When the federal Centers for Medicare and Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), recently awarded a nearly $10 million Health Care Innovation grant to the Icahn School of Medicine at Mount Sinai in New York City, the resulting Mobile Acute Care Team (MACT) program quickly began providing qualifying Medicare patients with high quality, acute care in their home for up to 30 days. The program’s viability is linked to a vital paramedic component to complement the patient’s medical team.
MACT, modeled after the Hospital at Home program developed at Johns Hopkins University, anticipates serving some 1,000 acute care patients in Manhattan before its three-year run is completed in 2018. In a study by Bruce Allen Leff, MD, director of John Hopkins’ Center on Aging and Health, the cost of acute care for more than 1,000 patients in the program was reduced by some 20 percent. Patients had slightly lower hospital readmissions and mortality rates and higher patient satisfaction scores.
“The idea of treating acute care patients in their home has been around for roughly 20 years in the United States,” said Linda DeCherrie, MD, associate professor of geriatrics and palliative medicine at Mount Sinai and clinical director of the program. “The pilot program at Johns Hopkins – the first of its kind – showed the first really impressive outcomes, with lower rates of infection, complications, and fewer falls that can happen in an unfamiliar environment. The Hospital at Home idea has spread to several Veteran’s Hospitals, and healthcare administrators are taking a closer look at the concept.”
One drawback: lack of a sufficient payment source, which has stalled dissemination over the last two decades. “VA hospitals have their own budget; that’s how they can provide the service,” she explained. “Medicare has never reimbursed for this type of program. Neither have insurance plans, for the most part. A few integrated health systems around the country provide it, such as Presbyterian in New Mexico, which has the most developed hospital-at-home program outside the VA system.”
How it Works
The MACT program is funded through CMMI with the goal to help create a payment plan for Medicare to reimburse for the care, and hopefully other insurances. This program can then work to publicize the model. The pressing questions were: can this be done in the Medicare population? Can we develop a payment model replicable for other hospitals in the U.S.? If so, would CMS buy into it, and eventually reimburse?
Under the MACT program, teams provide hospital-level care for specific diagnoses: congestive heart failure, chronic obstructive pulmonary disease (COPD) or asthma exacerbation, cellulitis, community-acquired pneumonia, diabetes, deep venous thrombophlebitis (DVT), and urinary tract infection (UTI) and dehydration.
DeCherrie pointed out that ICU patients are not eligible for the program. “That wouldn’t be safe,” she said. “We’re taking care of selected types of patients who need acute care hospitalization.”
From Inception to Practice
To learn about the program, DeCherrie journeyed to Presbyterian in New Mexico. Two important lessons learned: understanding the challenges of finding the right professionals for the program and ensuring safety for the patients. Because medical participants haven’t been trained specifically to provide acute care in the home, Presbyterian experienced a steep learning curve. For example, Presbyterian initially began with floor nurses as the nurse team member and soon learned they didn’t function well in the home environment.
“They were accustomed to their team, nursing supervisor, floor layout, and hospital environment,” DeCherrie noted. “Then they moved to ICU nurses, who couldn’t work well without immediate access to the technology found in hospital ICUs. Then when home care nurses were considered, it came to light they couldn’t effectively deal with the acuity of the patients’ health. It turned out that emergency room nurses were their best employees for the role. This is just an example, but for this program to be disseminated, there will have to be workforce training to ensure enough staff.”
Another challenge involved selecting the right patients for the program. “We have many safety measures in place for our patients,” she explained. “First of all, they’re given a 24-hour number to call that gets dispatched to the physician on call after hours. We eliminated the answering service and other barriers to direct communication. We have the ability to dispatch nurses at different times of the day. Our community paramedics typically help us from midnight to 6 a.m.”
Other elements play an important role in patient selection. “If a 50-year-old man with COPD exacerbation can get his own food, navigate to the bathroom, and have the ability to call for help, he would qualify for our program without requiring someone to be with him,” she pointed out. “Most of our patients do require family or an aide to be with them.”
Mount Sinai already had a significant home-based primary care program, with doctors and nurse practitioners accustomed to home settings. “Because we had the backbone of doctors and nurse practitioners already familiar with providing some of those services, we were able to build onto that with this program,” DeCherrie said. “It’s worked well for us.”
Bringing In Paramedics
The paramedic’s role took a little longer to fine-tune. “A paramedic sent to a patient’s home is normally not reimbursed if the paramedic doesn’t transport the patient to the hospital,” she emphasized. “If the paramedic arrives at the patient’s home and stabilizes the patient, the ambulance company doesn’t get reimbursed. We had to get special online medical control certification to direct a paramedic, which is normally reserved for emergency room doctors. We petitioned New York City to create a new designation similar to one for On Line Medical Control, which was called ‘telemedicine certification.’”
At the enrolled patient’s home, the paramedic evaluates their medical status and uses a HIPAA-compliant video messaging app to connect with a physician to determine the best course of action. “Hopefully, the patient can remain at home, and we pay the ambulance company through the CMS grant,” she said.
A lone insurer in New York – Healthfirst – reimburses MACT for the program. “We need to create a sustainability plan because realistically, when the grant ends, Medicare won’t automatically begin covering it immediately just because it was successful,” said DeCherrie. “We know there’s going to be a gap before we can take Medicare FFS patients again. When the grant ends, we’ll have to focus on Medicare Advantage plans that hopefully we’ll have contracted with by then, and continue to take excellent care of their patients at home.”
LINKS:
Center for Medicare & Medicaid Innovation
Hospital at Home, Johns Hopkins Schools of Medicine & Public Health
Icahn School of Medicine at Mount Sinai’s Mobile Acute Care Team (MACT) Program
Presbyterian Healthcare at Home
