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Health care in the United States is massively complex and constantly evolving. Those characteristics make the industry fertile ground for innovation, a process the Center for Medicare and Medicaid Innovation (CMMI) has been encouraging through a federal grant process.
A total of 39 three-year grants, ranging from about $1 million to $30 million, were awarded to healthcare organizations in 2014, the second round of funding (107 grants were awarded in the first round two years earlier). The goal was to jump-start programs that could potentially transform payment mechanisms and service delivery. In theory, the programs ultimately could be applied at other healthcare organizations as part of the effort to achieve the Triple Aim of improved patient experiences, improved population health, and lower costs.
Below are case studies of four programs that received grants, each with the potential to transform an aspect of the healthcare system.
Linda DeCherrie, MD, clinical director, Mobile Acute Care Team, Icahn School of Medicine, Mount Sinai. (Photo: Mount Sinai Health System)
The physician who makes house calls has been part of medical lore for generations, but the economics of health care today generally are not supportive of that model. An innovative program in New York City aims to show that providing acute care at home can improve the patient experience and population health while saving money.
The Bundled Payment for Mobile Acute Care Team (MACT) Services at Icahn School of Medicine at Mount Sinai, which received a $9.6 million CMMI Health Care Innovation Award, provides in-home acute care to patients who present at the hospital's emergency department (ED) and meet certain criteria. The patients return home via ambulance and receive three to five days of acute care and 30 days of follow-up attention.
"We do everything we would normally do at a hospital, but we do it at home," says Linda DeCherrie, MD, clinical director of MACT. "A doctor sees you every day, a nurse sees you two or more times a day, and a social worker and physical therapist see you at least once during that time."
Patients enter the MACT program via Mount Sinai's ED. Eligible patients have one of eight diagnoses—pneumonia, urinary tract infection, cellulitis, chronic obstructive pulmonary disease, dehydration, hyper- or hypoglycemia, pulmonary embolism, or congestive heart failure—and are on Medicare. They also need to live in Manhattan and cannot be on dialysis. About 150 patients have participated since the program was launched in November 2014.
"When an eligible patient enters the ER, we screen them for home safety and then offer them the program by saying, 'Would you like to go home with us instead?'" DeCherrie says. "If they say yes, they are sent home in an ambulance and met by a nurse at home."
The participants receive essentially the same care they would receive in the hospital—including IVs, tests, and professional attention—during the acute period. For 30 days thereafter clinicians are available for follow-up as needed, and a social worker meets with patients to make sure they have transitioned back to the care of their primary care provider.
An important element of the program is coordination with emergency medical services (EMS). If a patient experiences difficulties when clinicians are not in the home, especially at night, the patient can call the physician in charge, who can subsequently call EMS if appropriate. Unlike with typical EMS calls, the responding paramedics can be paid without transporting the patient to the hospital.
"The MACT physicians are certified by our EMS council to provide medical direction, which means they can order medications and treatment by the paramedics," says Kevin Munjal, MD, MPH, assistant professor of emergency medicine at Mount Sinai. "Typically only emergency physicians working in a base station can provide that role, not the patient's own doctor."
Evolution of concept: For the past 12 years DeCherrie has been the director of Mount Sinai's home-based primary care program, which treats about 1,300 patients with chronic conditions in Manhattan. Those visiting physicians occasionally also provide acute care, she says, but payer obstacles prevent such care delivery from becoming routine.
"It's frustrating because patients want to be treated in the home," DeCherrie says. "It's disorienting, especially for elderly patients, to come into the hospital, and they often develop complications."
DeCherrie was aware of pilot at-home acute care programs, such as those developed by Bruce Leff, MD, at Johns Hopkins Medicine, so she knew the concept could work. When the Innovation Award program emerged, she felt Mount Sinai's existing program would be a solid springboard for MACT.
Broader applicability: MACT's economics are not clear-cut, given that a home visit costs more than treatment provided in the hospital. But the idea is that keeping patients out of the hospital reduces facility costs and the incidence of common complications.
