N.Y. Mobile Acute Care Team Swaps Inpatient Services for Care at Home

When the Centers for Medicare and Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), awarded a nearly $10 million Health Care Innovation grant to the Icahn School of Medicine at Mount Sinai in September 2014, the resulting Mobile Acute Care Team (MACT) program almost immediately 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 roughly 1,000 acute-care patients in Manhattan before its three-year run ends 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 patients in the program was reduced by roughly 20%. Patients had slightly lower hospital readmission 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,” says 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 20 years. “VA hospitals have their own budgets; that’s how they can provide the service,” DeCherrie says.

“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.”

Selection of Patients and Staff

The MACT program is funded through CMMI with the goal to help create a payment plan for Medicare, and hopefully other insurances, to reimburse for the care. This program can then work to disseminate the model. The pressing questions are: Can this be done in the Medicare population? Can we develop a payment model replicable for other hospitals in the U.S.? If so, will 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 points out that ICU patients are not eligible for the program. “That wouldn’t be safe,” she says. “We’re taking care of selected types of patients who need acute-care hospitalization.”

To learn about the program, DeCherrie journeyed to Presbyterian in New Mexico. Two important lessons she gleaned were the challenges of finding the right professionals for the program and ensuring safety for the patients. Because its medical participants hadn’t been trained specifically to provide acute care in the home, Presbyterian experienced a learning curve. For example, Presbyterian initially began with floor nurses as the nurse team member, but 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 says. “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 that 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,” DeCherrie explains. “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 says. “Most of our patients do require family or an aide to be with them.”

The Paramedic’s Role

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 says. “It’s worked well for us.”

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 explains. “If the paramedic arrives at the patient’s home and just 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 online 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. “Hopefully the patient can remain at home, and we pay the ambulance company through the CMS grant,” she says.

Needed: Sustainability

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,” explains 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.”