May 2023 - Acute Care in the Home Lessons from the Field

- All right, well hi everybody. I'm Aditi, I should know most of you, but I'm a counselor this year and I wanna remind everybody that if you wanted to put in any council resolutions, we have until July 10th this year. I haven't gotten any interest yet and we're not gonna take up any time during this meeting to discuss it, but if anybody is interested, you can email me. I'm also gonna send out a call to the listserv as well. Regardless of whether or not we send any resolutions, I will say that last year, just attending it, there are a number of other committees or other groups that put in resolutions. There's always telehealth within it. So even if we don't put in any resolutions, it'll probably be something that we would discuss later on. But again, that's all I wanted to tell you and I will send an email out as well. Thanks.

- Awesome, thanks Aditi. Great, I'm seeing some people filter in. As a quick kind of reintroduction, I'm Rishi Kakar, I'm an ER doc, I practice at Mount Sinai Hospital. I'm a member of the ACEP Telehealth section executive committee. And we're here today to host an awesome panel around acute care in the home. The subtitle is "Lessons from the Field." I think we spend a lot of time in this section talking about a bunch of different sort of varieties of telemedicine and it's such a like big and sort of fuzzy place to sit. You know, we have everything from direct-to-consumer telemedicine, all the way to really specific models like hospital at home. Where we're gonna focus today is sort of in the gray zone in between and sort of programs like community paramedicine, ED at home, or ED replacement models. These models are heterogeneous, they typically involve some form of having a care extender in the home. Oftentimes they have a telemedicine supervising doctor. Sometimes that's an emergency physician, sometimes that's not. But broadly the goal for a lot of them is to keep patients healthy, happy, and outta the hospital. These programs have been around for decades in some form, but got a big boost through the COVID pandemic, the shift kind of away from fee-for-service medicine and towards value-based care and kind of regulatory and financial reimbursements through telehealth. So there's a lot to talk about here. We have an amazing lineup of panelists that I'm gonna let introduce themselves. So maybe starting with Emily, would you mind giving just a brief intro? Everyone obviously here knows ya so I'm gonna start with the easy one, about kind of you, your institution, the program you run, and a little bit of an overview of your care model.

- Yeah, happy to. So, hello everybody again. So Emily Hayden, I'm here at Mass General Hospital Emergency Medicine and not only as director of our telehealth activities when they exist, but it's also I'm the associate director and I co-founded our mobile response program and our virtual obs unit. So some of you have heard me refer to our virtual observation unit briefly. It is marrying the emerging telehealth plus our community paramedicine to take patients from our ED and our ED observation unit and have them continue their observation service, level of service at home, using the telehealth and the community paramedicine model. And we also have our mobile response program, which informed our virtual observation unit and that this one is one where it's an ED avoidance is the goal of it. And these are ones where ambulatory providers in our hospital can reach out for us to go out, meaning the community paramedic goes out and then we have a video visit with our EM attendings and can do the different labs, therapeutics, and so on in the home. And so those are the two models and it's been a wild ride and I'm really excited to hear from others on the panel, just sort of those different things and lessons learned and those surprises along the way. Trying to take what we're used to doing in a brick-and-mortar ED, and we're very familiar with that, and then trying to translate that into the home.

- Amazing and thanks for that. And we're definitely gonna get into the nuts and bolts of the care model itself. Who's in the home, what do they do, what are the capabilities, who are the patients? That kind of thing. So excited to hear more about that. Sarah, can I kick it to you next?

- Sure thing, Sarah Sossong. I am currently at Commonwealth Care Alliance which actually Mass General outsources care of the top 1% of their most complex members too. So CCA is a not-for-profit payvider focused on Dual Eligible and Medicare Advantage products. So we've been in Massachusetts for about 40 years. About 10 years ago moved into the payer space as well. So really trying to have innovative care models with the state. And I came to CCA five days before the lockdown began. So came here with the intent of doing other things, but got swept full into helping transform CCAs care model to incorporate virtual since I have 15 years of passion for telehealth. So started back at Kaiser in 2008, I helped launch Asynchronous Derm which then was successful and we scaled across all of Kaiser and was really Kaiser's first enterprise telemedicine program and fell in love with this space. And so it was very fortunate as I was looking for jobs, no one had even really heard the term, much less knew what it meant or had experience. So Mass General was looking for someone to help see if there was anything there with this whole telehealth thing. So was at Mass General from 2012 to 2018. So we were the first to ever do video visits in the home from the health system standpoint and were successful there. Second Opinions was really fortunate to get to work with Emily and the emergency medicine team to launch both tele-emergency programs and also our urgent care and partnership with a vendor partner. And so but really also was interested in, yeah, along the way did a lot of startup advising, judging, and hosting hacking medicine events and was interested in sort of the creation process that happened before these companies came to Mass General's doors. So spent a little time doing venture capital and learned a lot about what makes for a successful company and partnership, but really missed being closer to the operations and helping both sort of with the product and roadmap development of companies. So came to CCA more with the intent of doing that, but have really been focused on a lot of just the cultural change. CCA really prides itself on our in-person care model. Our members are very medically and behaviorally complex and so we primarily go into members' homes. We do have clinics, but for the most part we're sending clinicians into the field and it's also been very different just yeah, as opposed to Mass General where, yeah, I really, I don't think I ever really worked with non-physicians. I think we have a small group of physicians, many of them are in the instED program, but is primarily EPCs. We have about a thousand EPCs that do in home care. So I think that brings in, so thanks for the invite and I will pass it on to Erik.

