Stephen Parodi, MD, details model for providing acute care at home [Podcast]

In today’s COVID-19 Update, 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, discusses his health system’s unique model for providing patients acute level care at home.

Learn more at the AMA COVID-19 resource center.

Speaker

• Stephen Parodi, MD, executive vice president of external affairs, communications and brand, The Permanente Federation; associate executive director, The Permanente Medical Group

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're talking with Dr. Stephen Parodi, 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 about his health system's unique model for providing patients acute level care at home. I'm Todd Unger, AMA's chief experience officer in Chicago. Well, Dr. Parodi what's driving the move to provide patients with even more complex care at home than I think maybe we thought about even a year ago? Is this driven by the pandemic or is this something that was in process before that?

Dr. Parodi: Well, first of all, it's good to be with you. And really, this transformation was occurring before the pandemic. In fact, our medical group had been doing exploratory work over a year before where we had convened focus groups with patients as well as providers to understand how could we do this? Because you know, we're at a crossroads here where essentially it's almost impossible to build a new hospital nowadays. And to acquire new beds. And we actually don't really have a bed problem, from my perspective. What we really have is bringing care to the people and providing access where they want it.

So, we had gotten a lot of feedback from both physicians and patients that this was going to be something that was desirable, but there were a whole lot of questions. And then, of course, the pandemic happened, and all of a sudden it became not just an idea, but a necessity. And by the way, the technology was available to make it happen. So the ability to have good, safe monitoring in real time technology in the home, as well as getting logistics platform, meaning the computer platform, to be able to get stuff into the home at the speed of care was now possible. So, groundwork had been laid and then it really got transformed and supercharged during the pandemic.

Unger: You know, it's interesting that so many pieces of transformation, that technology is only one piece. Did the pandemic kind of spur acceleration that you wouldn't have expected before?

Dr. Parodi: Totally. This is all about cultural transformation, getting people to think about, "How can I actually provide that care remotely?" So think about the leap of faith that we thought we all had about providing telemedicine on an outpatient basis. So now take that and say, do that for complex needs patient that needs acute care.

So we essentially had to take what was a traditional hospital team—doctor, nurse, social worker and care coordinator—get them all together, get comfortable with being able to provide care remotely and work with essentially an on-the-ground team that looks different than your traditional home health services. So that is community paramedicine, physical therapists, occupational therapists and others that are going directly into that person's home in addition to your traditional nurse and providing that seamless level of care. And then actually being comfortable with a scheduled day because providing care in the home means that the patient needs to know, "Okay, I'm going to get the phlebotomist at this time. I'm getting my mobile radiology exam at this time. And I'm going to see my doctor just like a regular scheduled appointment at this time." And so riding that coordination game, people to think outside the box is really key.

Unger: It's kind of interesting system level changes on both ends of this process, both for the health system on your end and the patient on the other. It is a transformation. And as part of that, you have an interesting partnership with Mayo Clinic to bring this type of care to patients. Can you talk about the collaboration and how it will help?

Dr. Parodi: Yes. So, it made an exciting announcement about a month ago where both Mayo Clinic and then Kaiser Permanente are investing in the digital technology platform that is run by a company called Medically Home. And essentially, what this is, is it allows for the coordination of translating, essentially, the physician orders and the electronic health record into what I call vendor fulfillment requests. So, if I order oxygen, I order an antibiotic, then all of a sudden those get translated into the vendors that will deliver those materials or pharmaceuticals into the person's home. And we've mapped out the timing for when that needs to happen. So imagine a stat order versus a routine order, we now know what that means in terms of how fast something needs to get into a home. So, this investment's going to allow us to supercharge this, essentially expand the platform and get to more patients faster, both within our two systems, Mayo and Kaiser Permanente, but our real goal here is to increase access throughout the country.

We do have a problem in the U.S. right now with people having access to good high-quality, safe care that's hospital-level care in various communities. You can think of the rural communities. You can think of underserved communities in the urban areas. We saw that come out loud and clear during the COVID pandemic. And what we were able to do with this program at its nation stages are for 2020 and early 2021 has been to prove that this thing actually can be scaled. And so now we want to be able to bring it to more in the country, beyond the four walls of our two institutions.

Unger: That issue of access is critical and the health equity implications of this are pretty dramatic. Can you give us more of an idea of how and when you started to roll this out to patients?

Dr. Parodi: Yes. So, we actually launched our first two programs in the middle of last year, one in Oregon and one in California. And they're actually a little bit different. So, the one in Oregon, we use the Hospitals Without Walls waivers that were available through the federal government because of the public health emergency. And so that's allowed us to dip our toe into providing care for Medicare beneficiaries. And so essentially we've been able to target older individuals, people with the at-risk conditions to be able to get into their homes in, you know, a quicker fashion, and in Oregon is somewhat more rural type setting. In Northern California, we launched it in Vallejo and back about California, Solano county, a very diverse county, lots of social determinants to be addressed in addition to the medical conditions that the patients presenting for their hospital stay. And so we've been able to provide care to actually commercial beneficiaries as well. So we used a different process in California. So basically testing with both different insurance types, but also urban, rural settings. And combining that experience to understand how we want to grow in the coming year.

