Episode 29: Hospital at Home for Hospitals and Digital Health Vendors with Health System Virtual Care Expert Casey Papp, Esq.
Is Hospital at Home right for your organization?
Subscribe on Apple Podcasts, Spotify, Buzzsprout, or follow the podcast on LinkedIn for new episode drops.
In this episode you’ll discover:
What “Hospital at Home” means in the context of Medicare’s program and what the phrase can mean more generally
What role digital health companies and mobile health companies have to play in a Hospital at Home program
What both hospitals and digital/mobile health vendors need to consider in implementing a successful Hospital at Home program
What the future may hold as we shift towards healthcare at home, including acute care
Learn more from Carrie and Rebecca:
Healthcare insights (monthly email) | Telehealth/Virtual Care Mgmt Update (biweekly LinkedIn update)
Website | Carrie on LinkedIn | Rebecca on LinkedIn | NGL on LinkedIn
Learn More
Read the transcript:
Carrie Nixon (00:18):
Hi there. This is Carrie Nixon and welcome to another episode of Decoding Healthcare Innovation. I am thrilled today to be joined by one of my good colleagues and friends, Casey Papp. Casey is actually an attorney here with Nixon Gwilt Law and today we're going to be talking about a hot new buzz phrase, hospital at home that can mean different things to different people. But before we dive into that as a really kind of new and interesting healthcare innovation, I want to ask Casey to talk a little bit about her background in this space and we can go from there. Okay.
Casey Papp (00:54):
So, hi, I'm Casey Papp and thanks for having me, Carrie. I have been basically working in the digital healthcare space for the past 10 years, some nonprofit work a little bit of a telepsychiatry kind of startup environment, and then before coming to Nixon Gwilt was at New York Presbyterian for a number of years, and for the last couple of those I was on their digital health team. I worked with everything from our telehealth initiatives to our remote patient monitoring programs. I helped get five or so of those off the ground while I was there and as I was spending the last of my time before coming there, I was helping them to start to begin to build their hospital home program.
Carrie Nixon (01:39):
Wow. So okay, you've really seen things from both sides of the sides of the equation because I know here with your work with Nixon Gwilt Law, you have been working with a lot of digital health companies and that might potentially be vendors in the hospital at home space. So you have really kind of a unique perspective both from the hospital side and from the digital health side. So I'm looking forward to hearing more about that. I want to start off by saying, when we hear the phrase hospital at home, which we're hearing a lot these days it actually can mean a couple of different things. It can mean a specific CMS program, but it can also mean more about than that. Can you dive into that a little bit and explain some of the nuances of what hospital at home may or may not mean?
Casey Papp (02:31):
Absolutely. So when you think about hospital at home that right now is being used again, like you said as a buzzword to encompass really care at home. So everything from skilled nursing to when you think about remote patient monitoring is care at home and if it's being done through a hospital, that could be hospital care at home. But the actual phrase hospital at home is generally meant to refer to CMS'S waiver program for basically acute care at home. So when we're thinking about taking an inpatient stay during these waivers, CMS is allowing an inpatient stay to be done completely at home for a patient and for the reimbursement that a hospital would get, they would then get that for the at home stay. So whether it was in the hospital walls or at home, the reimbursement rate's the same. So really there's a lot of different things, again, that can be considered care at home, but the way that you can put them into the right buckets has a lot to do with how they're being paid for. So the same thing, reimbursement for remote patient monitoring is going to be on the fee schedule. Then you're going to have the DRG that's paid for the hospital at home, acute care at home program, and then skilled nursing is paid for on a completely different way.
Carrie Nixon (03:55):
So it's fascinating to think about acute care that would typically be provided in a hospital setting actually happening at home. That seems like a really big deal. I guess we now have the technology and the devices and the infrastructure to potentially bring that acute care to home. And really interesting to think about how years ago that wouldn't have even been imaginable, but for a hospital system who frankly relies on reimbursement for days that patients spend in the bed at their hospitals, this is a whole new opportunity, right? Because they can provide that same care at home for the same reimbursement, but also they're having beds freed up to pay other patients. Do you think that what do you see as through of the future of this waiver program? First of all, did it come about as part of Covid and second, what would you predict if you had to about the future?