- Thanks Sarah, nice to see you all and meet some of you. I know a few of you on the call already. My name is Erik Blutinger. I am a board certified emergency physician working with Rishi at the Mount Sinai Health System here in New York City. Also serve as medical director for the community paramedicine program for the entire health system. Our program has been around since 2017 and we've been growing gradually since then. I first became exposed to digital health really in the throes of the pandemic in 2020. Feels like decades ago. Have seen our platform grow and have been involved with digital health strategy also outside of community paramedicine for a few years now. As well as with ET3 efforts that have been underway with our health system in coordination with others across New York City. I'm excited to be here. I think there are so many in this room that I feel could also be serving on this panel and really look forward to having a discussion about where things are headed in this space. I sit on the ACEP Practice Innovation Task force with Dr. Pines and others. I've read a lot of literature and papers, including the likes of Dr. Hollander, who I see is on this call as well. And I just think that community paramedicine, digital health, a lot of these platforms that we're all part of, really is changing so quickly to your point, Rishi. And so it'll be great to at least have an hour to talk through some ideas, innovational concepts, and see where we should be heading. I can say that in New York State specifically, our regulatory environment has made it very challenging and so understanding how folks are doing it elsewhere is also particularly helpful.

- Yeah, and we'll certainly get to advocacy topics and regulatory, it's a huge piece of this care and especially if we're talking about scaling it nationwide, it's a real challenge, but kind of state by state how to scale this type of care. But Erik, I'm gonna stick with you for now just 'cause I know you and I can pick on you. Give me a bit more of the flavor of our CP program. Who are the patients, how do they get to us? What do they look like?

- Community paramedicine, at least at Mount Sinai, is really tailored to the acute, unscheduled care complaint. We are unlike a lot of other mobile integrated healthcare programs across the country that really handle chronic care management conditions. We do tap into the chronic care management space, specifically when it comes to congestive heart failure, where we are enrolled in a PCORI-funded study with Columbia and Cornell Presbyterian looking at how can we reduce downstream healthcare utilization for patients with CHF by coordinating a CP visit in their home within seven days of discharge. But by and large, our bread and butter is for the patient who has an acute, unscheduled complaint and calls their outpatient provider. That provider who has been through our training program then activates our program to send a medic to the patient's home. They perform a head-to-toe assessment, check an EKG, perform a finger stick, and connect with one of our board-certified emergency physicians through the digital health program through an iPad. And in coordination with the outpatient provider who activated us, the patient, possibly a caregiver, the digital health physician, and the medic, and what they're seeing on the scene, the team comes to a well-coordinated decision on whether the patient can stay at home or needs to be transported to the ED, or may perhaps need some kind of intermediate measure such as a care management referral. Our metrics I can dive into if you'd like, but by and large we handle a very sick patient population. Depending on the time of year, depending on the practice, depending on whether it's an internal or external partner to our health system, the transfer rates can vary, but we aim to have at least two thirds of our patients stay at home, which we've successfully done over the last few years. But that can sometimes be challenging when we have patients in their 80s or 90s who have multiple comorbidities and have a chief complaint of respiratory distress. So I'll stop there.

- Yeah, there's a ton there and I wanna kind of like pin that last piece around the 80 to 90-year-olds and sort of the patients that end up benefiting from this type of service rather than kind of walking into the ER or calling 9-1-1. Can you talk about that patient specifically, like maybe you have an archetype in your head or a specific patient in your head where you're like, "That's who community paramedicine is for."

- It's really challenging to your point, Rishi, and it really comes down to where is the fork in the road, where is the stone in the stream that's preventing that patient from staying at home safely and reliably? And part of the challenge is there's so many moving pieces to community paramedicine as an example. There's the provider engagement side. How do we educate our virtual providers who may be used to having a lot of ancillary testing, imaging available to them, being able to physically listen to their heart sounds or press on an abdomen? How do we convince them that with limited resources those patients who are pretty sick at baseline can safely and reliably stay at home with expedited follow-up? Then there is the outpatient provider. Training them and helping them understand this new care delivery model. We are not meant to supplement 9-1-1. The patients with stroke symptoms, with clear signs of having a STEMI should not be waiting for a community paramedic to arrive, have a dedicated virtual provider, and lead to delays of possibly transporting them either. So how do we have the outpatient provider education when many of these providers are not emergency medicine trained, they're across all specialties in medicine. And then the third piece is how do we leverage the technologies and the platforms that we have so that we can reliably evaluate the patient? I mean, how many of us on this call have even had a simple virtual visit where the patient can't connect on video or there is a lag in the connectivity with wifi and yet balancing equity, making sure that we can reach the patients in communities that may not be connected to broadband internet. So I would say there are a lot of these challenges that we continuously try to tackle, but depending on the partner and depending on the patient, there's a different set of potential solutions that we try to implement and test along the way.

