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Providing acute care in the home may be the best way to provide safer, less costly care that matches patients' wishes.
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Trading Spaces: Remodeling Acute Care for Seniors

By Liane Wardlow | Wednesday, September 19, 2018

Trading Spaces blog post

We can probably all agree that no one wants to experience an acute medical event. However, they’re simply a part of life — particularly for seniors who often live with multiple chronic medical conditions, which can, from time-to-time, escalate into an acute situation needing immediate medical attention. Unfortunately, seniors are not only more likely to experience acute medical events, they are also particularly vulnerable when they happen.

The traditional care pathway for acute situations is to call 911, go to the Emergency Department (ED), and then get admitted to the hospital. This traditional care pathway has important and unintended consequences for seniors related to health outcomes, experience of care, and costs.

First, older adults are more likely than non-seniors to be admitted to the hospital through the ED. Once in the hospital, they are particularly susceptible to hospital-acquired infections, delirium, and functional decline, which can lead to extended stays and disposition to skilled nursing facilities (SNFs).

Second, the traditional acute care pathway often leads to a poor experience for seniors. EDs can be overwhelming, complicated, and inhospitable places for everyone, but particularly for older adults. Hospitals are also suboptimal places to spend extended periods of time: patients often don’t sleep well, they lack privacy and familiarity, and often must follow institutional schedules that may be at odds with their normal routines.

Third, ED visits and hospitalizations are expensive. Even with Medicare coverage, seniors pay $1,340 at a minimum for a hospital admission (every 90 days) and they pay copayments and 20 percent coinsurance for ED services and observation stays (when not admitted).

Acute care in the home or SNF-type programs can address some of these problems for older adults by facilitating the delivery of acute care where the patients reside, which is often aligned with their wishes, helps avoid hospital-associated risks, and costs less to deliver.

At the West Health Institute (WHI), our mission is to enable seniors to successfully age in place, with access to high-quality, affordable health and support services that preserve and protect dignity, quality of life, and independence. To that end, we have been working closely with the Institute for Healthcare Improvement (IHI) to remodel the care seniors receive when they experience certain acute medical events to, in effect, trade the original “space” for treating these events (the hospital) for a new space (a senior’s home or SNF).

We began this work by exploring five existing programs:

  • Johns Hopkins’ Hospital at Home
  • Geisinger Health System’s Mobile Integrated Health/Community Paramedic program
  • Ohio Veterans Administration Hospital in Home program
  • Mt. Sinai’s Mobile Acute Care Team/Hospital at Home program
  • Presbyterian Healthcare Service of New Mexico’s Hospital at Home program

We compiled key model features related to operations, reimbursement, and obstacles to implementation. We then selected six Next Generation Accountable Care Organizations (NGACOs) and formed the acute unplanned event Learning and Action Network (LAN). The LAN provides shared learning experiences while several of the NGACOs develop home and community-based alternatives to offer seniors when they experience acute events.

Using IHI’s quality improvement methodology, participating NGACOs use shared aims and drivers while they engage in local, individualized testing of new initiatives. There are three specific and measurable aims developed in support of the overall mission:

  1. Decrease the percentage of ED visits;
  2. Decrease the percentage of hospital admissions following an ED visit; and
  3. Implement a program whose cost to operate is directionally neutral or positive.

The LAN also established three primary drivers toward its aims. These include aligning incentives for the health systems, establishing alternatives to ED and hospital admission, and engaging patients and caregivers.

For example, each of the NGACOs is testing a specific initiative related to patient and caregiver engagement with the goal of leveraging innovative ways to connect with seniors with acute needs in the ED, at home, and in SNFs. One NGACO is implementing a “call first” campaign that gives patients and caregivers a phone number to speak with a clinician who can triage and offer advice when acute events occur. Another NGACO is developing and testing an education program to help patients and their physicians understand the symptoms that might signal the beginning of an acute medical event for which urgent or emergency care is needed.

The organizations then use the IHI’s rapid cycle methodology — “Plan-Do-Study-Act” (PDSA) cycles — to test their initiatives. During these tests of change, they capture data and share it with the other members of the LAN. Although they are each testing local initiatives, there are enough similarities between the systems — including their objectives and roadblocks — enabling them to support and learn from one another.

At the conclusion of the LAN, in December 2018, we will compile our key learnings about mobilizing acute care resources in patients’ homes, SNFs, and the ED, including payment and reimbursement for such services. We intend to share our lessons learned and develop resources to drive scale and sustainability of these important innovations in health services delivery.

Liane Wardlow, PhD is a principal investigator at West Health. She and other members of the WHI/IHI team will present key findings and actionable learnings during session C28: Trading Spaces: Remodeling Acute Care for Seniors at the IHI National Forum (December 9-12, 2018 in Orlando, Florida, USA).

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