Intro: The following SHSMD Podcast is a production of DoctorPodcasting.com.

Bill Klaproth (Host): On this edition of the SHSMD podcast, we dig into the 2024 edition of Future Scan to be released in November, 2023, as we talk about in-home care. People it's here. The train has left the station. This is not just a thing that happened during COVID, it's here. It's moving forward and it's going to get bigger. So let's talk with Dr. Scott Rissmiller. He is the author of this section, as we talk about Care in the Home From the Waiting Room to the Living Room.

So let's not delay, let's get to it, right now. So let's not delay. Let's get to it, right now. This is the SHSMD podcast, rapid insights for healthcare strategy professionals in planning, business development, marketing, communications, and public relations. I'm your host Bill Klaproth. And in this episode, we talk with Dr. Scott Rissmiller Executive Vice President and Chief Physician Executive at Advocate Health.

As we discuss his article in the 2024 edition of Future Scan, Care in the Home From the Waiting Room to the Living Room. You can read the full article featuring Dr. Rissmiller in the 2024 edition of Future Scan, which will be released in November, 2023. Dr. Rissmiller, welcome to the SHSMD podcast.

Scott Rissmiller, MD: It's absolutely my pleasure, Bill. Thanks for having me.

Host: This is such an interesting topic. I can't wait to talk to you about this. So when we talk about care in the home, from the waiting room to the living room, what are the driving factors for hospitals and health systems to move care from the hospital to the in-home setting?

Scott Rissmiller, MD: I think there's several driving factors, and I'll cover just a couple of them. But coming through the pandemic, they always say necessity is mother of invention. And we were in 2019, I guess it was, seems like a decade ago. We were facing the possibility of significant capacity constraints in our hospitals. That caused us to think differently about delivery of care. It is something that, you know, at Advocate Health, we've been focused on for over a decade, delivery of care remotely through virtual means and that, so we had a pretty robust infrastructure to support it. But the pandemic really caused us to speed up that work.

 And it is one of the silver linings that came out of the pandemic. It also accelerated the expectations of our patients, cause they were able to see that we could deliver care in a convenient and very safe way in their home. And, our clinicians also, it accelerated their adoption of it as well. So that, that's one of the big drivers. It was out of the necessity of the pandemic. The other is just, the realization that we it's next to impossible to keep up with population growth in our country, in the needs of our country in regards to hospital beds. You know, if you look at, studies they show over the next five to 10 years, we're going to need up to 20% more hospital beds to care for patients. And those hospital beds can cost anywhere from two to 10 million. So you can do the math on that. Patients would rather be at home receiving care than, than in a hospital.

 And obviously you have to be in hospital for certain things. But the option to be able to receive hospital level care at home as long as it's delivered in a safe and high quality way; I think is something that our, our patients are looking for and are excited about and experienced through the pandemic.

And we have to change our delivery model if we're going to be able to keep up with population growth. So that's the second driver there. And then finally through the pandemic, we're seeing alignment of our reimbursement, to allow us to be able to continue to invest in development of virtual care and hospital at home, if you will, or care in the home. So those three things really coming together is the driving force. It, it was the silver lining of the pandemic, in my opinion, the acceleration of it, and there's no turning back, and that's a good thing.

Host: So we've got a convergence of these three things things that are really causing this now or making this really more viable as we move into the future.

Scott Rissmiller, MD: That's right.

Host: How many hospitals are adopting this model, are moving into this?

Scott Rissmiller, MD: The nidus of this was really again back to the beginning of the pandemic, CMS issued an acute hospital care home waiver and this allowed us to move quickly into the hospital and home area. About 200 hospitals applied for that waiver initially. But not all actually executed on the strategy because it is challenging and does require a pretty robust infrastructure to pull it off successfully.

So about 200 hospitals or so applied for it, a fraction, actually executed upon it. But it is something that we're seeing rapid growth and interest in. We have health systems and hospitals reaching out to us almost daily, it seems, to learn how we have been able to deliver it. And it's kind of very quickly become, I believe, not a, not a novelty, but rather just an expectation, if you will, of how care is delivered.

Host: So looking at your crystal ball, where do you think we're going with this? Is this something in 10 years, 15 years, 20 years, every hospital will offer some type of an in-home care program?

Scott Rissmiller, MD: Yeah, I think it's going to be sooner than that, to be honest with you. I, I think it's going to be within the next five years, I think we're going to see a redesign of how hospital level care is delivered and the movement to out of hospital and into the home setting for patients who are appropriate.

We're also going to, we're already seeing the significant movement of surgery into the ambulatory setting and into our ambulatory surgery centers and everything else. And I think we're seeing that pretty aggressively now on the medical side of delivery of care. And I'll tell you this, once patients experience it, that's how they want care delivered.

And on our side, we have been able to prove that we can do it in a very safe and cost effective way with the same quality metrics, outcomes and experience that you would expect in the hospital. So I think over the next three to five years, we're going to see rapid evolution of the in-home model. And if you're not able to deliver that, I think you're going to be left behind.

Host: So can you talk more about patient's reaction to this? It sounds like they are in favor of this.

Scott Rissmiller, MD: It's like anything else. Anytime there's a new care model, or anything new, uh, or hey, a new iPhone, right; there's people who are excited about it and then there's people who are resistant to it. So I think it's the same with this modality. Again, not to keep going back to COVID. I'm kind of tired of talking about COVID. I think we all are over the past several years, but that was really the thing that pushed us out of our comfort zone, both the patients and our clinicians, to adopt this new model. What I will say is, once patients experience it, they love it. Our experience scores are significantly higher even than our in the hospital patient experience scores are because patients really appreciate the ability to be in their own bed, eat their own food, but have wraparound services and comprehensive safe care in their, in their home. So there is I think initially, some resistance to it perhaps. But once they experience it again, it's what they expect and what I think they prefer.

Host: So patient experience scores are higher in an in-home care setting. So let's look at the flip side. How are the providers reacting to this?

Scott Rissmiller, MD: It's a learning curve. That first step can be a little scary to be honest with you. But it's like anything else. Once our clinicians started caring for patients at home and they realize they had all the information, they had all the tools at their fingertips that they have with caring for a patient in the hospital. All the data is integrated seamlessly into the electronic medical record. The video that they're looking at the patient actually works well and is high quality. The remote patient monitoring devices that we have that monitor their pulse and their oxygen levels, and other things, blood pressure, work very well and are uploaded seamlessly to the medical record. Once they see all of that, they quickly become very comfortable with it, and then our ability to send in our paramedicine team into the home to do a home assessment, to make sure they're set up well, and at any moment we can send them back in if the clinician is uncomfortable.

Our clinicians very quickly became comfortable with it. I will say though, there's a learning curve around it. It's different connecting with patients virtually through a screen, just like it is in an interview or anything else. There's a skillset that you have to sort of develop to make that connection with the patient virtually and to reassure them that they're going to receive just as good a care virtually.

But that is, once we go through some training around that, it happens very quickly and we are now, through our medical school as well as our residency programs and that we are starting to embed virtual training into the education process. Because this is going to be so much of the future for clinicians. They need experience with it, exposure to it. They need to understand implicit bias and to be on the lookout for the social determinants of health. That's the other really neat thing about home care is you get a firsthand look into the living environment and those social determinants of health that health that may also be interfering with the patient's ability to really recover and do well.

Host: Yeah, let's stay on that for a minute. I think that's a really great point. So is care in the home helping achieve health equity goals? It sounds like it is. They are more apt to receive care in an in-home setting, then having to travel to the hospital. Is that correct?

Scott Rissmiller, MD: That is correct, but you have to be intentional. And this is where I think we need to have caution, because as a non-for-profit hospital system, our mission is really to care for all. And we take that for all mission very, very seriously. A lot of the venture capital and nothing against venture capital or anything else, but a lot of those targeted delivery models are only looking at a certain segment of the population, those who can pay and those that are sort of lower acuity, if you will. And you know what, this leads to a fragmentation of care. And that fragmentation leads to, in my opinion, worse outcomes. But also those who do not have access to commercial insurance or to the ability to pay or broadband or other things are, can be left behind.

So you have to be very intentional. Our model, first we start with, let's design this for those who would have the largest barriers to receiving care and then move upstream, if you will, from there. So it really is how do we get into the home? How do we go to the patient? How do we set them up for success in their home? How do we train our teammates around looking for those social determinants health? Are we giving them the playbook that when they identify barriers, social determinant health barriers, that they can address them with resources in the community and others? What are those partnerships in the community that we need to have to bring those resources into the home and the community?

So you have to be very intentional. So I think this absolutely in our experiences, it helps close those health equity gaps. But have to be intentional around it or it actually could have the opposite.

Host: So speaking of closing health equity gaps and barriers of care, that makes me think about rural settings now and rural hospitals are disappearing. So this seems like it could be a model that could help with that as well. Is that right?