- Yeah, well said. And Sarah, I was thinking of you as Erik was talking about the outpatient provider and education, maybe a lot of folks on the call are pretty ED-centric and hospital-centric, so maybe can we hear a little bit more about Commonwealth Care Alliance, which is such a, like unique and forward thinking organization for how long it's been around and sort of like the attitude of the payvider attitude of sort of like outpatient providers there and the attitude of keeping patients out of the ED and the tools you have to do so.

- Uh-huh, yeah, so I think that was actually part of the creation of the instED program in the first place. So it's actually a separate company spun out from CCA in order to do that. So CCA is the biggest client and we work very closely, so I don't really think about that separate distinction, but they also serve for PACE programs and Point32 formally, Tufts. And so I think in terms of, one of the things I've appreciated about being at CCA is that there's very much a mindset of thinking about that. Not only from a cost perspective, but also most of the time our members and patients, they don't wanna go into the ED. They are often, yeah, our members are frequent flyers and so it's not comfortable. And so I think it's something that they have really engaged with. And you know, in general, most of our requests are coming from nurses doing symptom triage often in primary care offices. And so they log onto the portal almost like ordering GrubHub or something. They can see the paramedic, not the EMT, but a paramedic go out into the field. And I think, you know, we too have struggled with that when the patient or member doesn't have the right connectivity. We actually we found that CCA that 30% of our members don't have access to connected devices and we actually have a lot of programming that we're doing around that. We do virtual care readiness assessments of everyone when they join CCA. And so that's how we have that data. And so we have a lot that we've done around education or around video visits, especially with some of the different groups. There's actually a lot of fear around, you know, are you recording me? What else are you doing when you're tapping into video? But so completely agree with the challenges, but part of the beauty of the instED program, utilizing videos that at least the paramedics are more familiar with the technology and are able to tap into that. Although the wifi and connectivity is still an issue, regardless. So I think oftentimes telehealth video isn't used and oftentimes phone really does suffice, but where it is desired video can be choppy even with just because of the connectivity issues. So I think that's been a barrier for sure, but I think a lot of interest and I think it's just sort of remembering it in the flow of the busy workday. But yeah, happy to elaborate on many points, but take it back to you.

- Yeah, one thing I'm curious about with Commonwealth specifically is because you take, I assume full risk on a lot of these patients.

- Mm-hm.

- I think there may be, and correct me if I'm wrong, a culture of someone going to the ED or someone being hospitalized as being a failure of the outpatient system in some way and sort of like driving providers to do whatever they can and use whatever tools at their disposal to keep patients out. And some of that is really good chronic care management, but as all the ER docs on the call know, like sometimes you just need acute care, like something happens. So how do you encourage sort of use and teach outpatient providers that this is what's okay to call instead for, and maybe if you sent a patient into the ED for X, Y, or Z reason, maybe next time like instead would be a better option? Does that sort of educational infrastructure exist from a quality perspective?

- Yeah, well, I think actually the care delivery part of the organization and the health plan are separate. They work together, but in many ways I think a lot of the clinicians in the field are very thoughtful about yeah, whatever medical care. So I actually, I feel like there's been less. I don't see it being a risk in terms of, you know, ED avoidance being something that is happening because we're in a provider scenario. If anything, there's probably better education on the instED program. And so that's something, it's just constantly getting a bit in front of people and reminding them of yeah, how to do it, how easy it is, and also the numbers. So I think it was really helpful for me to take a look and I think, you know, they've gotten used to the right types of patients. So in general, of those that are referred to the instED program, only about 4% are denied in terms of "No, this person absolutely should go." All the rest do go out and only about 10% of the members who do receive that instED visit go into the ED within the next three days after that. So about 9 to 12% going to the ED right after the visit, 15% go in within three days, and 18% within 14 days. So really I think these are members and patients that would've gone to the ED in the first place regardless. So that's like huge savings and really just quality of life. I think CCA really prides itself on respecting the dignity of members' choices and what they would prefer. And they're oftentimes cases where they talk through the risks of staying in the home and the member can say, "You know, I know what to do, I know how to escalate, I'll go into the ED if X, Y, Z happens clinically. But you know, I've been to the ED countless times before and really wanna stay home because it's not comfortable." So I think it's a constant education process. And I think broadly I would say that just the continuing to tell the stories of where it works well I think is one of the best cultural tools we can use to sort of change physician adoption and clinician adoption. Both for the instED team, but then also the broader care team. I think we hear all the time from our care partners that, "Oh, my members don't wanna do telehealth" and we have a separate virtual care support team and when they reach out, the members say that they would love to do video visits, they don't really want someone coming into their home. So there is this balance of what the clinician is comfortable with versus the member and certainly there are a lot of places where someone doesn't wanna do video or doesn't have the capability or it's no appropriate. But I think we can't underestimate just the change and adoption piece. So I would love to hear how other people have tackled that because it's an evolving thing. But I think the more stories we can hear about where it works well, I think that's the best tactic I've seen for sort of slowly changing people's hearts.

