Colleen Hole, BSN, MHA, FACHE - The Value of Hospital at Home

Move to Value

In this episode we learn about the Hospital at Home care model from Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health, responsible for integrating the principles of Population Health and value-based care into clinical and operational practice.

Colleen Hole, welcome to the move to value podcast

Well thanks Thomas I'm really glad to be here

I'm curious Colleen, how did you become interested in population health?

Not to show my age but I've been at nursing for many decades and most of those years were spent in acute care in a hospital. And to be honest I think most folks in a hospital just work to get through their shift without really any visibility upstream or downstream as to what brought that patient in or what we're sending them off to. So, we often, not often, always do incredible care in that moment but it's really hard to have visibility into what else is happening in that patient's life that's making them struggle and circling back through our Ed and our hospital. And really, I could see miracles where we save lives every single day but largely in silos, but our patients don't actually live in a silo, they live everywhere else but the places that we take care of them.

So about 10 years ago or so clinical integration became a thing, and I was intrigued by that because I saw it as aligning care really across the continuum. Now our focus was more internal, how do we align care within our health system, but it was about providing care like we had been doing but more about coordinating that care among silos. And I always thought gosh there's got to be more to this than just what we're doing here. And then about seven years ago here at Atrium Health we launched population health and it kind of hooked that to the drive to value. And I was lucky enough to be part of that pretty early on and really loved seeing how health systems were starting to take responsibility for what happened outside of hospitals, around food insecurity and livable safe housing etcetera and then the social determinant of health thing became a thing. So, I guess it's evolved over many decades but really excited I think where I see health systems going now with pop health.

So, I know that you're involved with the Hospital at Home program can you tell me about this program as just an overview perhaps about how this concept came about?

Sure so if you go back 100 years ago where there weren’t brick and mortar hospitals much, many patients received what you might call hospital level care in their home. But with Hill-Burton and post-World War Two we built a whole bunch of brick and mortar across the world. But about I guess 30-35 years ago, the concept kind of came back around more in Europe and even Australia, where for various reasons health systems were starting to go back into homes to deliver hospital level care. And then here in America at Hopkins, Dr. Bruce Leff, a gerontologist, started a program there focused on the fragile elderly primarily recognizing that hospitals presented some risk to this population. So he started a small program and even today, it it's not 100 patients per day, but I think of him as the father of hospital at home if you will. And then when the pandemic hit many health systems were challenged with capacity. So it gave all programs a lift and here we are today with over 200 health systems approved for the CMS waiver which covers at full inpatient DRG, a Medicare hospital stay. So lots more to tell about that but it's kind of evolved over the past several decades, but never with the momentum that it us now

Can you tell me a little bit about and give me a timeline about the Atrium Hospital at home program and why it's been so successful?

Sure so I was busy doing my population and health work, I also serve as the chief nurse executive of our very large Medical Group, and I thought I was plenty busy. But on March the 13th, I was called to a meeting with seven people couple of physicians, couple of administrators, me representing nursing, and we recognized we had a tsunami of patients coming with COVID. We frankly didn't know much about how to take care of them. We didn't know much of anything all we knew was our hospitals in the winter were already full and then some. Traditional flu and all of those viruses, and really in in almost a panic mode of what are we going to do? We were watching Europe and Italy and New York and figured we got to do something quick. So it was kind of like an Apollo 13 moment where they throw all the stuff on the table, here's what we have what are we going to do and failure was not an option, honestly. So about seven days later on March 20th of 2020, we saw our first patient in hospital at home. Part of the benefit of being a large health system is you have a lot of stuff to cull together to make something. So we had clinicians who were available partly because we had closed some services, at least for a time. We also had a pretty robust mobile integrated health or community paramedicine program. So honestly threw all that stuff together, wrote some clinical protocols, work with our IS folks to build them in our EMR and got busy.

So we've been on a 3 year journey to iterate that program which essentially was an outpatient program for which we didn't send a single claim for a whole year, to a full blown inpatient level of care covered under the Medicare waiver. I often say it was the funnest silo busting I've ever done in my 40 years, because everybody leaned in to help. I picked up the phone and said Hey pharmacy I need some help we need medications. We’ll help. Respiratory therapy. We’ll help. It's kind of like a code and a hospital where regardless of the tension that there might be among you know respiratory and nursing, everybody leans in and saves the patient. That's what it felt like and that honestly the adrenaline rush that comes from doing that kind of work has really been the fuel, I think, to sustain the program. Because quite honestly, we're still in a capacity crisis. Our hospitals remain 110% to 120% occupied. And so, we still at least in this market have a have a capacity crisis. So that's still is the burning platform but obviously there are numerous other reasons why we're still at this business.