"We don't have the financial data yet, but similar programs have shown 15 to 19 percent cost savings," DeCherrie says. "And those patients have lower rates of delirium and other complications."
As for the status of the program after funding ends in 2017, DeCherrie says Mount Sinai is negotiating with other payers on contracts that cover the program.
MACT could be used in many other health systems, DeCherrie believes, but certain conditions need to be met. A hospital with an existing at-home care program is a better candidate than one that needs to start a program from scratch, she says, and the hospital also requires a density of patients sufficient to allow traveling clinicians to see multiple patients a day.
Another key to success is a strong interdisciplinary team that can see past the typical siloes.
"There's no question that it's a big lift," DeCherrie says. "Hopefully we can create the tools and implementation guides to help other hospitals do it, so it's easier for them."
Thomas Lewandowski, MD, project director, SMARTcare, a program of the American College of Cardiology
Decision making in health care can be fraught with complexity. Physicians and patients deciding on a treatment course, for example, have to evaluate numerous factors ranging from diagnostic information to intervention risks.
The SMARTcare program, designed by physicians in two chapters of the American College of Cardiology (ACC), helps cardiologists and their patients effectively make decisions about stable ischemic heart disease treatment. The program, funded with a $15.8 million CMMI Health Care Innovation Award, eventually may be applicable to other medical conditions.
"We want to make sure clinicians and patients have the ability to meet their goals using prospective decision support information that is easy to use at the site of care," says Thomas Lewandowski, MD, project director of SMARTcare. "We were looking at what the environment was asking clinicians to do to hit the Triple Aim, and we realized clinicians needed help."
SMARTcare bundles five decision-making software tools that had been used separately. The tools cover a range of issues that cardiologists and patients face before, during, and after a medical intervention.
For example, the FOCUS tool helps physicians make decisions about ordering imaging by asking questions about the situation and mapping the responses to established guidelines. Clinicians using FOCUS enter details about the patient, select a test, and then view on-screen advice that indicates a rating of "appropriate," "rarely appropriate," or "may be appropriate."
"Other tools include decision support education for patients," says Lewandowski, a cardiologist affiliated with ThedaCare Cardiovascular Care in Wisconsin. "These are tools patients can use before they see the cardiologist to help them understand the workup and treatment, so when they talk to the cardiologist he doesn't have to explain all of that. This makes the shared decision-making process more effective and gives the patient a better understanding of what it is they're agreeing to have, and how it may help or may hurt."
Evolution of concept: SMARTCare was developed by doctors in the Wisconsin and Florida chapters of ACC. The CMMI award allowed the program to scale up more quickly, Lewandowski says.
While SMARTcare is designed specifically for stable ischemic heart disease treatment, the creators envision the idea being applied to other conditions.
"We designed it to be more of a proof of concept or approach," Lewandowski says. "We wanted to show how you can work with clinicians and patients to attain the Triple Aim and make use of the data already in the electronic health record."
Broader applicability: Lewandowski notes that effectiveness data on SMARTcare have not been reviewed, but each tool previously have been proven effective individually. When the funding runs out in 2017 the project likely will continue to exist in some form, he says.
SMARTcare is being used by four integrated health systems in Wisconsin and a number of systems, cardiology practices, and multispecialty practices in Florida.
"So we are covering the gamut of geographic areas and various environments, including rural, suburban, urban, large, small, and medium-size," Lewandowski says.
Lewandowski advises others undertaking these kinds of major innovations to plan for the long run and be prepared for the environment surrounding the innovation to evolve. Projects with the potential to transform care delivery probably will take longer than expected, so having faith in the goal is important.
"You have to make sure that you truly believe in your concept and that you really understand what you're trying to attain," he says. "If you're really working toward something in the long run, you're more likely to maintain the excitement."
In the case of SMARTcare, Lewandowski has remained enthusiastic despite obstacles.
"Has it been harder than I thought? Yes," he says. "Have there been more hills and barriers than I expected? Yes. But am I still enthusiastic? Yes. I've loved every minute of it. There are great people out there who really want to make health care better."
