Integra at Home: A flexible continuum of in-home medical care for older adults with complex needs.

BACKGROUND: As individuals age, they may need new strategies to manage exacerbations of chronic disease to maintain their dignity and independence. Many end up in a revolving cycle of emergency department visits, hospitalizations, and post-acute care. Support to stay at home, which is often their preference, becomes a challenge and varies with insurance coverage, location, and financial status. There are few home-based options sufficiently agile enough to respond when acute conditions arise particularly with exacerbations of chronic disease. METHODS: In 2018, Integra designed a home-based option to treat acute exacerbations of chronic illness. A partnership with community paramedicine enabled faster response times and provided additional treatment tools. Using process improvement methodology, we developed "Integra at Home" workflows and team-based care. We counted averted emergency visits and hospitalizations, patient and staff satisfaction, and evidence of financial sustainability as a result of our program. RESULTS: Integra successfully developed a suite of home-based services, including responses to acute problems, to address beneficiaries' fluctuating medical needs. Following responses to 415 acute events, 74% (N = 307) resulted in averted emergency department visits. Based on InterQual® criteria, 34% (N = 103) of averted visits would have qualified as an averted hospitalization. All 64 respondents to patient surveys (N = 170) stated they would recommend our program. The staff indicated the model is a better way of caring for patients with higher rewards than traditional settings. The average length of stay in hospice for patients referred from the program (N = 22) was 4 weeks. CONCLUSIONS: Home-based care continuums are feasible, yet resources to manage acute exacerbations remain inadequate. To fill this gap, we created higher acuity services to respond to urgent needs and monitor symptoms between episodes. Amid successes and challenges, we are serving higher acuity older adults in Integra's home-based continuum model. We encourage further spread of longitudinal home-based acute care models.

Characteristics of home-based care provided by accountable care organizations.

OBJECTIVES: To describe the use of home-based services in accountable care organizations (ACOs). STUDY DESIGN: Cross-sectional analysis of 2019 ACO survey. METHODS: We analyzed surveys completed by 151 ACOs describing the characteristics of home-based care programs serving high-need, high-cost patients. We linked survey results to publicly available information about ACO characteristics, governance, and risk model participation. RESULTS: Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about their ability to demonstrate a return on investment (ROI), which was reported as a major or moderate challenge by three-quarters of respondents. CONCLUSIONS: ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs.

Hospital at Home services: An inventory of fee-for-service payments to inform Medicare reimbursement.

BACKGROUND: Hospital at Home (HaH) is a growing model of care with proven patient benefits. However, for the types of services required to provide an episode of HaH, full Medicare reimbursement is traditionally paid only if care is provided in inpatient facilities. DESIGN: This project identifies HaH services that could be reimbursable under Medicare to inform episodic care within fee-for-service (FFS) Medicare. SETTING: All data are derived from acute services provided from the Mount Sinai HaH program between 2014 and 2017 as part of a Center for Medicare and Medicaid Innovation (CMMI) demonstration program. PARTICIPANTS: The sample was limited to patients with one of the following five admitting diagnoses: urinary tract infection (n = 70), pneumonia (n = 60), cellulitis (n = 45), heart failure (n = 37), and chronic lung disease (n = 24) for a total of 236 acute episodes. MEASUREMENTS: HaH services were inventoried from three sources: electronic medical records, Medicare billing and itemized vendor billing. For each admitting diagnosis, four reimbursement scenarios were evaluated: (1) FFS Medicare without a home health episode, (2) FFS Medicare with a home health episode, (3) two-sided risk ACO with a home health episode, and (4) two-sided risk ACO without a home health episode. RESULTS: Across diagnoses, there were 1.5-1.9 MD visits and 1.5-2.7 nursing visits per episode. The Medicare FFS model without home health care had the lowest reimbursement potential ($964-$1604) per episode. The Medicare fee-for-service within ACO models with home health care had the greatest potential for reimbursement $4519-$4718. There was limited variation in costs by diagnosis. CONCLUSION AND RELEVANCE: Though existing payment models might be used to pay for many HaH acute services, significant gaps in reimbursement remain. Extending the benefits of HaH to the Medicare beneficiaries that are likely to derive the greatest benefit will require new payment models for FFS Medicare.

Testing a Strategy to Identify Incidence of Nurse Suicide in the United States.