Casey Papp (05:09):
Sure. So they've been considering this program in the way that the acute care at home waiver has been put into place for, I think it's now going on just shy of 10 years. CMMI has looked at this program and did a whole pilot study with Mount Sinai, I think is the one who got this off the ground, and then really thinking about the way that reimbursement could work in the future with this program. The waiver during Covid, as Covid did with everything has really kind of thrown digital health. Fast forward three to five years where we thought we'd be in three to five months and at least. So yes, COVID absolutely has made it so CMS committed to finally putting in a payment structure for this. And again, the waiver is contingent on the public health emergency, but with that being said, they also recognize that the genie is out of the bottle, if you will, and that there does need to be a permanent payment structure in place.
(06:14):
People say that maybe it won't still be a one-to-one, just like some of the flexibilities that they've put in place for telehealth won't cons continue to be a one-to-one reimbursement, but even if you go to the point where they get to and say potentially it could be 85% of the DRG, that's still a considerable value to having the patient at home when you're also looking at potential reimbursement or potential, I should say, gains in the value space. So better patient outcomes different opportunities to enter into value-based arrangements. If it isn't just this, the DRG or percentage of that, there's a lot of opportunities because it's showing to be improved care, if you will.
Carrie Nixon (07:02):
Yeah, absolutely. So just for some of our listeners who may not be familiar, DRG kind of represents the reimbursement amount that a hospital gets for certain sets of services that they provide to patients in the hospital. And so in hospital at home, they're getting that reimbursement for those services in the home setting. Super, super interesting. And so as we think about hospital at home and we think about healthcare innovation in general, what role do digital health companies have to play in general in the hospital at home space, and what are some examples of types of companies?
Casey Papp (07:45):
Sure, absolutely. So I've been in this position and often I have clients who come and say We're a remote patient monitoring company. We want to do hospital at home. And of course there is a huge opportunity for remote patient monitoring to be a component of hospital at home. So I guess first company type is a remote monitoring digital health company I think is absolutely a great fit for hospital at home, but that doesn't necessarily mean that that company is ready to take on the entire patient journey that's required to fit and meet all of the different components of the hospital at home program. There are components like in-person nursing services that need to be met on a daily basis. There's also a telehealth component when you think about the provider who's responsible for the overall opportunity, the overall visit for the patient, that they're going to be rounding on the patient on a daily basis.
(08:46):
So you need to have an interactive video platform. There's a lot of logistics involved in hospital at home when you think about needing to have mobile phlebotomy, if you need blood draws, if you need to have food delivery even. We don't think necessarily that food delivery is a digital health component, but it's definitely an indicator of whether or not a patient's going to get better if they have access to the appropriate nutrition. And in a hospital they would also, things like lab kits, if you're testing for certain things, having those type of innovative ways of testing for different things at home, there's a huge opportunity for that. So as much as it is remote patient monitoring, absolutely. There's also the digital health technology platforms, the clinical staffing models that can meet these needs. Again, the laboratory and the ways of having different services delivered to the patient's house are all different components because when you say you're going to take a patient who is just going to be in inpatient in a hospital and move them home, you have to be able to meet every single one of the needs that would have been met within the four walls of the hospital.
Carrie Nixon (10:09):
Yeah, that's actually a big task. I mean, I think there's a tendency to think of hospital at home as simply virtual care, but to your point, having these sort of at home visits as necessary, whether it's for a blood draw or whatever is a really important component. It seems to me as well that hospital at home lends itself to paying some attention to the social determinants around a patient and addressing those social determinants. How is it that hospitals are supposed to go about demonstrating that they can provide in a home setting basically everything that they can provide in a hospital setting? How does that work?
Casey Papp (11:01):
Sure. So to even get the waiver through CMS's process, this is actually something that has maybe potentially been a limiting factor for some folks to get involved in this space is that you need to be able to represent that you can support the entire program to CMS in order to get the waiver. So you need to be able to show in every single thing that you have in place that's going to meet every single factor of the waiver before you can get it. So this has been something where when you think of maybe an innovative program that would be introduced in the hospital world, often you'll see it happen as a pilot. There's no real way to pilot hospital at home because if you have to spend the money to put it all in place in the first place, chances are a pilot is not going to give you the ROI that you'll need to make that investment worth its while.