Scott Rissmiller, MD: Absolutely. You know, the, the biggest challenge for local rural hospitals and, and clinicians as well, is that they don't have the access to the resources or to the specialists or technology. And then when patients need those things, they have to send them to a big city, if you will, and they, it's a double whammy. It's uh, you know, the patients lose out on their support team, their family, and that that is there to support them cause they're going to a different town. And then also the community and the hospital loses out on the reimbursement that comes that supports the hospital. So bringing those specialists to the community virtually, whether it's in the home or in the clinic or in the hospital, helps sustain those hospitals, and those clinicians locally, so patients can stay in the community, and those hospitals can continue to thrive. The hospital at home model or the home care model, also, if a patient needs to come to the city, if you will, to receive higher end care; when they return home, they don't have to drive back for their follow-up appointments, which often can be several hours and those type of things. We can do that virtually in their home through the same model. So it helps keep the patients local. It helps keep them within their community. It helps the keep them within their support system, their family, their friends, and others around them. It connects them to their local community resources and it allows the hospital and the health system in that market to continue to receive the, the compensation or the reimbursement, if you will, to reinvest in their system.

Host: And this seems like it would help with the nursing shortage as well.

Scott Rissmiller, MD: So that's nationally. Again, there's silver linings in every challenge. And what we know is nationally significant challenge with staffing and especially nurses in our hospitals, and our clinics. So we have aggressively gone after a virtual nursing model, which allows nurses to remotely care for patients. And in doing so, they can care for a larger number of patients, a larger geography of patients, from the comforts of their home, and to be honest with you as well, that helps with work-life balance and longevity and reduces burnout for our nurses. So looking at different models where rather than do a week being 36 hours, three 12 hour shifts in a hospital, our nurses can do two in hospital 12 hour shifts. And the third one, each week could be done from home. And seeing a larger geography of patients and allowing those, uh, those hospitals to have access to that, as well as reducing burnout, for our nurses, which is our most precious resource.

Host: This just seems to be a win-win, win for everyone. When we were talking about this earlier, you mentioned the alignment of reimbursement. Let's talk about that. What is the current reimbursement scenario for hospital at-home care and, and what does the future payment outlook look like?

Scott Rissmiller, MD: You know, at the beginning of the pandemic, there was the CMS waivers around providing care in the home, which allowed us to really accelerate into this. And, fortunately for us, that has been extended, at this time through 2024, which, uh, gives us time to really continue to develop this model and to invest in it and that as well. The other thing it's done, by CMS extending the waiver, through the end of 24 is really put more pressure on our commercial payors to cover in-home services and virtual care as well. And we have seen significant movement progress, if you will, with commercial payors as well. So we are moving in the right direction, but without the alignment of reimbursement to the delivery of care in-home or virtually, the model will fall backwards. So I'm encouraged by the progress that we've had. I'm very thankful for the CMS waiver and the extension that has allowed us to continue to be reimbursed for this care through the end of 2024 and the pressure that it is put on others to step up because I do believe this is the future and is a lower, can be and should be a lower cost delivery model as well.

Because you're able to, it's less brick and mortar, less infrastructure costs. And we're able to, uh, have internal savings as well as pass that on to the payors.

Host: Absolutely. So what are the strategies then for a healthcare executive wondering about this or considering this if they want to offer hospital at home services?

Scott Rissmiller, MD: I think it's really important that you're honest at looking at what are your current capabilities and the infrastructure that you have in place. We are fortunate again, that we have been at the virtual health and the home health strategy for over a decade, and we have invested millions and millions of dollars in the infrastructure to be able to deliver this in a safe manner. So you really have to have an honest assessment of the infrastructure that you have and your ability to scale it. Otherwise, you need to be looking for partners to do this, and make sure you're picking ones that are aligned with your mission.

The other thing I would say is you, you need to make sure that there is a real commitment to this from the very, very top. We are fortunate to have a CEO in Jean Woods, who has embraced this from the beginning and not just embraced it, but has pushed us to continue to grow and develop even when the payment model was not aligned to support it. You need to make sure you have that commitment because, if you do not have the commitment at from the very top and throughout the organization, those malaligned incentives will fracture the program and you'll not get the traction that you need. So those are really two big ones is to make sure one, is your, do you have the capabilities and the infrastructure to be able to do this in a safe manner and to do it well? If not, are there partners that you can partner with to get that capability? And number two, do you have from the very top, support and a commitment to do this, right? Because, done well is a game changer for our patients and our communities, but done poorly, it brings inherent risk.

Host: So can you kind of boil this down for us? Do you have three important takeaways that we should remember when we're talking about in-home care?

Scott Rissmiller, MD: What I would say is, you know, care is care and just because we're delivering it at home or in a clinic or in the hospital, doesn't change the expectation around quality and safety. And when I say quality and safety, I mean for both the patient as well as the caregiver. We are going into homes, that can sometimes bring new risks into the model.

So we have to ensure that it is safe for the patient, safe for our caregivers, and that you have the ability to deliver that high quality care in that way because care is care. This is just a different modality. No different from in the hospital, and you have to hold yourself to that expectation. That would be the first one. The second one is done right, you really have to have an eye towards equity of care and that requires investment and a strategy that requires investment to make sure you're doing it safely for all. Otherwise, we're going to lead to fragmentation of care. That's going to lead to higher cost, worse outcomes and is not going to be sustainable.

And then the final thing I would just say is, this is no longer the shiny object or the, the futuristic model. This is the now. There's no putting this genie back in the bottle even if you wanted to, and we don't. We embrace it fully. This is the future of healthcare. And by future, I don't mean 10 years. I mean, today and even more so going forward. To ignore it, is at your own peril. Because we do not have the ability to build enough hospital beds and that for our growing population, nor should we, because there's more innovative ways to do it. So health systems really need to be thinking about how can you do this? How can you partner, how can you build the capabilities? How can you, care for patients in this way? Because it truly is the here and now as well as the future.

Host: So I love those three takeaways. Care is care number one. Number two, have an eye toward equity of care. And number three, this is the now. So you better get on board cause the train is leaving the station, if it hasn't already left, it's moving down the tracks.

Scott Rissmiller, MD: I wish I would've said it as succinctly as you just did, but thank you for summarizing that. You nailed it. Yes.

Host: So earlier you talked about having a real commitment to this. So talking to you, Dr. Rissmiller, why are you so passionate about this? You have a real commitment to this. Tell us why.

Scott Rissmiller, MD: Well, it's one of the answers to the sustainability of our healthcare system and to be, or, uh, healthcare in the nation. And our communities need it, and they're asking for it. We know that the current model of just brick and mortar hospitals and brick and mortar clinics, is not delivering on the, the quality and safety outcomes that we want traditionally and nor the expectations of our patients.

We live in an on-demand easy access world these days with Amazon and everything else, and your healthcare, should be no different. Now we have a higher bar in regardless of quality and safety. And that's a must, but this is the way forward, to be able to bring that equitable care to our communities to provide the easy access as well as to meet the underserved and address those social determinants of health, so to me, this is non-negotiable, and it is the path forward. But it's a tool. It's one of many ways to deliver care, and we have to have that comprehensive portfolio to meet the needs of our different segments of patients who are looking to interact with us in different ways.

Host: Yeah, very well said. So generally, Dr. Rissmiller, we talk about marketing tactics and strategies on this podcast. So I'm curious from your point of view, for a healthcare marketer listening to this, how should we approach marketing this?

Scott Rissmiller, MD: It has to start with quality and safety. This has been proven to be a high quality, very safe modality to deliver care. And number two, convenience and access. Those are selling points. Those are the must-haves around this. The rest is just infrastructure, strategy and approach. But the selling points around this for our communities and for our patients is going to be around quality and safety first, convenience and access second. And then it will help with affordability and the cost of care. So those are the, the driving factors around it. And it's how we, when we talk to our patients about we're going to care for you in this modality at home; that is how we present it to them.

Host: So start with quality and safety. It's a good way to, to lead off with it. This has been great, Dr. Rissmiller. I've really enjoyed talking to you about this. So as we wrap up, talking about care in the home, from the waiting room to the living room, which is going to be in Future Scan coming up, anything you want to add? Any final thoughts?

Scott Rissmiller, MD: No, I, I greatly appreciate the time and the opportunity to share our experience. I really believe that this is the here now, it is the future. Done right, it can be a significant tool to help solve for the challenges that we have in healthcare right now nationally, whether it be equity of care, whether it be access, whether it be convenience. So I'm very excited about the future. I'm very excited that reimbursement is aligning with it. And if you are out there listening to this and you're a health system or a hospital and you're considering, should your strategy start to align with this type of model, I would strongly urge you to do so because the moment is now, and is very quickly going to become the expectation, as it should be.

Host: As it should be. The moment is now and you can read a full article on this topic featuring Dr. Scott Rissmiller in the 2024 edition of Future Scan, which will be released in November, 2023. Dr. Rissmiller, thank you again.

Scott Rissmiller, MD: It's my pleasure. Thank you, Bill, for having me.

Host: And once again, that is Dr. Scott Rissmiller. And if you found this podcast helpful, and again, how could you not, please share it on all of your social channels? And please hit the subscribe or follow button to get every episode. This has been a production of Dr. Podcasting. I'm Bill Klaproth. See ya.