Boston-based Mass General Brigham’s Home Hospital program is one of the largest in the country, with five participating hospitals and more than 5,000 admissions since January 2022. Stephen Dorner, M.D., M.P.H., the program’s chief clinical and innovation officer, recently spoke with Healthcare Innovation about keys to the program’s success as well as the current limbo hospital-at-home programs find themselves in as they wait for Congress to extend a Medicare waiver for five years.
Healthcare Innovation: You’re an emergency physician. How did you get involved in the hospital-at-home program? And what are your responsibilities as a chief clinical and innovation officer?
Dorner: Part of why I wanted to become an emergency physician was because as a safety net for healthcare, you get to see so many areas where there are problems that need fixing, where it really shouldn’t have shown up in the emergency room unless something had gone wrong someplace along the way, because in an ideal world everything would be proactively anticipated and reacted to in advance and proactively managed.
Alongside my clinical work, I get to spend the rest of my time focusing on solutions to healthcare challenges. In my role as chief clinical and innovation officer, I oversee all clinical operations for the home-based space and our home-based portfolio across Mass General Brigham. I’m responsible for things like building innovative care models like our Home Hospital, and being able to address so many of the challenges that we have, whether that’s capacity or finances or quality or patient satisfaction.
In college I spent about four months down in Peru doing community health-related work, reading all about Paul Farmer and his work and fell in love with the idea of what in-home and community interventions could afford to patients. When I came to Massachusetts, I did work with Commonwealth Care Alliance, which is a managed care group that was doing in-home interventions with paramedics to try to avoid preventable emergency department utilization. Then I came over to Mass General Brigham, where I helped stand up their mobile integrated health program, which involves sending paramedics in to do kind of what I had done with Commonwealth Care Alliance. I went from there to now being in this role supporting the expansion of a home-based care continuum.
HCI: It seems like one of the issues hospital-at-home programs have involves deciding which conditions can be treated at home vs. in the hospital setting. How do you collaborate with hospital-based colleagues on their comfort level and make the case that certain patients are good candidates for in-home acute care?
Dorner: What you’re touching on is the fact that nobody went to medical school to learn that this is how you deliver care. There’s a lot of change management that’s wrapped up in this. I think that home hospital care is greatly benefiting from the tremendous amount of research that has been done in this space that, time and again, has demonstrated the quality elements that are afforded through home-based care delivery. As an integrated academic medical system, bringing that data to clinicians and showing them the information is helpful. But then also, as we’ve scaled the program, the positive feedback loop of them having patients who have benefited from it, and then really amplifying the patient voices so that they can hear firsthand how life-changing this care model was for them really makes all the difference, and that’s helped to propel our growth over the last few years.
HCI: Could you give an example of a condition that wasn’t initially treated in this program, and maybe there was skepticism on the part of some of the clinicians, but now is part of the program?
Dorner: We started off taking medical patients by and large. The biggest volume of patients that we’ve cared for since we started back in 2017 have been cellulitis, heart failure, COPD, pneumonia, and urinary tract infections. The data there is great on patients with all these conditions. I’ve long believed that those same benefits around improved rates of ambulation, decreased sedentary time, improved quality outcomes, and decreased rates of readmission could extend from the medical patient population to the post-operative patient population, because the earlier you get up and move after surgery, much of the time, the better your recovery rate is going to be. So we’ve taken patients who have had partial pancreatectomies, we’ve taken patients who have had other intra-abdominal surgeries. We’ve just launched a pathway to take patients who undergo lumbar spine surgery and are constantly looking to find new surgical pathways that we could enable to help patients recover at home after an operation. And many folks thought you would never take those patients. But it’s created that positive feedback loop where once some of the surgeons have heard the positive stories of their own patients, it’s generated this interest and they want their patients to benefit from that. That’s really how things start to grow in an organic, grassroots kind of a way.
HCI: Are there some technology building blocks that have been key to scaling up the program more widely?
Dorner: I think that fidelity of connectivity has improved significantly over the last five years, and that’s enabled a lot of different things, including remote patient monitoring and vital sign capture. We’re even conducting telemetry in patients homes now for patients with heart failure and Afib, for example. That’s been tremendous, because it gives folks the confidence that they’re going to actually know how their patient is doing when they’re not physically present with them, just as if they were down the hall from them at the nurse station in the hospital.
That connectivity has also afforded more portability. With mobile diagnostics, we’re doing labs in patients, living rooms. We’re sending in ultrasounds and X-rays to capture images right there at their home. I think we’re going to continue to see growth in those spaces, not just with diagnostics, but also with therapeutics, too, where you’ve got programmable pumps that you can remotely modify.
I think we’re going to see medication management systems come into the market that are going to be able to manage and dispense meds that are provided in the home, so that if we need to adjust the dose of something that’s available, it’s already right there; we don’t have to get a new shipment just for that dose change. And then the connectivity between patients and their team obviously is tremendous, so that they don’t have any interruption there. The minute that you have any kind of interruption or gap in connectivity, it would disrupt the faith in the program and the service, and that’s not what we want. We’re all about trying to inspire faith in this kind of care.
HCI: What about deciding which things to build and do internally and which things to partner with vendors or service providers on?
Dorner: We perform all of the clinical care delivery with our own clinical staff, but we outsource some things that just would be better to outsource, like food preparation for our patients, and remote patient monitoring with Best Buy. Home imaging studies we do with an outside company. We have a courier service that we use, instead of dispatching all of our own drivers to go move supplies and materials. That’s the kind of thing where we leverage our strengths, but then we recognize where there are other folks who really can help round out our team.
