With a proper supply chain around a population of patients, and medical experts available to remotely oversee their care, a home could theoretically be transformed into a hospital on a moment’s notice. It’s a pioneering idea that the Mayo Clinic began actively exploring this summer with a pair of pilot programs in Jacksonville, Florida, and Eau Claire, Wisconsin. The Advanced Care at Home model is expected to serve up to 60 patients by the end of this year, expanding to well over 1,000 patients across the country and world by the end of 2022, according to Michael Maniaci, M.D., chair of the division of hospital internal medicine at Mayo Clinic Florida in Jacksonville.
Advanced Care at Home is an innovative approach to remote healthcare that “goes beyond telehealth,” says Maniaci. The breadth of the model is limited only by the strength of a supply chain—diagnostic laboratories, retail and specialty pharmacies, rehabilitation providers, home health nursing, durable medical equipment (DME) suppliers, and infusion therapy services—within a roughly 25-mile radius of patients.
“I can take care of patients here in Jacksonville, up in northern Wisconsin, in Los Angeles and technically also in Spain as long as the supply chain there can deliver care that is up to my standard,” he says. With that infrastructure in place, individual Mayo physicians could on any given day be remotely caring for 20 to 30 patients living just about anywhere.
The supply chain needs to be within a certain proximity to patients to get the Amazon-like turnaround time on labs and the delivery of medications and DME, Maniaci continues. Patients are eventually going to start expecting that level of convenience. “We need to stop focusing on building hospitals and start focusing on building supply chains.”
The infrastructure in Jacksonville includes Guardian Pharmacy, which delivers medications to patients’ homes, and Brooks Rehabilitation Home Health, which provides a litany of services ranging from lab draws and infusions to skilled nursing, physical therapy, and home health aides. In rural Eau Claire, the supply chain is almost all Mayo-owned, Maniaci says.
The locations are intended to field-test the Advanced Care at Home program in a large, sprawling city with an abundance of healthcare resources as well as a small community with limited options, to ensure it delivers the same quality of care to patients that they’d get at the hospital, he adds. Optimizing the model for both types of markets is what will enable its nationwide reach.
A chief component of the model is a “command center” on the Mayo Clinic Florida campus that houses the medical knowledge of physicians, nurses, and case managers. Separate command centers may ultimately be needed at Mayo’s two other primary sites in Rochester, Minnesota and Scottsdale, Arizona, Maniaci says. Mayo could thereby “lay a triangle throughout the country … for different areas and time zones.” Rochester and Jacksonville would likely be making most of the international connections, based on their current book of business abroad.
“We’re building this as a platform, a mainstay of Mayo Clinic… that we will market and share with the world,” says Maniaci. Advanced Care at Home will also be a packaged offering where Mayo sets up the supply chain and software through which smaller communities could run their own virtual care model but link up with Mayo for needed tertiary care via a co-branding agreement.
Advanced Care at Home is a highly disruptive idea, Maniaci is quick to note. Providers as well as patients may be initially hesitant about the home hospital option since they likely equate acute care with big buildings and operating suites, hallways bustling with uniformed staff, and bedside buzzers to call for help.
30-Day Bundles Of Care
The other critical program element is the technology that’s brought into patients’ home, says Maniaci. This includes X-ray and ultrasound machines as well as Bluetooth-enabled blood pressure cuffs, scales and pulse oximeters that link back to the command center via the Cesia Continuum software of Boston-based Medically Home Group.
Care is orchestrated by Mayo physicians in the command center. If Maniaci writes an order for medications, for instance, the information goes into Epic (Mayo’s electronic health record system) and gets automatically transmitted to Cesia. Guardian Pharmacy is immediately informed of the order, fills the prescriptions and has them delivered to an awaiting Mayo Clinic paramedic in the patient’s home.
Medically Home Group is originator of the virtual hospital concept and protocols, Maniaci says, and its Cesia software is what links program components together.
The first pilot program started in Jacksonville in early July, followed by Eau Claire a month later, using the one command center at Mayo Clinic Florida, says Maniaci, who is rounding on patients in both locations. To date, 28 patients total (16 in Florida and 12 in Wisconsin) have been admitted to the program.
The home hospital program packages care in a 30-day bundle, so patients are carefully monitored not just during the initial few days as they would be in a bricks-and-mortar hospital but for weeks afterwards to prevent complications, Maniaci says. This includes watching their diet and fluid intake as well as ensuring they make their follow-up appointments and, as necessary, educating patients to take better care of themselves.
