6 million masks, targeting vulnerable communities. Furthermore, to reduce the likelihood of spreading the virus, Atrium in partnership with Charlotte and Mecklenburg County is operating a hotel where COVID-19-positive patients can reside as they quarantine from friends and family.
- Henry Ford’s approach: Henry Ford’s community engagement and social determinants strategy is tightly aligned with the specific needs of its community. Paramedics who visit patients in the home conduct a full SDOH screening and bring boxes of food to patients with food insecurity.
Response and results: In response to the pandemic, Henry Ford scaled its programs to meet heightened demands and has pursued additional funding sources and partners to help enable this expansion. In partnership with three payers, they are scaling the Henry’s Groceries For Health program to meet food insecurities for 1,000 patients, a three-fold increase from prior to the pandemic.
Additionally, the system created COVID-19 Care Kits to give to patients with symptoms as they await test results. The kits include a pulse oximeter, thermometer, Gatorade, information about who to call with concerns or questions, and additional support resources. Henry Ford also expanded its initiatives to address housing insecurities through a shared grant facilitated through UnitedWay of Southeast Michigan, to provide a hotel room post-discharge if the patient’s home environment was not supportive of healing.
Sustaining innovation: Both Atrium Health’s and Henry Ford’s commitment to social justice and investment in community engagement start at the top. Atrium Health created a board committee to guide its strategy around employment, housing, food and specific interventions for conditions. “COVID-19 really spurred our organization from a momentum standpoint to go broader and deeper on SDOH,” shared Atrium Health’s Krystopolski.
Henry Ford’s CEO intends to maintain their progress in this area. The system recently hired a director fully dedicated to overseeing social care strategies and community engagement. In addition, the system’s CEO has committed to rolling out an expanded Diversity, Equity, Inclusion and Justice strategy, focusing on Detroit and its surrounding communities first.
How to Build and Maintain Innovation Through the Pandemic
Atrium Health and Henry Ford are tremendous examples, but innovations stemming from the pandemic are present within health systems across the country. Leading health systems are developing a post-pandemic strategic plan to expand care transformation and emerge stronger.
Their key capabilities include:
- Developing and supporting at-home care, including hospital at home, home health, and in-home primary care and urgent care
- Optimizing virtual solutions to appropriately divert inpatient and ED admissions
- Managing patients with complex conditions and advanced illness needs
- Addressing vulnerable populations and health equities, including the Medicaid and low-income uninsured populations
- Developing a payer roadmap that moves the organization closer to the premium dollar and value-based care
Premier is helping hundreds of health systems and hospitals transform to offer forward-thinking, quality care through the pandemic and beyond. Learn more today and read on here: