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“More studies are needed to fully understand the impact of in-home hospital care programs on quality and cost. Extending the waivers will give physicians, health systems, health services researchers, and policymakers the opportunity to further analyze these programs’ results to determine the future for this person-centered care model.
The movement from inpatient to in-home acute-level care started long before COVID-19, and the pandemic accelerated it. Congress should extend the acute care at home waivers to ensure these innovative and patient-centered programs continue for those who rely on them.”
Stephen Parodi is an infectious disease physician and health care executive.
He shares his story and discusses his KevinMD article, “The public health emergency brought health care into the 21st century. Let’s keep moving forward.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Stephen Parodi. He is an infectious disease physician and health care executive. He wrote the KevinMD article “The public health emergency brought health care into the 21st century. Let’s keep moving forward.” Stephen, welcome to the show.
Stephen Parodi: Kevin, great to be with you.
Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where we are today?
Stephen Parodi: Oh, sure. Yeah, so I’m an infectious disease doc, and I have always been interested in epidemiology and improving the clinical care of patients. A lot of my practice has been moving care out of the hospital, so early on, home IV antibiotic therapy. And when I moved into some more operational roles in hospitals, it was how can we move more care out of the hospital, like surgical care. Back in 2015, we actually introduced a program within Kaiser Permanente called the Enhanced Recovery After Surgery program, which ended up literally taking total joint surgeries and moving them to the outpatient setting.
And then, lo and behold, we said, “Can we do that for medicine patients?” And so back in 2018-19, we started talking about how we can actually provide this care and do this safely. So we actually did patient focus groups and clinician focus groups, and we started putting together what the logistics would be to provide hospital-level care in the home. And then the pandemic hit, and that sort of supercharged things, where we were able to get a number of regulatory waivers in place, and then to actually put together the teams, both the remote teams and the in-home teams, and connect them together with an IT system that allowed us to do this.
Kevin Pho: So when you talk about hospital-level care at home, what kind of conditions are we typically talking about?
Stephen Parodi: Yeah, so since we’ve launched the program, we’ve had about 1,600 patients enrolled in the program, both in Oregon and in Northern California. The vast majority of them, I’d say probably about 70 percent, are some kind of infection-related issue, although I want to just point out that most of them were not COVID. So these are more bread-and-butter type infections: pneumonia, cellulitis, urinary tract infections, that type of thing.
But then we’ve actually branched out and are taking care of a lot of conditions: heart failure, small bowel obstruction, complicated multisystem-level sepsis, that type of thing. So it’s a broad-based program. These people have to, at the very least, meet InterQual criteria, but moving beyond that, these are people who I think most clinicians would say are typically med-surg-level patients.
Kevin Pho: So give us a case study here, an example. Let’s say an elderly patient with COPD comes to the emergency department and gets diagnosed with pneumonia that requires hospitalization. If you were to implement this program, hospital-level care at home, what would that look like?
Stephen Parodi: Yeah, so the way it works is, I’ll just sort of walk you through the patient journey. A patient shows up to the emergency department. We’ve already done a lot of pre-work to make sure that the ED physicians and the hospitalist physicians are comfortable with the concepts of the program. They’ll do a medical assessment, a clinical stability assessment, and then a social screen assessment to make sure that the home is safe. And then they’ll offer the patient the option of potentially going home. We also offer the option of being admitted to a regular brick-and-mortar hospital.
If the patient says yes, then we actually have the virtual hospitalists come into the room and do a virtual examination. They write the orders just like you would in a regular hospital. They’re admitted, and then we transport the patient to the home. There, they’re met by either a physician assistant or a community paramedic, who again does a screen of the home itself. They actually set up the Wi-Fi. They set up the IT system that the patient’s going to need to communicate with the remote command center, which has a typical team: hospitalist, nurse, social worker, and program coordinator.
And then the patient’s able to actually have direct remote access. It’s pretty cool. It’s got either an iPad, where you hit a button and it gets you directly to the command center, or, if they can’t handle video technology, we give them essentially what looks like a bat phone. Pick up the phone, and it goes directly to the command center. And then it’s two-way communication, so then we can actually radio in. And then we have remote patient monitoring, so we can get vital signs, and the patient can call for help at any time, even using a watch-like device.
And then they’re typically in the program, in the acute setting, for about three to four days on average. And then we have what’s called a recovery phase as well, so basically what would look like post-acute care from a typical hospital. So the same team can actually provide that longitudinal follow-up as well.
Kevin Pho: So how about things like intravenous medications? How are they administered at home?
Stephen Parodi: Yeah, so basically what we do is, once the orders are written, the medications are delivered, typically by the paramedic, and then they will be administered. So we place the IV in the home. If they’re going to need long-term IV therapy, we can place PICC lines in the emergency department and have them transferred to the home, and then the IV medications are delivered however often they need to be delivered. So typically a patient’s being seen at least twice a day in person, but if they need additional IV therapy, we can do that.
And I’ll just give you another sort of really interesting example. We’ve figured out workflows for being able to push high levels of IV fluids, and so we’ve admitted people with rhabdomyolysis and actually have the correct type of IV pumps that can deliver a liter of fluid in rapid succession in the home.
Kevin Pho: All right, let’s talk about the KevinMD article that you wrote. It’s titled “The public health emergency brought health care into the 21st century. Let’s keep moving forward.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?
Stephen Parodi: Yeah, so one of the most important things about the ability to stand up a program like this has been that the traditional rules that allow us to provide care, either in the hospital setting or, like, do home health care, none of them seem to really apply very well to being able to provide this high-acuity level of care in the home. And so with the start of the public health emergency, we were able to implement a lot of what I just described, because there were waivers put in place related to the public health emergency, some of them related to telehealth and then some of them related specifically to hospital at home. There was an actual waiver called the Hospital Without Walls waiver. All of those are tied to the public health emergency.
And of course, all of us hope that the public health emergency is going to complete, or at least end, and there’s a lot of anticipation that by the end of the year, the federal government will say there is no more public health emergency. And so, unfortunately, with that comes a cliff, essentially, as it relates to all these waivers. So the reason that I was compelled to write this article is that we now have more than 200 hospitals in 34 states that are actually operating using this waiver to provide hospital-level care in the home, and the only fix here is actually, literally, an act of Congress. So I thought it was important to get the word out that, number one, this is an emerging and important, I think, therapy, and an extension of the hospital and an extension of physician practice that we don’t want to see. And the more voices, the merrier here, in terms of pushing this forward.
Kevin Pho: So tell me about the legislation that’s currently being considered to continue this.
Stephen Parodi: Yeah, so there is right now a bipartisan and bicameral piece of legislation that is called the Hospital Inpatient Services Modernization Act. Essentially, it would extend the waiver protections beyond the public health emergency. It would waive the requirement for the on-site 24/7 nursing that’s required in a brick-and-mortar hospital and continue to allow us to provide those in-person services, as long as we’re providing two in-person visits a day with nurse virtual backup.
The other thing about the legislation that I think is really important here is that it sponsors, or at least pushes, CMS to do studies to actually look at the efficacy, the cost-effectiveness of the programs, and the safety of these programs, and we definitely need more data. I cite in the KevinMD article a New England Journal article that has shown promise in terms of these programs. And of course, there are a number of programs, including the ones that we’ve been doing, that really show that this program is promising from a safety perspective, a length-of-stay perspective, and a patient satisfaction perspective. I mean, patients prefer to be at home.
And I’ll just tell you, as a clinician, it’s so much more satisfying to be able to tackle “Why is this person getting heart failure? Oh, let’s open up the refrigerator and actually see all the salt that they’re eating.” And I always use this other example here, which is that we’re required to do med reconciliation at the time of discharge. OK, let me just tell you, there’s no way to do real med rec. Real med rec is when you’re looking at the person’s kitchen table, and you see a bunch of medications that are expired, a bunch of medications that are actually probably old prescriptions they shouldn’t be taking anymore, and maybe what their cousin gave them. And that’s actual real clinical practice.
It’s very satisfying, because I can remember, actually, early on, when I started my practice and was doing HIV care, I had a number of patients who, for transportation-related issues, couldn’t come in, and I would literally go to their home. And I can tell you, the insights that you get are really incredible.
So yes, one patient that we admitted into our program was what people would term a frequent flyer, so he was coming in with repeated lower extremity cellulitis. And actually, he got fed up with being readmitted to the hospital, so he refused to be admitted to the hospital, but he was willing to be admitted into this hospital-at-home program that we had set up. And we got him back there into his home, and it was interesting. The PA actually came up with the idea of connecting with this patient. He noticed that this patient had a bright red truck in his driveway, and he said, “What’s the deal with that bright red truck?”
And the patient was like, “Well, you know, that’s my pride and joy, and I’m not able to drive it because my leg keeps getting infected.” And he’s like, “OK, so your goal of care, essentially, is to get back into that truck.” He’s like, “Yeah.” And he said, “Well, you’re going to need to change your diet. You need to deal with the diabetic management that you’ve not been adherent to, and you’ve got to take the antibiotics we’re prescribing.”
And what ended up happening is we redirected the focus. Instead of medicalizing all of it, the entire team focused on the red truck. The patient’s way more satisfied. He hasn’t been readmitted. And it just gives you the social insights as well as the medical insights that we couldn’t otherwise have.
Kevin Pho: So I think what you said about medicine reconciliation certainly resonates. I’m an internal medicine primary care doctor, and the only true way to do reconciliation is to literally have the patient bring their plastic bags full of medicine bottles and go through exactly what they’re taking, or the duplicate medications they’re taking, and, like you said, what other people are giving them. So what happens if this piece of legislation doesn’t pass?
Stephen Parodi: Yeah, so it is a real risk to a number of the programs, in terms of being able to continue. And certainly, I can tell you, where I work, Kaiser Permanente is committed to continuing this program, but it’ll be done in a patchwork fashion. I mean, right now, unfortunately, the regulations really limit our ability to extend the program and expand it. So I don’t think the programs will completely end, but it will certainly slow down the momentum that we’ve had, and I can tell you that in terms of being able to enroll patients at scale, which I think is really what we need to do.
And by the way, let me just say another reason why I think this is a can’t-fail type of moment is that our hospitals are still chock-full of patients. Right now, our EDs are full of patients who have delayed or deferred care. We still have COVID going on, by the way. And so we need this additional hospital capacity. So my answer to you is, today, this is really something we can’t afford to have fail.
Kevin Pho: We’re talking to Stephen Parodi. He is an infectious disease physician and health care executive. He wrote the KevinMD article “The public health emergency brought health care into the 21st century. Let’s keep moving forward.” So, Stephen, under ideal conditions, let’s say this piece of legislation passes and funding continues. What do you see as the future of hospital-level care at home?
Stephen Parodi: So I actually see expansion of this program. What I envision here is that, of course, we’re working with hospital at home, and what we’re finding is greater continuity of care. I referenced this a little bit here. When you discharge a patient from their home hospital setting, they still have ongoing needs. Now, they may need limited follow-up, where they need follow-up with the primary care physician, and we’re now finding that we’re able to bring in the primary care physician earlier in the process. So there’s actually a cleaner handoff and a warm handoff, instead of one where there’s a cliff after you leave the brick-and-mortar hospital.
But people have post-acute care needs, so they need ongoing PT, OT, and speech therapy, and we can provide that with a lighter touch than the full hospital team, but we don’t have to completely transition off the hospital team. So we may have a physician who rounds every couple of days or every three days, but they’ve got the PT coming once or twice a day. And again, that prevents readmissions, literally readmissions into either the hospital home program or into a brick-and-mortar. So just to give you a sense of that, we’ve seen basically a 40 percent reduction in readmissions, in terms of 30-day readmissions.
To give you another example, I mean, why would you admit a person in the home, be able to take care of their acute needs, and then put them in a skilled nursing facility? You wouldn’t do that. So we’re actually dipping our toe into what skilled nursing care might look like in a home.
I’ll give you one other sort of example that has been piloted, and that’s providing cancer care in the home. One of our partners that we actually exchange with, the Mayo Clinic, has actually done a study, as has Mass General, looking at and enrolling people who are getting cancer chemotherapy and doing that in their home, and providing the post-acute care, like a neutropenic fever, for example, in the home. So I don’t think this is just going to be limited to bread-and-butter hospital care. I think there are going to be others. Just think about the things that we put into an infusion center today. Why couldn’t those be done in a home as well?
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Stephen Parodi: So, a couple of things. I think this is such an exciting time. We’ve been through a difficult period here with the two and a half years of the pandemic, and no doubt this has been complicated for our patients and complicated for us as clinicians. And yet there’s an opportunity here to shape and reshape the way we provide care. This program is so exciting to me because it is person-centered. It is really getting literally back to the future, getting virtual black bags and being able to go into those people’s homes, but doing it at a greater scale than, say, perhaps the folks who were back in the early 1900s doing this. It just feels very genuine to me, and it’s very person-centered.
And I’ve got to tell you, the feedback from our patients has been through the roof. When you ask them, “Would you rather be in a brick-and-mortar hospital if you had to be admitted again?” the universal answer is no. So I think what we’re seeing here is a transformation of the way we can provide care, and probably the way we should do it.
Kevin Pho: Stephen, thank you so much for sharing your time and insight. Thanks again for being on the show.
Stephen Parodi: Thank you, Kevin.
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