(11:55):
So you need to be able to show that you have either a relationship with a vendor, and again, a great place for digital health companies to come in and to be able to sell themselves as filling in the pieces of a hospital at home program where maybe a hospital doesn't have that already available or you're going to need to be able to show that you've built it from within as a hospital. And again, that can be a difficult choice if you're trying to say, do you have all the resources already and now is there enough bandwidth with all of the vendors and relationships that you have as a hospital system to now build this entire acute care at home program?
Carrie Nixon (12:35):
Yeah. So what does a hospital look for when they're seeking partners or vendor relationships to make hospital at home work? What are some of the most important things that they're seeking?
Casey Papp (12:45):
So I think I've seen a lot of success with vendors who really understand that the unique needs of each hospital are different, and also recognizing even something as much as location is different. Because when you think about logistics and getting all of these different things to the home of someone who lives on the 30th floor of a New York City high rise versus someone who lives more in a remote area where weather may be difficult, you may be up against snow storms. So the logistical challenges are very different, and you still have to be able to ensure that there is a plan and an emergency plan for all of these. So I think one thing is the hospitals are looking for our vendors who understand this also, those who are coming in and they are able to show that their technology is user-friendly and has really thought about the patient populations that are going to be operating in this space.
(13:43):
Because when you think about the Medicare population and the demographics there, if you have really complex systems and devices that are necessary to do this, that's going to be really hard not only to convince a patient that it's safe to go home, but also then to convince them that they're going to be able to do all of the things that would've been necessary that someone would've done for them in the hospital. So I think it's recognizing the patient population, the barriers that the hospital is facing, and also recognizing that there's a huge change management component to hospital at home that's going on at the organizational level because you're taking clinicians who have been operating in a specific way their entire working career and asking them now to comfortably say, you know what? I would've actually admitted you and you'd have gone upstairs and I didn't know exactly what was going to happen after that, but I'm going to send you home and I'm sure that we can do just as good there if not better. There's as much of a component of having to get the clinicians on board and the hospital system itself as much, much as there is recognizing what it's going to take to help explain this to a patient and to have them again also be comfortable with all the pieces that are going to follow from there.
Carrie Nixon (15:01):
Yeah, it's a great point. I can see very clearly practitioners who are used to operating in hospital setting going, aint no way we going to do this stuff at home. Right? There's no way. How do you think about getting clinicians on board with a program like this?
Casey Papp (15:22):
I mean, I think that it starts really from a hospital perspective. It starts at the top. I mean, you really have to have organizational buy-in at every single level, and it really is a commitment of the entire organization to decide that this is worthwhile from not only the organization's perspective but their patient population. And I think it also is getting some champions on board who are already comfortable with some maybe other digital health technologies and how they're interfacing with those and how they've already recognized better patient outcomes from maybe some less holistic types of care that are being done through digital platforms. So I think that getting some champions on board, and again, it's really an organizational commitment to doing this. It's very hard to just have one doctor championing to championing the idea of moving sick patients home and taking care of them well.
Carrie Nixon (16:24):
Yeah. So what do patients think about it? Does it make them nervous to not be in the hospital or are they delighted to be at home? I can imagine a scenario where patients just might be, they might be doing better from a mental and psychological perspective because they're at their home. Have you seen whether they seem to appreciate this model or whether it makes 'em real nervous?
Casey Papp (16:48):
Sure. I would always say, I mean, your point to entry into the acute hospital at home program is the emergency room. That is one of the requirements, and I'm sure you can imagine that if you've not ever had any exposure to this at first from the emergency room, you really do have to have a great care coordination plan in place where not only are you making sure that the patients are the right fit for the program, of course, if you already don't have access to things, that would be as of social determinants of health, if you don't have access to a support system, you don't have access to housing, you already have a food scarcity issue going on, it's probably not the right fit for you to be in the program. So I think there's it. It's really important to have the right screening measures in place to get the right patient population.
(17:37):
But once patients are home, they're already showing that overall patient satisfaction and patient outcomes are improved across the board. For hospital home programs, you also have to think that you don't have things that are happening like hospital acquired. Infection rates are not of a concern. The patient is in their own home surrounded by the things they're comfortable with. It feels less limiting like you are stuck in a certain place, but you get to be around the things. If you have pets for instance, and it's appropriate and safe for them, you're not worried about what's going to happen there. It's much easier. You don't have visiting hours at your own home. All of those things lend themselves to just an overall better patient interaction.