Katherine Possin (left-center), PhD, an assistant professor at the University of California San Francisco School of Medicine, and her colleagues discuss the Dementia Care Ecosystem program. (Photo: Elisabeth Fall/fallfoto.com)
Caring for people with dementia is a costly struggle that likely will grow in the coming decades as America's population ages. On the other hand, the lives of individuals with dementia and their caregivers can be greatly improved with inexpensive interventions. Furthermore, those interventions probably can reduce care costs over the long term.
Katherine Possin, PhD, an assistant professor at the University of California San Francisco (UCSF) School of Medicine, and her colleagues have been striving to develop a program to efficiently provide those interventions.
"The UCSF Memory and Aging Center is a very collaborative unit, and we like to dream big and solve big problems," Possin says.
Possin and her colleagues, in collaboration with experts at the University of Nebraska Medical Center, developed the Dementia Care Ecosystem, which provides personalized and continuous care to individuals with dementia. The program was launched in September 2014 with a $10 million Health Care Innovation Award.
The philosophy behind the Dementia Care Ecosystem is that patients with dementia can lead better lives if they get professional attention on a regular basis, rather than only when crises arise. In addition, a dementia care model should include support for caregivers.
The Dementia Care Ecosystem tackles those issues with four modules:
Patients enrolled in the program are contacted at least once a month, and in most cases more frequently, by a care team navigator who makes sure the patient is doing well and taking advantage of the program's services.
An important aim of the Dementia Care Ecosystem is to delay the admission of patients with dementia to nursing homes, which should save money for the healthcare industry.
"Nursing home placement is the biggest driver of healthcare costs in dementia," Possin says. "We also think we can decrease unnecessary hospitalizations and reduce the cost of medications. We hypothesize that those savings will pay for our program."
Evolution of concept: The CMMI innovation program encourages grant recipients to modify their programs as needed, and Possin and her colleagues have done that.
"One of the exciting things about this award is that it is an agile research study," Possin says. "In most randomized trials you need your intervention finalized before you enroll patients, but in this trial we are encouraged to improve the intervention throughout the award as we learn what works best."
For example, the group learned that the interventions need to be personalized to each patient and caregiver, so which services are provided—such as medication review or respite care—and when they are given is decided through discussion with each family about its needs. And after receiving feedback from the enrolled families that they would like more connectedness with other caregivers, the group developed an online portal that will go live this summer and link families to targeted resources and online support groups.
Broader applicability: The collaboration with the University of Nebraska Medical Center ensures that the Dementia Care Ecosystem can be applied to patients with dementia who live in rural areas.
"We wanted to show that we could make our model of care available to all kinds of patients, urban and rural, from a range of socioeconomic backgrounds," Possin says. "We also want it to be available to multilingual patients—our team provides care in Cantonese and Spanish."
The CMMI grant expires in 2017, by which time Possin hopes to have enough data to demonstrate that the program is sustainable and that payers should support it. The fee-for-service model does not support this kind of care, making it a great example of the justification for alternative payment models.
"The care of dementia stands to benefit more from new payment models than any other disease," Possin says. "Dementia is the costliest medical condition in our country, and care that is continuous, personalized, and proactive could drive down costs. Our country is focusing a lot of effort on making sure this type of dementia care is affordable in the future."
Michael Englesbe, MD, associate professor and a liver transplant surgeon, University of Michigan Health System.
Frailty is a significant problem for individuals facing major surgery. If a patient cannot withstand the stress of surgery, how well the operation itself is performed does not matter.
Michael Englesbe, MD, an associate professor and a liver transplant surgeon at the University of Michigan Health System, and his colleagues created the Michigan Surgical and Health Optimization Program (MSHOP), which helps patients better withstand operations. After piloting the program for about two and a half years at the University of Michigan, Englesbe and colleagues earned a $6.4 million Health Care Innovation Award in 2014.
MSHOP is a two-part program. The first part consists of a web-based app that helps surgeons, nurses, and other clinicians explain the risks of surgery to patients, based on the type of surgery, the patient's comorbidities, and other factors.