Brooks Rehabilitation Home Health has staff in patients’ home daily during the “acute” phase of care, typically the first five to seven days, according to Kris Roberts, chief operating officer for inpatient and home health. “I have been extremely impressed with how this has rolled out. [Mayo] went through scenario testing for a solid month and trained all of our staff [on the equipment].” The command center ensures nursing staff in the home know a patient’s broader care plan for the day, including what tests will happen and deliveries to expect.
Currently the focus is on medical patients, Maniaci says, but the plan for the remainder of the year is to broaden program access to postoperative patients and those being treated for blood disorders and cancer or receiving bone marrow transplants. COVID-19 has only heightened attention to keeping vulnerable populations out of the hospital to avoid unnecessarily exposing them to infectious diseases.
Access to Advanced Care at Home is limited not only by geography, a 25-mile “bubble” around the Mayo campus in Jacksonville or Eau Claire, but also insurance, Maniaci continues. “This a new concept, so there is no payment model. We have to go to each payer [individually] … to negotiate a 30-day bundle to take care of people in their home.”
The negotiated price is calculated off the traditional total cost of care for a patient with a particular disease over the course of 30 days, he explains. This would include not just the index hospital stay and visits to the intensive care unit, but subsequent stays at a rehabilitation facility, home health care services, and hospital readmissions when complications arise. If an insurance company is currently paying $20,000 per episode and the Advanced Care at Home model can do it at scale for $15,000, for example, a deal might be struck where the payer is only on the hook for $15,500 (a $4,500 savings). Mayo would use most of the bundled payment to care for patients and the remainder to cover technology and staffing.
In keeping people healthier, the program could contribute to a lot of downstream savings for patients and the healthcare system as a whole, Maniaci adds. An estimated 300,000 people die in the hospital each year due to medical errors such as central line-associated bloodstream infections, and complications can also emerge after discharge when needed follow-ups don’t happen.
The model is also a nice fit with Mayo’s population health ambitions where the financial incentive is to keep people healthy and not just treat them when they’re at their sickest, says Maniaci. While hospital supply chains are what’s being built currently, similar infrastructures could also be set up for primary care and emergency services in the home so patients could access the appropriate tier of care “as [they] need it on their own terms.”
‘Star Wars’ Monitoring Capabilities
Up to now, only Medicare beneficiaries who already spent several days in the hospital and were medically stable have been admitted into the program, says Maniaci. The home also has to be a safe place for patients and for providers to render care. Diagnoses being addressed include heart failure, chronic obstructive pulmonary disease, cellulitis, and pneumonia—conditions with established treatment plans and outcome expectations. As more commercial insurers signing on, the program will expand to include more patients, zip codes, and supply chain hubs.
For Mayo, Advanced Care at Home represents a piece of a broader clinical data analytics platform that will be applying artificial intelligence (AI) to “take medicine to the next level,” says Maniaci. The focus is on the patient experience and individualized healthcare.
Part of that is getting people the help them need when they need it, he continues. The next phase is using AI to monitor people for signs of failing health by harnessing data from wearable medical devices to help guide their healthcare, including when to see the doctor or change medications. The same AI can be used to predict future pandemics, much as social media has empowered flu predictions based on connections between people and their self-reporting on where they go and symptoms they experience.
More Bluetooth-connected diagnostics will be getting deployed at home in the future, says Maniaci, including small endoscopes providing a better picture of the ears, nose and eyes, and stethoscopes that collect sounds from the heart and lungs. Bringing AI into the mix will enable next-generation patient monitoring with “Star Wars” level capabilities, spotting early signs of trouble that would be undetectable by human diagnosticians—including an impending stroke that would require intensive treatment in a traditional hospital setting.
More immediately, the Advanced Care at Home model has some natural crossover with decentralized clinical trials. Mayo Clinic Florida will soon be involved in safety trials where participants get monitored at home, Maniaci says. This will also extend trial access to entirely new populations of patients of diverse races, ethnicities and environmental exposures, by removing geography and travel as barriers to participation.
Tufts Medical Center has already partnered with the Medically Home Group as part of its COVID-19 response strategy and is now providing chemotherapy at home to a small group of cancer patients as part of a research protocol. “We’re looking [at doing that] at a bigger scale,” says Maniaci. “Our multiple research entities will be doing [decentralized trials] by the end of the year.”
By Deborah Borfitz, Diagnostics World, October 2020