HCI: What about the data-sharing aspects? Does all the data from in-home care flow into the EHR so that the patient’s entire care team can see it?
Dorner: Yes, we use the same medical record system, and it looks exactly the same as if they’re in the brick-and-mortar hospital. That kind of seamlessness and consistency has been really important. If we want to say that this is truly substitutive for traditional hospital-level care, which we strongly believe that it is, then it really needs to leverage as many of the same tools as possible. There’s an inherent friction where these tools were not built for a home-based environment. We’re seeing a bit of an interesting feedback loop where lessons learned as care moves into the home-based space are feeding back into the brick-and-mortar space as we make broader changes that can benefit the entirety of the healthcare system.
HCI: Are there opportunities to include more patient-reported impressions about their experience?
Dorner: I think that patient-reported outcome measures have been demonstrated to be extremely important in benchmarking and tracking a patient’s progress of recovery and healing.
HCI: I think CMS is going to start asking people to start doing more with patient-reported outcome measures, right?
Dorner: Yes, and I think this is a perfect space for us to be able to do that. Also, patients with diabetes have their own glucometers. We should be able to see that information and track that information, but recognize that it’s different from our glucometer that’s gone through our QC testing and been validated. That doesn’t mean that we shouldn’t know what the value is from their non-quality-controlled glucometer, for example. I think we’re going to see that continue to evolve, because there’s a huge role for patient empowerment in this space as we shift care out of hospitals and really make it more patient-centered in their homes.
HCI: You’ve already mentioned some of the ways in which you think things are evolving in this space. Are there any others that we haven’t talked about yet?
Dorner: The elephant in the room we should probably acknowledge is the need for congressional extension of the Medicare waiver. That’s the single biggest thing that everything else is hinging on at the moment. The congressional framework for this, from a regulatory and a financial perspective from 2020 until now, created such an incredible runway where so much innovation and care enhancement and increased capacity has been afforded through this waiver that I can’t imagine why folks wouldn’t want to continue that. Being able to extend it for an additional five years the way that they had agreed to prior to the last-minute shuffling in D.C., would provide the runway that patients, hospitals and innovators in the market are looking for.
There’s a lot of opportunity here for us to really enhance care delivery. I think that just like from November 2020 until now, when we went from six hospitals to 370 that are participating in the waiver, it’s going to go from 370 to triple that over the next five years, if not more, and then all the new technological advancements that are going to be afforded through it, as well as folks really focus on maximizing the quality and efficiency and capabilities of what this care model can deliver.
HCI: Let’s say the extension of the waiver happens. Are there still questions from CMS about how much to reimburse for acute hospital in the home versus in a brick-and-mortar setting and which conditions make sense to reimburse for this? Or has that already been decided?
Dorner: In the drafted bipartisan legislation that afforded the five-year extension, there was pretty robust language around the study requirements that would need to be produced prior to the end of the five years, and it included more robust reporting on financials, for example, to address exactly your question. That’s why the additional waiver extension is important, because we don’t have all of the answers yet, and that’s a really important one to address, because there are many folks in this space who fundamentally believe that this is the secret to curbing healthcare cost growth — that if we shift more of a sizable percentage of care out of the brick-and-mortar hospital and to the home environment, we can decrease healthcare costs overall.
I think that’s a really important thing for us to evaluate. This is one of the most disruptive elements of care delivery that we’ve had in a generation. I’ve heard two parallels drawn to this. One is the conversion of traditional surgical sites and hospitals to ambulatory surgical centers, and the move to push as many surgeries as possible into ASCs. There was reticence at first to doing that, and then all of a sudden the floodgates opened, and now everybody’s adopting ASCs. The other is the adoption of hospitalists within hospital inpatient units. It’s no longer PCPs going in and rounding on their patients after clinic, or at the end of the day, but there’s a dedicated team available in house, 24 hours a day, caring for these patients, and people now see the value of it, enhancing care and quality and patient experience. I would put home hospital care right up there alongside those two shifts in care delivery models over the last generation, and this is going to be what drives the greatest period of fundamental change going forward.
HCI: So in a worst-case scenario, Congress gridlocks and doesn’t do anything in March. What happens to all the programs across the country? Is everybody going to be in limbo or uncertain at that point?
Dorner: It’s a complex question. The delivery of in-patient care at home is tremendous, but it speaks to the need for us to really diversify the way that we are structuring and financing encounters in the home-based space. There are going to be a lot of folks trying to figure out how they can structure things in a way that can realize the imperative of delivering care at home. I think we are going to see a bit of a split where there are going to be hospitals who get that, and there are going to be those hospitals who don’t, and those hospitals who get it and recognize that the future of healthcare is in the home are going to be the ones who maximize that potential going forward.
HCI: Are some of these patients treated in home hospital programs also in Medicare accountable care organizations and could that impact how ACO leaders think about total cost of care in their value-based care arrangements?
Dorner: Yes. I think that the value-based care proposition of using the home-based space is a perfect example of where you get clinical and operations leaders and financial leaders who are thinking about creative ways to structure encounters and care delivery in a way that is most cost-effective and affordable and highest-quality for their members. We’re going to see that just expand across other areas. I think that’s a perfect example of what I’m talking about. We’re going to see that value-based care driver really expand for the home base, as it should anyway, regardless of what happens with the waiver.