"We developed the app ourselves," Englesbe says. "It allows us to put a number on the risk, like a speedometer. It distills the data down to a single composite number from one to 100."
The patient's surgeon or another clinician can use the speedometer narrative to frame the risk discussion and make sure the patient is comfortable with the risk involved. It also helps the clinical team identify high-risk patients who may need pre-surgical intervention, which leads to the second part of MSHOP: a program that "trains" patients for surgery, usually beginning about a month before the operation.
"Once the surgeon and the patient decide to do the surgery, the patient gets a pedometer, a breathing exercise machine, information on nutrition, and information on relaxing," Englesbe says. "The cornerstone of the program is that they start walking and the program gives them feedback, such as 'How many steps did you walk today? OK, great, walk more tomorrow.'"
The progressive walking program, nutrition guidance, and lung exercises are all aimed at preparing patients to withstand the rigors of surgery. However, Englesbe says the biggest benefits of the program are not physiological, but emotional and psychological.
"People are scared before major surgery and looking for something to do to affect their outcomes," Englesbe says. "This gives them something to do. I think it primarily works because they feel empowered, they are part of the team, they are doing everything possible."
Englesbe says that among the first couple of hundred patients, data show a 30 percent reduction in time spent in the hospital after surgery and a concomitant 30 percent reduction in care costs.
The most important outcome, however, is less tangible. The vast majority of patients who enter the program stick with it, and in patient evaluations prepared post-surgery, nearly all of them note that the program helped them during that stressful time.
Evolution of concept: Englesbe says the idea for MSHOP emerged from his experiences, and those of his colleagues, working with frail patients.
"My clinical practice is liver transplantation, and a lot of my patients have a significant decline in function before surgery," he says, adding that he discussed the situation with U of M colleague Stewart Wang, MD, PhD, a trauma surgeon. "Frail patients are poorly suited for big surgeries, and in our frustration with that we tried to come up with some opportunities to impact their outcomes."
Five years of discussion led to the creation of MSHOP. Englesbe applied for a CMMI grant during the 2012 round of funding but was denied. "By the second round we had more experience and the technology was well-received, so we got funding," he says.
Broader applicability: MSHOP has been expanded to 14 other hospitals in Michigan, and Englesbe hopes the number reaches 40 before the grant runs out in 2017. About 1,000 patients have experienced the program so far—fewer than the number Englesbe had hoped to reach by this point.
"We've found it's hard to reach as many patients as we'd like," he says. "As intuitive as the program is—using the technology adds less than about five minutes to the care time—it has been hard to implement among surgeons and nurses. We've had to come up with a different implementation strategy for every surgeon and nurse."
Another challenge, perhaps related, is that some hospitals view the University of Michigan Health System as a competitor and thus are reluctant to implement the program. Englesbe says the MSHOP administrators take pains to not look like they are trying to interfere with competitors.
MSHOP's innovation grant expires in 2017, and Englesbe and his colleagues have launched a limited liability company called Prenovo to foster the program thereafter.
"We hope to show that the program can have a big impact, and if we can demonstrate this, it can continue with investment and payers like Medicare or Blue Cross Blue Shield of Michigan," Englesbe says. "We are hopeful that we can help a lot of patients. We're optimistic that we can continue to drive change forward."
Ed Avis is a freelance writer based in Chicago who frequently writes about healthcare management topics.
Interviewed for this article:
Linda DeCherrie, MD, clinical director, Mobile Acute Care Team, Icahn School of Medicine at Mount Sinai.
Kevin Munjal, MD, MPH, assistant professor of emergency medicine, Mount Sinai.
Thomas Lewandowski, MD, cardiologist, ThedaCare Cardiovascular Care, and project director, SMARTcare, American College of Cardiolog.
Katherine Possin, PhD, assistant professor, University of California San Francisco School of Medicine.
Michael Englesbe, MD, associate professor and liver transplant surgeon, University of Michigan Health System.
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