One of the most renowned hospitals in the U.S. recently celebrated the three-year anniversary of its hospital-at-home program.
In 2019, Mayo Clinic CEO Gianrico Farrugia stated that high-acuity home care would be part of not only Mayo Clinic’s future, but the health care industry’s at large.
With that declaration, Mayo Clinic launched the Advanced Care at Home model the following year, partnering with Medically Home. The program has since seen 2,600 patients, delivering positive outcomes and cost reductions on the way.
Yet, Dr. Michael Maniaci — medical director of Advanced Care at Home at Mayo Clinic — is still thinking about where to go next.
Home Health Care News recently caught up with Maniaci. During the conversation, he talked about Mayo Clinic’s plans to expand the hospital-at-home program, the organization’s interest in ED in the home and how he believes everyday data should be used to better care for patients in the future.
The conversation has been edited for length and clarity.
HHCN: Can you start by giving me an overview of the Advanced Care at Home model?
Our home hospital program is a virtual hybrid. Both our physicians as well as our bedside nurses are all virtual. They’re all located in a command center that’s in Jacksonville, Florida. They only do virtual visits, and then we build supply chains around the patient that deliver in-home care.
That may be an advanced practice provider once in a while. It might be a nurse, or a paramedic a couple times per day to give IV medications, do an exam that can be zoomed in with the provider virtually, as well as physical therapy, drug pharmacy, medication delivery, so on and so forth.
We’ve found over the last three years that we have decreased readmissions to the hospital. This varies on the type of patients, but it’s at least 15%, and up to 50% in certain populations. We’ve had decreased mortality, meaning less people die in home hospitals than they do in the physical hospital. There is some selection bias. Obviously, we don’t take home people who need ICU care and emergency surgery, for example. But even when you match it to regular patients that could go either to the home hospital or the brick and mortar hospital, the patient experience is higher. People enjoy seeing patients in their natural environment and then catering the care plans to treat them how they should be treated in their home, as opposed to a generic care plan, which is usually used in the hospital.
When we look at our numbers, care in the home costs at least the same, if not lower than care in the hospitals. What we’re finding over these years, there’s a lot of startup costs. You have to automate, you have to scale, you have to have enough patients in your program, or else it is expensive. But when you get the right amount of patients, and you’re automating correctly, and treating patients with the right amount of care at the right time, it’s at least cost effective, if not better costs.
We’re very happy with the outcomes thus far, because when it comes to safety, affordability and satisfaction ,we’re at least equivalent – if not better – than the physical hospital.
How is this program reimbursed?
About 75% to 80% of our patients are Medicare CMS waiver. The rest are commercial payer. We started out before the waiver existed in July of 2020. We started first with CMS patients that were admitted to the hospital for at least two days to activate a DRG. Then they moved into the home setting as well with a couple of commercial providers. When the waiver came along, it really helped us, because we were able to take patients right out of the emergency room.
Last year, the Advanced Care at Home model was available in Wisconsin, Florida and in Phoenix. Can you give an update on how the expansion has been going?
The grand scheme of things is to expand to every part of the Mayo Clinic Health System and our Destination Medical Centers.
We’re in the midst of a randomized control trial right now. We’re randomizing patients at our different sites because there’s not been a real, highly acute, randomized control trial done of this virtual hybrid model. While we’re running this trial, we’re not doing any further expansion. We’re going to hold off until the end of the year. Starting in 2024, we’re going to look first at our health systems, our critical access hospitals and smaller systems in both Minnesota and Wisconsin, whoever needs the most help — and expanding to those campuses. Then we have a plan to expand to Rochester.
After that internal expansion, we’re looking at our Mayo Clinic Care network, these are our partner hospitals. How can we help them activate their hospital home programs, and be partners with them? It’s a long runway of virtual care that we have planned over time, when it comes to hospital at home and Mayo.
Have there been any challenges or roadblocks to offering this model? What are these challenges, and have you found ways to navigate them?
The first challenge is deciding if you do it all on your own or move forward with a partner. A lot of systems try to do it on their own, some systems are big enough that they can pull that off. Most systems are smaller, and don’t have the resources. Then your hospital-at-home program kind of stays as a side project. It never goes past three to five patients. We knew we wanted this to be a standard of care and have many patients. We needed to find the right partner to make sure we could expand and make it scalable.
The next roadblock is just patients and provider buy-in. Would the patients accept this as an alternative to a physical hospital? Would physicians and other providers allow the patients to go in the program? COVID helped us a bit because patients didn’t want to be in our physical hospital. Now, three years in, patients actually ask, ‘Can I go to Advanced Care at Home?’ Providers have also gained steam with this over time, they’ve seen the successes and the ability to treat very sick patients in the home environment with very good outcomes. They’ve come on board.