- Totally. And those non transport rates seem really impressive. And that's something that hearing from folks who are doing the work like that meaning success, you know? In the emergency room we're really focused on dispo, you know, like getting people to the destination that they need and changing that and sort of flipping it on its head and saying that, "No, like keeping you away from anywhere else and keeping you here at home is what success means to me" is a bit of a, at least for me was a mind shift set, you know, change when I started doing this type of care. So I think that's a really important point. Emily, I'd love to hear a little bit more about your care model. In the couple of programs that you mentioned, you alluded to it, but who's in the home? Who are the patients and how do they get referred? Does what Erik and Sarah say kind of vibe with you?

- Yeah, it completely does. And of course, each of these programs have nuances and so the numbers of sort of acceptance rates, I was surprised to hear from Sarah that 4% decline. That's amazing. We found it was higher. We found that we were probably having to decline 25%. So it goes into some of that education and some of those, several things, right? Education, and this is also, sorry, one little riff then I'll get to your actual question. Is the what is our scope of practice outside of the ED when we're doing this as telehealth? And so some of the things we're being asked to do may not be an ED avoidance, if you really look at it, you could say it's actually a PCP visit avoidance and that the patient probably could have made it to the PCP in a few days, but that the PCP is like, "Well, if you don't take this patient, we're just gonna send 'em into the ED," right? So these are patients that we're still taking care of in the ED, but should we be taking care of them? Like is this part of the guidelines or part of the like marketing and advertising that we'll take all comers. So we're definitely in more of a resource restrained, constrained environment when we're going out there. We had, as someone said earlier, we don't have all those ancillary tests ready to just go ahead and just click a button on Epic and all of a sudden we're gonna get our MRI.

- Yep.

- And our labs and all those things. So back to your original question though, the way our care model works is that we have the only person going into the home is our community paramedicine, our community paramedic. They have their hotspot, the tablet, and all of their gear in the big SUV that's like souped up with like the fridge for the medications and everything else. So it's a non-transport vehicle. Our physicians for a mobile response program where it's the ED avoidance program, they're remote so they could either be in the office or in their homes. They are remote and they're doing things by the video with the paramedic. For the virtual OBs unit, we also have funding where we have a virtual OBs nurse who's also remote, as well as a case manager who also is remote. So again, the only person going into the home with the patient who becomes a functionally the telepresenter plus, right, like a telepresenter who can help with this and they can go ahead and do an EKG and transmit it to us right away, and they can do labs, and they can press on the belly, and they can listen to the lungs, and they can go ahead and do a home safety eval. So we have a falls patient pathway right now where we have the community paramedic has their checklist of what they should be doing with the tug test timed up and go. Is this patient actually safe at home? Which is actually probably better care than what we do in our actual sterile ED observation unit to see if they can actually walk around safely in a very, you know, very easy place to walk around compared to their home with throw rugs and no railings on the showers and so on. So did a couple riffs there, but yes, community paramedics are in the home, the rest are all coming in virtually.

- Yeah, it makes a ton of sense. And a couple of things that you mentioned are things we think of medics doing already? Medics, they come into the ER, they give us an EKG, they give us a 12 lead, they've done, you know, they give us a story, but then you mentioned some stuff that medics don't actually normally we don't think of them doing, labs and maybe even imaging. Talk a little bit about that and sort of the development of like how you pick what risk stratification tools to give both your physicians and your medics and kind of the thought that goes into that and how that's used kind of clinically.

- So I think I'm gonna be answering this correctly, but let me know after I say it. If I'm hitting what you would like. So each community paramedicine program, for those who are not as familiar with this, there really aren't standards that are nationwide. It really is locally responsive. So if you are working with a EMS company that is willing to do some community paramedicine, there is training towards whatever is needed at the time. So currently we are training our paramedics up on using Butterfly to be able to do ultrasounds and ultrasound-guided IVs. Others may not have that as part of the skillset that they want their community paramedics to, that EMS company may just decide that's not something that's gonna be high yield enough or not. So each one's a little bit different. So we have a very, very close working relationship with our community paramedicine partners and have a lot of communication in terms of what are some skillsets we need for whatever it is we're trying to do. To the question of how we decide sort of a yes, no, are we gonna go or not, are we gonna say we're gonna dispatch a paramedic out to this resource out to the patient's home. We have very specific exclusion, inclusion criteria. Some are hard and fast and some are going to be relaxed if and when we have other resources available. So we initially had home imaging available, so home plain films and ultrasounds. So get that lower extremity Doppler ultrasound to make sure the person doesn't have a DVT. Unfortunately that wasn't working anymore for us. And so we don't have home imaging anymore. So there's a subset of patients that we could have seen, but now we cannot, not safely. Some of the like absolute no-gos is some of the active substance use disorder currently and the decompensated mental health. And I'd be curious actually to hear from Sarah because you have such complicated patients with not only non-mental health specific CHF and other things, but also with mental health that for us, we have one community paramedic, right? You said who goes out into the home? It's one community paramedic. When you have a transport vehicle, you have two, right? So you always have someone for safety-wise. In the ED, we all know ED violence is going up, we know violence is going up so many places it feels like when we watch media. In the ED we have our security, we have other colleagues there. We have to be really careful with our community paramedics going out as a single person out into these homes. So I don't know if I answered what you wanted me to, did I answer it or at least did I dodge it with my tangential thoughts?

- No, you perfectly did. And then I've said, so imaging you had it and then sort of no longer do and then labs, is it go to a nearby lab facility or is it point-of-care?

- Could, yeah. So we currently do point-of-care labs. So we have point-of-care labs, we can, we do have one of the, we're Epic shop for the EHR, we have an Epic label printer on these non-transport, the community paramedicine, MIH trucks. So we could send, technically we could send a troponin, we could send any labs to our lab. We print out the date. As long as they have the tubes, right? So that's another thing is that if you decide you're gonna start sending formal labs in that are not point-of-care, there's only so much space on these non-transport vehicles. So if you're gonna start sending stuff that actually needs to, you know, stuff that needs to be on ice and other things, that resource is probably not available. But we could potentially do that. It just, do we have all the stuff on board? But any lab that you write there, it can be sent in if we have the tubes and the timing and ice if it's needed.

- And building off your point, Emily, I think an interesting concept in this space is not only understanding what tools and technologies we have available, but how do we strategize on which one we should use in a world of finite resources depending on our intended target audience, the patient population, and what we can fit within the confines of our actual programs. An example, we have an ability to either incorporate point-of-care testing or phlebotomy based lab. Both are great, both give you a lot of extra data. Both can potentially reduce your transport rates and keep patients safely at home. But both achieve very different outcomes. And they have their own set of costs and their own set of regulatory hurdles. Point-of-care testing is awesome because it's at that point of service. The digital provider knows what the results are. Hopefully we'll keep the patients more safely at home. But then you have to worry about CLIA standards. You have to worry about the size and the weight of a piccolo versus an i‑STAT or an EPOC. So then you think, okay, should I incorporate lab-based services? Yes, that's certainly a possibility. But then how do you coordinate the follow-up? Who's gonna follow up the labs? What if you can't get ahold of the outpatient provider? So I think it's a really interesting quandary, if I can even use that word here, because even though we may have the technology available to us, how do we use it strategically to our own advantage that makes the most sense on the ground in the right clinical context?

- Yeah, 100%. Judd asked a question in the chat that kind of dovetails with what I was gonna ask too. And he kind of provocatively says like, "What type of providers are best to manage acutely sick patients who stay home?" And I kind of, the thing I'd piggyback and maybe Erik, I'll stay with you, is how does emergency medicine as a skillset, even if you're not in the ER, help here? Like what is it, what is the attitude of the right emergency physician in this case and how do they act?

- It's a great question and I don't have the best answer, but what I can say is based off our experience here in New York where we have an a selection of different providers from different specialties, we've consistently received the highest quality of care provided by the board certified emergency physician. And I'm biased being in a webinar hosted by ACEP, but it's true. We're used to, we're a jack of all trades. We're used to using different digital platforms. We're used to being able to facilitate communication with different outpatient providers. And we did test our platform with urgent care providers who had to unfortunately balance the digital health program with seeing patients in person in clinics. It's much harder to stand up quality metrics and pillars for achieving successful outcomes. I do think though the traditional board certified emergency physician does need to have some EMS understanding, they need to understand what medics can and can't do, and they do need to understand what can be done on the tech side. Because if you put an emergency physician who doesn't have a lot of experience in digital health or in out-of-hospital care with even medics, it becomes a really big challenge crafting their decision-making to the community paramedicine context. So the best answer is probably it's a Venn diagram and in the middle of multiple circles of different specialties, the middle is the ideal candidate from a physician perspective, but I think the emergency medicine specialty is the right starting point if we can tailor our algorithms and right educational processes.

- So Erik, I wanna kick in with some follow-up, mostly comments to have other people beat up or you could beat up. I think what you say is probably exactly true for the upfront management and the way I've come to think about it is because we as emergency physicians know what we could do at home and the difference, if any, into what we could do in the emergency department. But there are some things that we actually honest, oh this is recorded right? There are some things that we're not perfect at, which is elderly geriatric patients that come from a nursing home where our reflex is to order a bunch of stuff and admit 'em, right? And so we are not the best people to do that. We're not the best people at day three 'cause luckily we mostly don't have three-day boarders so far. So we need people that wanna follow people and we tried to troubleshoot this dilemma and never implemented. So I don't have any experience to speak from, but we grew out a hospital-at-home program far enough that we had done simulated visits and everything was up and we got our Medicare waiver. We just couldn't get anybody to pay for it. So we never launched the program. But what I realized, right or wrong, is who knows whether a patient needs to come back to the hospital to be readmitted after discharge? That's the hospitalist, right? And so when we thought about when you're discharged from hospital-at-home or you're getting care in hospital-at-home, the person, much like us in the community paramedicine upfront know is there value in going to the ER, it's the hospitalist who would know is it worth your while to come back in or are we just gonna do the same things we could do at home? And so I don't have an answer to it, but I think we need to think that there's different care phases at home and there's different areas of expertise unless we're gonna make somebody the expert at that whole span. But I don't know that that specialty exists right now.