How is the hospital at home program doing now? Tell me how things are going now that we're sort of, I don't want to say on the backside of the pandemic because I do realize that there's still a lot of issues, but now that things have have become a new normal where do we go moving forward from here?

Yes so we were all COVID in the beginning and we were so unsure that when a patient showed up at the ED, they knew about hospital at home, and it was an automatic, oh good send them home with hospital home. COVID? Send them to hospital home. Over the past three years the pandemic has waxed and waned obviously. In January of 21 so almost one year in we had a peak census of 130 patients on census. That was our highest COVID peak in in our market. So you know literally chest pain in that moment, but since then COVID has only about 10% of what we're taking care of. So we've had to figure out how do we draw patients with heart failure, COPD, various other infections. So really we've seen probably 150 different diagnostic groups if you will of patients still mostly medical but we also will do some post-op surgical patients who often stay in the hospital for lab you know labs to settle or frankly even to have a bowel movement. That that's not a really good reason to tie up hospital beds so we're really constantly looking at what other populations would do better in a home recovery than in a hospital.

I will tell you it's still a challenge to find those patients we've got over 2000 inpatient beds in this greater Charlotte region, and I'm budgeted for a census of 32. So we run high 20s low 30s census daily but most experts in this space believe that 20 to 25% of a market beds could be done with hospital at home. So we've got a long way to go that would be a couple of 100 patients on surface at least. I think it's completely possible Mass General Brigham for example is going for 200 plus. I hope to get to 50 to 75 by end of year but we've still got to decompress our hospitals. They're still full not of COVID but of chronic conditions that didn't get enough attention through COVID. So these patients are sicker than they might have been 3-4 years ago.

So again, being in a growing market is the blessing and a curse. People are still moving here to North Carolina, we've got to make room and building brick and mortar beds is costly and time-consuming and a waste. So if you're talking about value based care that's not value added to build beds at anywhere from a million to five million a pop just to create room, when we know this model works.

Agreed. That's some great insight. When you presented at the move to value summit recently you were talking a lot about holistic patient centered care. Why is providing care in the home, in your opinion, better than in a clinical setting and would there not be risks involved?

Well there's risk everywhere. But I'll talk to that in a minute. I learned about holistic person-centered care and nursing school nearly four decades ago. And I was so excited about it I thought wow this is so cool and we wrote nursing care plans that considered the whole person. And when I became a nurse in a real hospital it was pretty evident that that's not how we actually practice. Because we're built around professions and payment not patients. And I know that's a provocative statement, but in truth how we get paid is how we build health systems. So they're clunky and there's a lot of waste in them and they're expensive. We also know through value-based models and population health that only about 20% of a patients well-being is the medical care that they receive, and even of that 20% of medical care only a small part of that is the physician or provider orders that are written. The rest of the story is where I think our opportunity is in healthcare. What else is preventing that patient from living their best life even with chronic disease that they inherited, can't do anything about that, but how do we help them live their best life to decrease the need for these high cost complex medical interventions? And unfortunately, that's the stuff that most payers still don't cover in America. All the things that we know health coaches and care managers and what nursing does. The domain of nursing is mostly not a line item on a bill. So we've got our priorities kind of messed up in this country. I may not live to see it different, but I'm going to keep pushing because I think it could be done so much better. Other countries in the world spend far less on healthcare and have better outcomes at a lower cost.

Now about the risk thing. About 30% of Medicare patients have a harm event, some severe, when they enter a hospital, about 30%, that's coming straight out of CMS. So, it's true, hospitals are dangerous places. Patients fall, they get infection, they have delirium or sundowner syndrome, they don't sleep well, they don't eat well, and they don't move well in a brick-and-mortar facility. If you've ever been there you know it to be true. Hospitals, they're dangerous places but we'll always need them. Why would we not develop care models where patients can be cared for in the familiarity and comfort of their home. Yes patients fall at home they got rugs that are in the wrong place and they slip, but I guarantee they find their way to the bathroom a whole lot easier and safer in a familiar environment. So we know that some homes are not safe, they've got no air conditioning, or the roof leaks, there are there are stairs to navigate. But in most cases, if you do a good evaluation of appropriateness, the home is a safer place for most patients so they also tell us that's where they want to be that's holistic patient centered care.

Colleen Hole, thank you for joining us today on the Move to Value Podcast!

Thank you for having me.