Another one is the regulatory environment. Every rule that applies to a hospital patient really applies to a building, not an acuity. What I can do inside the four walls of the hospital, if I step outside, sometimes the law, or different rules say I can’t do it. Working with state and national regulatory providers to change some of the rules to adapt to the new age of health care delivery is very important. We’ve gone to Tallahassee many times and changed some state rules to use our own pharmacy to treat people in the home as hospital patients.
Also, the payer environment. We’re working with national providers to get a permanent payment system, and then working with commercial entities as well. What does the payment model look like for these commercial payers? Is it fee-for-service? Is it bundled 30-day payments? All those things have to be figured out as we move forward.
Aside from the Advanced Care at Home model, what are some of the interesting things that Mayo Clinic is doing in the home?
Hospital at home is the highest acuity, sickest patients, but it’s just one level of multiple tiers of virtual and digitally enhanced care that Mayo Clinic is doing, or plans to do, in the home setting.
Right below that are patients that have chronic diseases, or just got out of the hospital that need remote patient monitoring, or the different types of virtual interactions with specialized consultants, such as cardiologists, pulmonologists and endocrinologists. Below that, there’s app-based care. People in their home, or wherever, can access Mayo Clinic. We have different interactive care plans. If somebody has certain diseases, they can plug them into the phone, and it can tell them the next steps to do. Some of them get guided treatments to do on their own, and others are connected to a Mayo provider. We virtually connect you and decide what care we can activate in your community.
We’re also looking at different modalities in the future of what we can do in the home setting. We’re doing a proof of concept on chemotherapy in the home. Patients who have cancer, and undergo chemotherapy often, have 16 to 18 visits to a cancer center within a year’s time. We’re seeing if we could activate resources in the community and give them chemotherapy at home monitored by in-person and virtual nursing, as well as other resources. We want to give them a better experience.
We’re also looking at emergency room level care, or acute clinic level care in the home. If you feel ill you can activate a virtual emergency room. A provider can make a decision — ‘You need to come to a physical emergency room,’ or, ‘Hey, it sounds like you might be developing a bad cold or a bladder infection. Let me activate some resources, send a paramedic, get some labs, start some medication.’
One of the big features of this is really, the right amount of care, for the right patient, in the right setting, as opposed to just relying on hospitals, clinics and emergency rooms for everything.
Given its standing and reputation, what are some of the ways that being part of Mayo Clinic has helped push hospital at home forward in general?
One of the main things is we’re part of – and helped form – the Advanced Care at Home Coalition. This is a coalition of 17 to 20 hospital systems throughout the United States, including big names, like Johns Hopkins and others. It’s all of these different providers coming together. We want to push forward both the regulatory and payment models so that we can protect our patients.
Apart from hospital at home, is there a care delivery model or technology solution that you find fascinating, and why?
I think there’s a lot of neat things on the horizon. Some of it exists today, and some of it will exist in the future and will really help out with this new decentralized health care delivery model that we’re working on to help save health care in America.
One thing is just wearables. Everybody has smartwatches, they have things in their home that are monitoring what they’re saying and what they’re doing. I think we’re going to get away from a lot of current remote patient monitoring models.
A lot of the remote patient monitoring models are monitoring heart rate and blood pressure in your home. On an average day, that doesn’t really help you. Those things go up, or get in the critical ranges right before you have to visit a hospital. Instead, we’ll be gathering data on — are you up out of bed less? Are you coughing more? Are you eating or drinking differently than you did the last couple of weeks? A lot of this ambient collection of data will help drive some of the better models of care and prevent bad things from happening to people and prevent hospital stays, or other types of illnesses.
There’s also a lot of new technology coming out. Collecting vital signs or data through the camera, as opposed to a wearable device, for example. Instead of putting a blood pressure cuff, or a pulse oximeter, or heart rate meter on your body, cameras have algorithms now that can pick up pulsations in your skin that we can’t see with the human eye.
Finally, I think on the horizon is non-medical data being used for medical advancement. What I mean by this is, to diagnose heart failure, for example, I have to see a patient several times. They have to come to me with certain symptoms: shortness of breath, swelling of the legs, weight gain, and different things before we can say, ‘Oh, let’s do an echocardiogram and figure out what’s going on with you.’
What if we could look at data stamps of people and what they do in their daily lives? They bought bigger pants, they bought compression socks, they bought skin cream. Years ahead of when a diagnosis was made, we can notice a weight change. They’ve changed their lifestyle, they’re doing something with their skin, they need to see a physician to rule out diabetes or heart failure. Catching people years ahead of time based on their everyday lives. That’ll take a lot to put together, but as we become a more digital world, that data is out there to help and be used for good, as opposed to being used for shooting a bunch of ads out.