Carrie Nixon (18:24):
Yeah, I can imagine that mean, fortunately, the only time I was in the hospital was when I delivered my daughter, and it's not pleasant to be in there <laugh> even I have night and a half or two nights that I was in there. You're woken up constantly. There's all kinds of noises. People are checking on you at all hours and it's disrupting your ability to sleep and just get comfortable and you're in the terrible hospital gown and all that stuff. So to the degree that you can move something like that to a much more comfortable setting, I can see where it might be easier to relax into that care. All right. So let's script flip the script for a moment and come at this. From the perspective of a digital health company that is looking, that would like to partner in some way, shape or form with a hospital at home program what should they be thinking about?
Casey Papp (19:23):
I think it's absolutely thinking about whether or not and at your size and where you're looking to grow. If you're ready to tackle a portion of what is required to meet a hospital at home program or if you are looking to basically build, there are a handful of players in the game who have come at the hospital at home space from being a one stop shop. I don't necessarily think that that isn't is needed from everyone. Of course, there's different avenues to take, but I think no matter where you are on your journey, you can decide that you have the best remote monitoring platform there is, and you're going to go to hospitals and show them why that's going to be the best for them, or you're going to, again, fit. Maybe it's the mobile phlebotomy space, the logistics, the whatever the piece of it is going to a hospital.
(20:19):
One thing that you need to make sure is that you are ready for the things that come along with partnering with the hospital. It may be a little bit of a slower process to get into a hospital. There are a lot more systems reviews. Making sure that you've got all of the compliant processes in place that hospitals are going to be double checking to make sure that you have making sure that you have the right security systems on your programs is really important and will get you through the tech audits a lot faster. If you've thought about these things ahead of time. They're really looking to see that you're ready to partner with the health system, which can, I mean added levels of scrutiny. I think it's also being ready to go into the hospital and making sure that you're not trying to tell them what they need, and instead you're really trying to figure out what the needs of that particular health system is. Because the last thing that a bunch of clinicians want when you come in is for you to tell 'em all the problems they're having instead of listening to where they're actually finding their pain points. Because if you can listen to those particular pain points from those individuals and you can solve their problems instead of telling them what their problems are, I have found that is a much more reliable approach to success.
Carrie Nixon (21:41):
I mean, it seems obvious, right? Or it seems like it should be obvious, but it is absolutely the case that vendors, I think in any industry frankly, go in there saying, I can do this. I'm going to solve this, this, and this problem for you without ever actually asking what the pain points are and taking the time to listen. So yeah, that is an important lesson to learn across the spectrum and based on our experience, certainly hospitals can be a very long sales cycle. So if you are a digital health company that is looking to get into hospital at home programs you've got to be prepared for that long process of evaluation and scrutiny, just as you said, especially around privacy and security and all of that good stuff. Well, so let's see. Casey, if you could leave us with just a thought or two on the future of hospital at home and maybe health at home in general one key takeaway, what do you think that would be?
Casey Papp (22:56):
I think it is really saying that this is a huge step towards CMS's investment in the future of everything turning to value-based care. I think hospital at home really does show that that's where we're going. We know that, but this is a really big step for them to recognize that there is a lot of potential to be value-based relationships around shifting these care models in less from what we've always considered to be the way that things need to be done, and that needs to be within four walls in person, and really recognizing that there is potential savings for payers and potential savings for health systems, which will ultimately result in being able to also then provide better care because we're going to see better outcomes in those value-based relationships.
Carrie Nixon (23:57):
Yeah, totally agree. I think healthcare is at home in the future as much as it possibly can be, and absolutely I think that's going to be for the good of everyone. Yeah, thank you so much for joining us. Again, I love the perspective that you bring both from being in-house at a hospital, a large health system, but also from working with hand in glove with some of the vendors of the digital health companies that are parts of these part of these amazing healthcare innovations. So you know, can always reach out to Casey if you want to learn a little bit more. She'd be happy to talk with you. Please stay tuned for the next episode of Decoding Healthcare Innovation and thank you Casey. We'll see everyone next time.