Colleen Hole, BSN, MHA, FACHE – Holistic Patient Care in the Home

In this episode we continue our conversation with Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health, about how the Hospital at Home care model contributes to value-based care and better patient outcomes.

Colleen, in our last episode we left off talking about holistic patient care in the home. Having cared for several elderly family members myself, I have seen the difference that it made for them to be in familiar surroundings versus being in the hospital. I guess home is where the heart is, right? Would you share with us the Hospital at Home Scope of services being provided?

So essentially anything you could receive in a brick and mortar facility, we can do in your home. Short of an invasive procedure or surgery, obviously, we don’t do that and advanced imaging like MRI and CT scan, although that technology exists, we’re not quite that there yet. But you can get pretty much any medical nursing intervention that you would get in a hospital, respiratory treatments, oxygen therapy wound care, IV fluids, IV antibiotics, chest X-ray, ultrasound, I mean though that’s mostly what you’re going to hospital for, obviously your medications we provide all of that is provided by 24/7 virtual nursing team. That patient can hit a button and have my nurse pop up on a screen just like a call bell in a hospital. They also get two visits by our community paramedicine or mobile integrated health team, you might hear it called both things, they’re in the home twice daily for anywhere from 45 minutes to an hour twice daily. That is absolutely more time than you’ve got a clinician in your hospital room. You also have a daily virtual visit with the provider who is on camera real time doing an assessment while the paramedic is in the home. We’ve got electronic stethoscope, they could listen to your heart and lungs, they write orders, and then our nursing and community paramedic team carry out those orders. We also have, just like in a in a hospital, pharmacy, care managers, social work, respiratory therapy, physical therapy, occupational therapy, behavioral health, chaplains, all of those things mostly provided virtually, which we learned how to do now after three years of COVID. The other in-home service sometimes is our therapist, our physical therapy and occupational therapist. But a good bit of their work is done just literally on camera in a virtual visit. So it’s hospital level care delivered in the safety and comfort of a person’s home

I didn’t realize that it was such a comprehensive program. That’s pretty amazing that the capabilities for that are there. I think that’s definitely a good thing and can you tell me how this model enhances value-based care and what is the typical savings here?

So, the purest definition I know of value is the same or better quality at a lower cost. I mean that’s maybe oversimplified, but the hospital home actually does that. Our Ed visit, readmissions, mortality, all of those are lower than brick and mortar and our patient experience is higher significantly higher, not surprising probably, right? But when you have the opportunity to actually go where patients actually live, you can address some of those issues that are causing this repeat readmission. When we go to the home and we look in their pill box and it’s empty or there’s no food in their refrigerator or it’s 100 degrees and their air conditioner is broken, you can hopefully address some of those things. Cost wise significantly less costly and there’s research out there Mount Sinai has published several have, it’s estimated 20% to 30% and maybe more less costly than brick and mortar hospitalization. So again if you think about the drive value how do you deliver the same or better outcomes at a lower cost. This is certainly that.

You also just by being in a physical facility utilization tends to be higher. For example, you’re in the hospital bed and you need a chest X-ray. oh but while you’re here we might as well do that CT scan, and we might as well run that other panel of labs while you’re here, you can see how costs will escalate because of the availability of services. And that’s a that’s a gray line, one could say well they really need all of this. Maybe, but if we can deliver the same outcomes and not do all that stuff, it it’s probably the right thing to do

That’s definitely a cost savings. You know in value based care we talk a lot about the triple aim and that’s moved into the quadruple aim. How have you seen if at all with that fourth quadrant being provider burnout, have you seen any movement in the provider satisfaction with the hospital at home program?

I believe we absolutely have. I’ve got six provider FTE’s designated for this program. So this is all they do. They provide this care and they all came out of traditional hospital medicine within our health system, and they love hospital medicine but you know just being up on a nursing unit in a hospital, it’s noisy and it’s distracting and it’s a wheel, I mean they’re just constantly running. They’re very busy in our program. They care for as many patients as they do in the hospital. They round if you will on anywhere from 14 to 16 patients each every day. But they find that they’ve got more time to focus and spend with the patient and also the nurse and the paramedic are in the home when they are doing that virtual visit so it really feels multidisciplinary. And they’re able to see the patient in their own environment so they make a better assessment and a better plan of care.

One of the most compelling examples of this, we also are an academic health system, so we’ve sent some or that by their selection some residents through our family medicine program residency have come through as an elective in their coursework, and one of them wrote the most beautiful letter about her experience actually caring for patients in their home and she called it a sacred trust. She said it’s so true it’s true of home health nurses and anyone who has the privilege of delivering care in the patient’s environment it’s a complete power shift. In a hospital we put you in our gown in our bed and we tell you when you’re going to eat and sleep and bathe. But in the home environment, there is a power shift to where the patients in charge, as they should be. So the physicians that we, and we use some APP’s, I think that’s going to be even more in the future, they love this model of care because like me they learned about holistic care in medical school and rarely have a chance to practice it in our traditional care settings

That’s powerful. I guess the patients are better off in this setting, in your in your mind, and I tend to agree. Do you have a story that you can share where hospital at home impacted a patient?

Yes. I have a lot. We have our quantified data that comes from our patient experience surveys so that’s scored, but the best stuff comes from our anecdotal letters or comments within there. So we’ve countless stories from the patients themselves, from family members, even from neighbors who said you know we were so scared with our neighbor how sick they were but it was so comforting to see the Atrium vehicle pull up in their driveway because we knew oh they’re getting what they need today. And many patients, particularly more elderly fragile patients have had very negative experiences in hospitals to where they didn’t do well and did so much better at home.

A recent example and I think I did share this on our recent Move to Value Summit, but was an elderly couple, the wife had pretty advanced Alzheimer’s, but the daughter wrote us a letter thanking us. Both parents had COVID, so if you remember early COVID, you were isolated family could not visit and many patients died alone, which I think is the greatest tragedy of the whole thing. But here was the couple with COVID the husband had had very bad experiences with delirium and confusion in the hospital in the past. But they were able to be at home. The daughter was able to visit them in their home. They had their pets which is a huge part of healing, honestly, able to be at home. So the husband recovered and did well and was back to gardening and enjoying his life in the summertime. The wife did pass away but she was able to be there with her family when that happened. So I’ve told that story a zillion times because it really pulls together the whole sense of community and family and dying alone and so that should never happen.

I just you know it’s not perfect. We’re still learning and iterating on this model, but if you just go from the basic principles of value based care, holistic care, lower cost care, and better outcomes, I know this is the best thing since sliced bread to do that in healthcare. So I’m excited to kind of see where this goes over the next few years I wish this had happened when I was in my 30s, and I’d have more of a runway to see it through, but I think we’re on to something here.

The last thing I’ll mention is partnering with community agencies. So when we go in and we see the issues that are keeping patients from living the best life they can despite poverty, despite chronic conditions, we can actually do something about it. So we are partnering with some community agencies around food insecurity that extends past their hospital stay, frankly, to make sure they can continue to do well, nutritionally. And also safe housing so where we identify a leaking roof, or unsafe stairwell, or they need a shower bar, we can work with some community agencies to get those things put in to avoid the falls, to avoid you know the diabetic who isn’t eating perfectly. All of those things help patients live their best life and frankly put our money where our mouth is. If we if we say we believe in health equity and lowering the cost of care and we believe in access, then we have to do it differently than the way we built it half a century ago.

I like that. What’s the plan going forward?

So, as I mentioned, we are currently running a census around 30. Our next milestone is 50, which is just around the corner I hope by year’s end where it’s 75 or perhaps even 100 patients on service. Again from a operational administrative perspective our whole reason for being is still largely capacity management. Our hospitals remain beyond full and I don’t see that changing anytime soon, particularly as the community continues to grow at about 100 hundred people a day I think or something crazy. We do also though believe that this is transformative care, which again in the drive to value that’s what we’re supposed to be building toward. So I do think much like Mass General Brighams is planning, this could be 200 plus. If you think of 20% of your market beds could approach 500. So to be seen and determined.

I don’t know but I know we’re not stopping here. We didn’t talk about payment models, but a lot of this is contingent on what CMS decides to do at the end of the two year CMS waiver extension. So Medicare will be covered at full inpatient DRG through the end of 2024. We still have to work within our state licensure and CON restrictions to figure out what this means, because quite frankly they don’t know either. And then payers are coming along with covering the service, again, I would say they need to put their money where their mouth is and work with us to deliver care differently and better. So all of that legislative and payment work is still underway and it’s a pretty heavy lift but we decided as a health system we’re doing this regardless of the payment model because it’s the right thing to do.

I couldn’t agree more, and I look forward to checking back in with you in the near future and seeing how things are going if you would be so kind as to join us again to talk more about this program. I think this is outstanding work that you’re doing.

I would be more than thrilled to come back hopefully I’ve got even more wonderful stories to tell.

Well, you’ve been a delight. Colleen Hole, thank you for joining us today on the Move to Value Podcast!

Thank you for having me.