- I totally agree. The one other thing I'll add onto that is one of the things that fits into this discussion is understanding the value-based care model. To your point, it's not just a point discrete episode in time, it's a continuum of care that we have to be able to provide patients. And so I think, you know, that's a totally other separate topic of how do we start thinking value-based care more minded as a specialty? But to your point, Judd, I totally agree. It has to include continuous, there has to be a warm handoff, there has to be an understanding that it's not just that episode in time, otherwise we're not going to show the kind of outcomes that we need to show to health insurance companies and to federal regulators if we wanna grow in this field.

- [Judd] Thank you.

- [Emily] I'm gonna add onto that. Oh, go ahead Sarah.

- Yeah, well, I think you're definitely speaking about there's a broader picture to this, which I completely agree with and you all are much more capable of thinking about that. But I wanted to comment too on just the involvement and who are the right emergency medicine physicians generally? Yeah, certainly you all know that in the ED more is more. And so as we think about the people that are the right fit for the instED program, certainly ones that are good team members, they like solving a puzzle, thinking creatively really thrive in this model. So I think there's not everyone I think is a good fit for even doing this. And a big part of it is that they enjoy working with the medics who bring great experience, but aren't trained in the medical decision-making aspects. And I saw a question about how you've gotten engagement from the paramedic teams. You know, actually the way that we've thought about it is and have been able to to getEMS on board is that they see it as a great business. Their medics love the work and they're growing their MIH team significantly, even sometimes at the expense of some of their other service lines. And one, I have a couple quotes from some of the paramedics, one person said, "This job has been the most fulfilling of my career. I love being here and working with our patients, many of whom I've built relationships with." And then the director of one of East Ambulance company said, "Paramedics are really good at walking into a room and determining whether someone's sick or not. Working on an ambulance they were just grabbing someone in the street and bringing them in." So I think they've found it really has helped increase their scope of practice. So I think that's not speaking to what happens on day two and beyond, but I think that that partnership is really key too. Back to you, Emily.

- Amazing, Emily.

- Oh, so I was just gonna do a so yes, yes and. So yes on Sarah's and then also just piggybacking on to what Erik was saying and something that Judd I think was mentioning or alluding to, if you notice the three of us that are speaking right now, we all are, we have home hospital programs also. That this is not the instED program that was spun off, Mount Sinai's program for the ED avoidance and for these things. Each of these programs also have a hospital-at-home arm to it and robust ones, right? And so this is something where from my emergency medicine heart meeting right now, right? And telehealth heart, it's also recognizing that to be able to have that adjacent possible to do that next innovation, having some of that infrastructure in place. So if you're gonna try to do this, which I know Mike Gonzalez who had to jump off, but with his ETHAN program down there in Texas, in Houston, there wasn't home hospital programs, but he sort of started some of those like what was pre ET3 for the non-transport. For these where it's the referrals and that this truly is gonna be, "Are we gonna avoid an ED visit and are we maybe gonna avoid an observation stay or maybe avoid an inpatient stay?" They're all along a continuum there. Sort of what Judd was saying is that like the hospitalist is the best to decide back there and I agree like on day three, four, or five, like I can guess, but they're the ones that see this much more all the time. So having these types of programs that are ED avoidance, you can try to grow it and grow at grassroots and it's much easier to do this when you have the buy-in from the hospital to already be doing inpatient level. Caveat to that is that what's gonna actually be reimbursed more is the inpatient level of care, not like it already is, but in this home-based care environment, it's a little bit of a Wild West right now. It is a Wild West in terms of the emergency medicine version of reimbursement for this and financial sustainability. So healthcare systems put more energy into the hospital-at-home programs, sometimes more than the emergency medicine one. So it's a little bit of an uphill battle for us with trying to innovate and trying to figure out what's best for the patient. Back to what Sarah said about dignity for the patients and sort of what they want in care goals, I would sort of wonder if there's anybody on this call working ED shifts these days and feel like patients are actually getting dignified care no matter what, whether they're older and they wanna stay goals of care at home or if they just have an emergency and now they're stuck in our overcrowded EDs. So having a hospital-at-home program really helps do this and it also can be the favorite child of the healthcare systems. And so for the emergency side medicine side to be able to do this, we have to keep advocating and keep demonstrating the value we do have and do bring to the system to the patients.

- Yeah, totally agree. And you mentioned the financial piece, I think that's so true. It's like, you know when you get access to a DRG, it's an easy sell for a hospital to blow out a hospital-at-home program and when you don't then it's a little bit of an uphill battle. Can you speak to maybe Emily and Erik to start and then we'll move to the value-based care world a little bit with Sarah, but how do you get paid? What does payment look like from a financial perspective? Is it a professional fee? Is it telemedicine, the EMS, how does it work generally?

- I can say we are, that is a constant moving target, but from the cost and revenue side, from the cost side, the bulk of our costs come with our medic agency and with staffing the actual platform. We get paid, we owe per unit time essentially to the medics and we pay per hour to the virtual providers. The costs and on the revenue side we can bill for the telehealth encounter. We are very limited in billing for the actual home visit and evaluation, which more regulatory push needs to happen. And the revenue also comes from our partners, depending on which one per call. We have sort of a subscription model with a lot of our external partners where they can expect upwards of 10, 15 calls per month and each additional call is X amount of dollars into our program. So if you think about it, we really are a fee-for-service funded initiative, but our goal is value-based. And so I think that's another challenge that we have as a program is identifying how do we align our payment structure and our incentives to really match the value-based part of the argument, which is why we exist. Yeah, and I heard the little bit of shame in your voice that we're a fee for service program, but it's okay, you're still doing great work.

- The light's on.

- Emily, does that line up with generally how things are at MGH?

- Similarly, it's a little simplified where every visit it's contracted rate for per visit with the EMS agencies. We also pay per hour. It's moonlighting for our physicians and for the nurses it's also similar. And then for the reimbursement, we're heavily subsidized by the healthcare system. We'll say that. And then for the reimbursement we are pulling office-based emergency, sorry, office based E and M codes, professional fees and technical fees, observation level care for Medicare patients and then the office-based codes for all others.

- Got it.

- And I can speak to this too, maybe it relates to the value piece.

- [Rishi] Yeah.

- As well, and so in our model, obviously, and I think this is what we've already heard, the cost of providing the care greater than any of the CPT codes that could apply. So we do bill those codes, but it's an arrangement where CCA pays instead a contracted rate. But again, we've done a lot of data analysis and they continue to do that in partnership with us because you know, for us, every admission is 14,000 and observation's 2,800. And so with the avoidance rates that I talked about previously, in general we're finding an estimated savings of about $1,900. So similarly we pay the physicians to be on call for this and it's a rotating schedule. So I think similar model with the others, but I think overall, yeah, it wouldn't work without the overall value piece.

- And Sarah, does full risk just fix this, you know, obviously there needs to be some internal accounting, but is it, do you find you, you sort of had a foot in both camps having spent some time at the health system and now at a more value-based care sort of like whatever, you know, the payvider world. Is it just easier in the payvider world?

- It's easier in some ways and I've learned how payers talk and think a little bit, which is helpful, but it's easier because we have all of the data. So it's much easier to do all of the follow-up with the claims data, which sometimes I found being at MGH it was harder to get at that. But I think it doesn't solve any of the adoption and other challenges. But I think financially it definitely makes it more clear. But even so, instED is a separate entity and we are contracted with them. So I think it, but it definitely helps.

- [Rishi] Awesome.

- [Sarah] Yeah.

- And I find it interesting, obviously there needs to be some internal accounting, but instED still gets paid fee-for-service-ish like within the organization and then is able to show some sort of ROI. Like at the health system it's a little more comp, just more payers and more people you have to show ROI to, more contracts, more complicated.

- Yeah.

- It's nice to have all the incentives at least somewhat sit under one roof. And I wonder sometimes if emergency medicine doesn't dig into that enough or think about that enough just 'cause we live so in the ER.

- That's a good point and I think that actually with Point32, one of the challenges has actually been, and this was one of the things in our early days of telehealth when we were only paying our physicians at MGH for their risk patients is, you know, they don't think about what payer their patient has. And so at Point32, you know, they're really only trying to route their risk patients to the model. And so, but you know, the contracted all the providers in the network don't think about their patients in terms of who has what payers. So I think within CCA at least it really does drive the right incentives because everyone is someone that we're at risk for with the state and federal government.

- So, you know, hey Rishi, can I comment on that? Because one of the things we did differently at Jefferson and you know, we were fortunate that we had a C-suite that understood this is we never tried to have a P&L on telemedicine. We're infrastructure. I'm the same as the elevator. You don't get to the 10th floor without an elevator, but there's no P&L on the elevator. No one tries to figure it out and people fix it the minute it's broken. You know, I normally talk about this and say I'm the third floor. Without a third floor you also don't have a fourth, fifth, sixth, and seventh floor. You know, I don't know what your data is at Sinai, but you know, most health systems, 10% or more are visits at telemedicine. That's $40 million in revenue last year. It doesn't come to me, it goes to whoever saw the patient. I don't want it to come to me, but you know what, my budget is a couple million bucks and there's 40 million that came in as a result of me. Don't even ask me about my P&L, I don't know it, I'm not showing it to you. It's not even a reasonable request. And the good news is the people around here understand that. If you start trying to show you have your own independent P&L, you are gonna lose, you cannot show positive profit and loss statements for telemedicine with the exception of, I know Ed Barthell's on here, with the exception of reducing you left without being seen and doing a tele-intake or tele-triage program. Everything else is negative, but there's more goodness that comes out of it and it is infrastructure support. Your shop invested $300 to $700 million in Epic. What's the ROI on Epic? It ain't $300 to $700 million. Right? It's infrastructure and and we do this wrong. This is on us. We should refuse to put P&Ls forward for our telemedicine program. They are not gonna be profit centers ever.

- Yeah, that's provocative. And it's a unique point of view and I think as the ER, we're used to that world, like we are a cost center. That's what we have been for many, many years. I do think that the difference, especially in some of this type of care is that you're avoiding admissions and in a value-based care world, there are big, big dollars associated with that. And lots of people spend lots of money trying to do that. And we're not used to an emergency medicine taking credit for something like that.

- Don't take credit for it. Let somebody else take credit. That's my point. Nobody does downstream revenue. Nobody's gonna give you credit for avoiding the admission 'cause you are one part of avoiding the admission. There's everything that happens before you and there's everything that happens after you, you don't want it, that's what I'm saying, you don't wanna try and take credit. You will lose if you take credit.

- [Rishi] Yeah.

- They know avoiding admissions is good. Nobody's gonna argue that. We helped avoid admissions, done.

- Yeah, there's like an hour more of conversation to be had about this.

- Yeah.

- But I know we have to get to Alison Haddock who's joined us, but before we get to her for some board updates, I wanna give just a huge hand to our panelists. Thank you so much for sharing your expertise. It's been a pleasure to have you. I wanna give you each 30 seconds or so to talk about one thing you're excited about in terms of the future of one of your programs or something sort of advocacy related in terms of stuff going on at the state or federal level or just to be on your soapbox and say goodbye to the gang. Maybe Emily, I'll start with you.

- I'm gonna let the others speak 'cause I get to say lots of stuff whenever I went to one of these other meetings. So Erik and Sarah, you get the floor for a few moments here.

- I'll take a first stab. I just wanna say thank you all for having me be here. As much as you've heard me talk, I'd love to hear about your story and what you go through. So by all means I'll put my email in the chat, let's connect if we haven't already. And to answer your question, Rishi, one thing that I'm really interested in is how do we connect rural and urban communities with similar initiatives and platforms? It's happening with the Indian Health Service as I've seen it in South Dakota where I periodically will work part of the year. It's interesting to see how they connect communities and patients with digital health and medic based care compared to a busy, crazy place like New York City. I think that's a really important area that we haven't really touched upon as it pertains to scope of practice funding. I won't say P&L, Judd, but other things. And that's something that I think we need to do more investigative work on that I'm excited to learn more about.

- And there's so many things I could talk about being excited about. That's one of my flaws. I think too many things to be excited about in this space. And I won't even mention ChatGPT, but I'd say personalization and really digital literacy, again, it's been unique at CCA with our membership, but whether it's, you know, in the instED visit in a hospital discharge into the home, if it's in our member onboarding, I think I used to really think about digital literacy as impacting the member patient's ability to connect to their healthcare. But through, I could go on and on and I think this will resonate, but this is just our member's ability to live and thrive in the world. And so really the more that we can support their digital enablement and their understanding of how to access things that supports food, housing, security, all sorts of things and connection with their communities. So, and I think the more we can make that personalized, culturally sensitive in the language and words of their choice, I think really I'm hopeful about the future. So thank you very much for the opportunity and yeah, likewise would love to continue to learn from all of you. Over to you, Emily.

- I'm good, again, I get to speak all the time. I think I've said my stuff earlier in this one, so Rishi, if you wanna give Allison the floor, Sarah, thank you. Erik, if you're still on, you may have had to drop off, but really appreciate you guys joining this.

- Yeah, amazing. And I love bringing it back to the respect and dignity 'cause I think that really hits home for a lot of folks here, including me. Allison, for board updates.

- Yes, thank you so much. So just a brief board update at the end of your call. For those I haven't met before, I'm Alison Haddock. I've been the telehealth board liaison for, I don't know, gosh, a lot of years. Five years. So some of the stuff that we've been working on that's related to telehealth is ongoing conversations around telehealth reimbursement. You should have gotten an email sent out to the section listserv about some of the regulatory stuff that's been going on with that. Like that just came out to the board today. So the board has been following that. We also know that there was some discussion of telehealth codes recently at the RUC which is the group that's involved in kind of setting reimbursement. And so ACEP is keeping a close eye on that and trying to be an advocate for all of our colleagues who are practicing telehealth without jeopardizing in any way those who are practicing in brick and mortar emergency departments. So I really try to be part of the voice of education about all the cool things telehealth can do and cool places telehealth can be to kind of broaden the imagination of those who haven't been involved in telehealth so far. The telehealth task force report looks great and we're just working on trying to get it on the website. We've been having some technical barriers to that, so stay tuned. We will disseminate the link once it's posted. Another report that's gonna come out soon is the taskforce report on new practice models which includes some mention of telehealth as a practice model that's not entirely new, but maybe a little bit more evolving than just the practice model of physician in the emergency department. And I know you guys were starting to talk about some of those roles and transitioning the patient and the hospital at home and that sort of thing. So those kinds of roles are included. And I think in our discussions of the future of the EM workforce, just really important I think to decrease burnout. So I'm getting a little bit on a personal soapbox here, but I think both to decrease burnout and give docs options and to make sure we have flexibility. If there should be an oversupply of emergency physicians coming, which is a point of controversy, I think for us to have options like the practice of emergency medicine via telehealth in our scope is potentially what's gonna keep our specialty thriving. So I am always happy to talk with any of you about your ACEP-related concerns. I will say just encourage you, talk to your friends. We've been running a membership campaign, ACEP plus one. We are seeing our membership dropping post-COVID quite a bit. And so if there's anything you can do to bring people into the section and to the college and let them know about the good things that are happening, that is critically important at this time. So thank you all for the work that you do and I think it's great that you've been putting on these sessions every month. And sorry I can't be here every month 'cause I have a recurring scheduling conflict, but I was able to conclude that and get here to be with you guys for most of the session today. So thanks for having me.

- Thanks Allison, and thank you all. We'll see you next month.