OBJECTIVE: The aim of this study was to test a strategy for quantifying incidence of nurse suicide using San Diego County data as a pilot for national investigation. BACKGROUND: Worldwide, 1 person dies by suicide every 40 seconds; more than 1 000 000 suicides occur yearly. Suicide rates for nurses in the United States have not been evaluated. This methodological article tested a strategy to identify incidence of nurse suicide compared with those of physicians and the general public. METHOD: Deidentified San Diego County Medical Examiner data from 2005 to 2015 were analyzed with a descriptive epidemiologic approach. RESULTS: Overall RN (18.51) and physician (40.72) incidences of suicide per 100 000 person-years were higher than the San Diego general population, excluding nurses (15.81) normalized to 100 000 person-years. CONCLUSIONS: Establishing incidence of nurse suicide is confounded by variation in reporting mechanisms plus incomplete availability of nurse gender data. Relatively small outcome numbers compared with the general population may underestimate results. Research using a larger sample is indicated. Nurse executives may decrease risk by proactively addressing workplace stressors.

Health Care Usage and Suicide Risk Screening within 1 Year of Suicide Death.

BACKGROUND: Research indicates patients often seek medical care within 1 year of suicide. Health care encounters are a crucial opportunity for health professionals to identify patients at highest risk and provide preventative services. OBJECTIVE: Study aims were to determine the characteristics of persons seeking health care within 12 months of suicide death and evaluate suicide risk screening (SRS) frequency in the emergency department (ED) vs. clinic settings. METHODS: Medical examiner and hospital data of patients who died by suicide from 2007 to 2013 were evaluated. Descriptive analyses included demographics and frequency of ED vs. clinic visits. We also compared SRS before and after implementation of The Joint Commission's recommendation to assess suicide risk. RESULTS: The 224 deceased patients were primarily single white males (mean age 67 years). Mental health issues, substance abuse, and prior suicide attempts were present alone or in combination in 74%. Visits were primarily behavioral health or substance abuse problems in the ED, and medical issues in the clinic. After implementation of universal SRS in the ED, screening increased from 39% to 92%. Among patients screened in the ED, 73% (37 of 51) screened negative for suicide risk. CONCLUSIONS: Universal SRS increased the number of people screened in the ED. However, negative SRS may not equate to reduced risk for future suicide within 1 year. Future studies might investigate targeted screening of individuals with known suicide risk factors, as well as alternatives to patient self-report of intent to self-harm for patients with mental health or substance abuse problems.

National Survey of Emergency Physicians Concerning Home-Based Care Options as Alternatives to Emergency Department-Based Hospital Admissions.

BACKGROUND: Emergency departments (EDs) in the United States play a prominent role in hospital admissions, especially for the growing population of older adults. Home-based care, rather than hospital admission from the ED, provides an important alternative, especially for older adults who have a greater risk of adverse events, such as hospital-acquired infections, falls, and delirium. OBJECTIVE: The objective of the survey was to understand emergency physicians' (EPs) perspectives on home-based care alternatives to hospitalization from the ED. Specific goals included determining how often EPs ordered home-based care, what they perceive as the barriers and motivators for more extensive ordering of home-based care, and the specific conditions and response times most appropriate for such care. METHODS: A group of 1200 EPs nationwide were e-mailed a six-question survey. RESULTS: Participant response was 57%. Of these, 55% reported ordering home-based care from the ED within the past year as an alternative to hospital admission or observation, with most doing so less than once per month. The most common barrier was an "unsafe or unstable home environment" (73%). Home-based care as a "better setting to care for low-acuity chronic or acute disease exacerbation" was the top motivator (79%). Medical conditions EPs most commonly considered for home-based care were cellulitis, urinary tract infection, diabetes, and community-acquired pneumonia. CONCLUSIONS: Results suggest that EPs recognize there is a benefit to providing home-based care as an alternative to hospitalization, provided they felt the home was safe and a process was in place for dispositioning the patient to this setting. Better understanding of when and why EPs use home-based care pathways from the ED may provide suggestions for ways to promote wider adoption.

Survey and Chart Review to Estimate Medicare Cost Savings for Home Health as an Alternative to Hospital Admission Following Emergency Department Treatment.

BACKGROUND: Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED. OBJECTIVE: We sought to estimate Medicare cost savings resulting from using the Home Health benefit to provide treatment, when appropriate, as an alternative to inpatient admission from the ED. METHODS: This is a prospective study of patients admitted from the ED. A survey tool was used to query both emergency physicians (EPs) and patient medical record data to identify potential candidates and treatments for home-based care alternatives. Patient preferences were also surveyed. Cost savings were estimated by developing a model of Medicare Home Health to serve as a counterpart to the actual hospital-based care. RESULTS: EPs identified 40% of the admitted patients included in the study as candidates for home-based care. The top three major diagnostic categories included diseases and disorders of the respiratory system, digestive system, and skin. Services included intravenous hydration, intravenous antibiotics, and laboratory testing. The average estimated cost savings between the Medicare inpatient reimbursement and the Home Health counterpart was approximately $4000. Of the candidate patients surveyed, 79% indicated a preference for home-based care after treatment in the ED. CONCLUSIONS: Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED.