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Featured topic and speakers
It’s been two years since The Permanente Medical Group started its acute care at home program. Returning to discuss how the program has grown and the impact it has had on patients and physicians is Stephen Parodi, MD, executive vice president of external affairs, communications and brand at The Permanente Federation and associate executive director for The Permanente Medical Group. AMA Chief Experience Officer Todd Unger hosts.
Learn more about AMA's Integrated Physician Practice Section (IPPS).
AMA members can access and comment on the "Advancing Acute Care at Home" resolution. Login to view.
Register for "Breaking the wellness silo: How The Permanente Medical Group engages operational leaders to combat physician burnout" on Thursday, May 11, 2023, at 1-2 p.m. Central.
Speaker
- Stephen Parodi, MD, executive vice president of external affairs, communications and brand, The Permanente Federation; associate executive director, The Permanente Medical Group
Transcript
Unger: Hello and welcome to the AMA Update video and podcast series. Today we're talking about acute care at home with Dr. Stephen Parodi, the executive vice president of External Affairs Communications and Brand at the Permanente Federation and associate executive director for the Permanente Medical Group in Oakland, California. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. Parodi, it's great to have you back on the show.
Dr. Parodi: It's really good to be with you, Todd.
Unger: The Permanente Medical Group was an early adopter of acute care at home, which is still a relatively new concept in medicine. And we had a chance to talk with you about this back in 2021. We're eager to hear about what you've been learning. But let's start by giving the folks out there a brief refresher on what you mean when you talk about acute care at home.
Dr. Parodi: It's a great question, Todd, and happy to be back talking about this important topic. So basically, at its core, we're providing advanced care services in the home, so hospital level services. A patient that you would otherwise admit on a medical surgical floor in a brick and mortar hospital are now being taken care of in the home.
Now, you can imagine the logistics that it takes to accomplish that. And essentially, you need a couple of things. One is that you need a virtual hub that has a traditional hospital team—a doctor, a nurse, a social worker, program coordinator, discharge planner. And then in the field, you need services such as community paramedics, nurses, physician assistants, PT, OT, speech therapy, DME, EKG, mobile radiology.
All those things that you traditionally want in a hospital, you want in a home. And then you have the remote patient monitoring component, where we're able to bring the tech into the home, where we're able to monitor the patient's vital signs, their clinical condition and the patient can contact us. So that in a nutshell is what hospital at home looks like.
Unger: So just from what you outlined there, that's a huge effort. And I'm curious, what's driving that for you?
Dr. Parodi: So for us, I've got to tell you, our hospitals are full. And this is post-pandemic. We have a lot of patients coming in with a lot of advanced conditions that are related to deferred and delayed care. But I think also it's related to the aging population. So that's number one.
I'd say number two, big factor here is our patients want this. Since we've enrolled patients, and we've actually enrolled 2,600 patients into the program, the satisfaction for this has been gangbusters. People like getting this care in the home. It's more patient-centered, person-centered.
And the clinicians love it because we're able to actually touch the patients, not just medically but also socially, understand the social determinants of health that are driving some of those underlying conditions that are resulting in hospitalization. So it's an exciting program both from a patient provider perspective and then just from a hospital capacity perspective.
Unger: That's so interesting to hear it really coming from both sides there. Well, I'm eager to learn more about how it's been going. You started the acute care at home program in 2020 in just two areas and you saw some impressive initial results. Talk to us a little bit about how the program has grown since then.
Dr. Parodi: So it's pretty amazing. We now are running an average daily census of somewhere between 20 and 30 between our Oregon and California programs. We are taking care of really all comers when it comes to the type of payment model—so Medicare Advantage, Medicaid patients, as well as commercial patients, a broad swath of patients when it comes to socioeconomic needs.
So 45% of the patients are coming in with the highest categories of socioeconomic needs. So this is not just for people with fancy homes. It's for anybody who has a home, who has running water and electricity. In terms of diversity, somewhere between 8% to 10% of our patients are African American, 6% are Latinx, 79% are white.
The outcomes have been impressive when it comes to readmission rates. They vary between 8% and 13%, depending on the current month. We've had literally one hospital-acquired infection, very few mortalities, one total in the entire program so far. No sentinel events. And when it comes to ED escalations and hospital escalations, those are on the 1% to 2% range.
So good quality and good satisfaction from our patients, significantly rating us between a 4.9 out of 5 on all categories since we've launched the program.
Unger: So really impressive results. And obviously, a lot going into putting a brand-new model like this together. Not easy. I'm curious, over these past few years, what are the kind of challenges that you've encountered as you've begun to expand the program?
Dr. Parodi: So a lot of complexities in terms of making sure we're moving at what I like to call the speed of care. So making sure that we've got the logistics in place to get all the things that a patient needs on time. And you can imagine that that involves coordinating both the virtual hub team with who's going to be on the ground and then everything in between.
And you just can't underestimate the amount of coordination that requires. That's number one. Number two, we're in a regulatory no-person's land, if you will. So there's a lot of regulation around hospitals. There's a lot of regulation around home health. Not a whole lot in terms of defining what good looks like and what a regulator is willing to allow.
And this is literally a state-by-state set of questions. So we've had to overcome a number of hurdles there. We've had coordination with other health systems as well to help overcome some of those barriers. And then, of course, there's a payment model that has to be put in place. That's largely been driven by waivers that occurred during the public health emergency.
As all of us know, the public health emergency is expiring or has expired in multiple states. So keeping these programs going while we're still learning is going to be critically important going forward.
Unger: Now, you talked a lot about the patient satisfaction side. Very high writing ratings for this alternative I'm curious, on the physician satisfaction side and all of the issues that we've experienced with burnout even before the pandemic being complicated by it, have you seen any change in the level of burnout among physicians? And how satisfied are they with this mode?
Dr. Parodi: So let me speak specifically first about the physicians in the program. They are extremely satisfied with this program. In fact, many of the hospitalists that are participating see it as an additional outlet—additional opportunity to exercise their skills in a new way, and doing it in a virtual way.
Increasingly, actually we're finding that the—I called it a hub, but many people are now working from home as opposed to in a physical hub when it comes to providing this care. So that provides some additional job satisfaction in addition just to the clinical care that we're providing.
That's not to say that—physician wellness is critically important. It needs to be addressed. And Kaiser Permanente is no different than everyone else and we are experiencing increased loads of physician burnout. So I really actually encourage everyone to attend the AMA Becker's webinar about operationalizing wellness and registering for the May 11 session because there are a lot of innovative ways to bring people back together.
I'm an infectious disease doc. I've got to tell you, Todd, one of the most important things in terms of bringing people back and actually communing and talking over both the issues that we're dealing with to keep the operations going, but also the clinical care that we're providing and exchanging about patients, I can't tell you how important that is.
And so I think our ability to commune again is going to be critically important going forward.
Unger: And we'll put some information about that webinar in the information below this episode so you can be sure to sign up for that. Dr. Parodi, I'm curious, when you think about where you are in terms of scale right now with this program, what's the multiple—what's the future look like in terms of how big you'd like to see this?
Dr. Parodi: My hope is that we basically take care of increasing numbers of patients in the home. There are always going to be a need for people to be in brick and mortar facilities—people that need intensive care, people that need complex surgery. But I think what we're seeing here is the ability to scale in ways that are new, ways that are person-centered, ways that we can reach people into their homes.
So my hope is that we're able to grow this significantly, that this becomes—when I'm talking to you 10 years from now, is just part and parcel to how we provide care. Think about this, Todd. If you were talking to folks that were part of the AMA maybe 100 years ago, most of us had black bags and were going into people's homes. This is the modern day version of what the black bag is going to look like in the future.
Unger: It's a little bit back to the future, but with a very, very high tech side of this that wasn't there before. Really interesting. Now, you alluded back when you were talking about some of the expiration of the provisions that were part of the pandemic and how important that was. And it really does speak to, again, the importance of health policy when we think about care models like this.
So I want to talk a little bit about your work with the AMA, and specifically in your involvement with the Integrated Physician Practice Section, which is advancing a resolution now about acute care at home. Tell us a little bit about what that resolution is hoping to achieve.
Dr. Parodi: So the AMA has actually played a really important role in making sure that we actually could continue these programs with the expiration of the public health emergency. And so part of that advocacy allowed for the omnibus bill that was passed at the end of 2022 to extend basically the protections of those waivers through 2024.
So we now at the IPPS feel like we want to continue that advocacy. So the resolution hopes to actually make permanent some of those provisions and ask the AMA to advocate for the permanence of a model that would allow us to provide hospital at home services.
It also asks the AMA to explore those barriers that currently exist at the state level and working with state associations to see how can we help others, whether that's mobile integrated community paramedics, opposition from unions, opposition perhaps from other advanced care providers, and making sure that we understand those perspectives and actually help advance those benefits that I was talking about earlier.
Unger: I'm curious whether you'll be talking to fellow members of IPPS or any health system out there that might be looking to start its own programs. You've got a number of years now of experience. What piece of advice would you give them?
Dr. Parodi: My biggest one piece of advice is persistence. Whenever you're launching something that's new, novel, groundbreaking, there are going to be folks out there who think maybe this can't be done and/or they think that the barriers are too high. And you just have to be persistent.
Work through those issues. Work with people. Collaborate. Sometimes push. But never give up. And really, the eye is the prize—eye on the prize, which is taking care of that person in their home in a way that's person-centered.
Unger: Dr. Parodi, thank you so much for being here today and giving us your perspective. That's it for today's episodes. But I do want to mention, if you're a health system leader and you're interested in hearing more about the work of folks like Dr. Parodi and best practices of people working on new models like this, visit ama-assn.org/enhance-support to learn more about the AMA Health System Program.
We'll be back soon with another AMA Update. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks again for joining us and take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