Unger: So when you look at all those variables, as part of this kind of this test, what are you learning? What's working, not working, what kinds of patients are benefiting the most from this type of arrangement?

Dr. Parodi: So first of all, when you think about what are we tackling. Who is being admitted to an acute care at home model? I just want to make it clear, these are not home health patients. These are people that are in the emergency department, and they would otherwise be admitted to a brick-and-mortar hospital. And it ranges from the simple conditions, pneumonia, heart failure, skin and soft tissue infections, urinary tract infections, but it actually expands to some of the more complex care as well. So people that have something like rhabdomyolysis, which is a muscle breakdown, auto immune diseases, and now actually pilots for taking care of cancer care in the home. And so we're looking at several different conditions that we can tackle.

Secondly, and I think most people will know this, to get admitted into a hospital nowadays, you don't come in with just one condition you're generally coming in, because you've got exacerbations and multiple conditions, chronic conditions. And so we've been able to do is prove that we can actually walk and chew gum, if you will. We can take care of multiple conditions at once in a home setting.

The third big win that I think we've seen is the ability to address social determinates, the underlying causes for some of these diseases like never before. So I'll give you an example. Where in a home we can actually look in the person's refrigerator and understand what they're eating, what's causing those CHF exacerbations. We can actually do what I call real med reconciliation. I'm literally looking at, or clinicians looking at the medications that are sitting on that person's kitchen table and realizing that what I've got in my EHR doesn't match up with what they're actually putting into their body. And so being able to address those issues.

And then the other thing is actually understanding fall hazards like real fall hazards. So it's not about will they trip in the hospital? It's no, let's actually change that home environment so that person's not going to get injured. Or if they're in an unsafe environment or have transportation issues, we can address those things. So I would say those are the big wins.

What have we learned in this process in terms of opportunities? It really is shown, at least for me, particularly in both the Oregon and Northern California markets, that everything comes down to local connections and relationships when it comes to making sure we get the right vendors at the right times into the home in a timely fashion, and perfecting that.

The second thing is you cannot underestimate the cultural transformation that's required. When you first present to a patient, you have an option to go home. Instead of being admitted to the hospital, that's actually for someone who's never had hospital level care in their home, a big leap of faith. And so being able to describe what that is and how we make sure that they know that we got booked their electronic and reel back is really key.

And then I think on the clinician side, it's also really important. So, we've had to make sure that we have full disclosure and understanding with our ER physicians, our hospitalists, that this thing is safe, that it's doable and actually had to have some people actually go in and immerse themselves in the command center, which is available 24/7 to our patients to show what we're really doing.

Unger: So how were you seeing the results and measuring ... what are the metrics behind something like this?

Dr. Parodi: One of the things that we said at the outset is that we've got to treat this just like we would if we were taking care of somebody in a hospital setting. So what's that mean? All those quality metrics, all the star ratings, all those kinds of things. We're measuring those same levels of characteristics. Hospital-acquired conditions, the safety measures that we're all held to, we're doing the same for this Hospital at Home program. The second piece that's really key beyond the quality and safety is also looking at satisfaction. And we're looking at satisfaction both on the patient side, as well as the physician and physician team side of the equations. Because if people are not happy with this, that's going to be a big problem. And what we've seen is actually the opposite.

If anything, when we measure things that are comparable to HCAHPS scores, we're seeing higher scores with the Hospital at Home program, as opposed to if you were actually in the brick and mortar facility. We're not seeing increases or changes in terms of the safety measures. And if anything, we've seen with some of the hospital-acquired infections reductions in the Hospital at Home program, as opposed to the in-person program. And we've now, it's early days, enrolled about 500 individuals into the program successfully over the course of this past year, we've seen enough positive results that we plan to expand. It's part of the reason why we're working with our Mayo Clinic colleagues to invest in the actual technology platforms, so we can expand this to more people.

Unger: Just hearing you talk about this, it's incredibly exciting, and it feels like we're at this kind of inflection point in a very transformative time in health care. I mean, a year ago, it was, "Can you stand up a telemedicine practice?" And now we're talking about far wider range of delivery going forward. How you look ahead at this and think about it from a long-term perspective about where this is going for health care and for your system?

Dr. Parodi: I think we're actually at a critical inflection point coming out of the pandemic here. We've been able to demonstrate both on the outpatient side, as well as inpatient side now, that we are able to provide high-quality effective care and actually cost-effective care using telemedicine. What this is showing, I think are couple of different things. One is that the technology's arrived. It's here. It needs to be shaped by physicians. So, my key message here is that while we have the technology platforms available, we have the EHRs available. The only way they're going to be fully realized in terms of improvements in the health care system is if we, as physicians, actually drive that change.

The second thing is that for me, watching this unfold over the past year and with this Hospital at Home program, is that the nature of what a medical team looks like is going to be fundamentally different into the future. So, looking at a hospitalist now, which traditionally has been a completely hands-on specialty, where you're literally rounding on individual patients in a hospital. Now with their practice scope, being expanded to take care of multiple types of patients in home care settings with different forms of extenders is really going to be important.

And again, I think we have the opportunity to shape what that looks like. So it's the physician practice but it's also going to be the practice of a nurse or a community paramedic which, by the way, wasn't in my parlance a couple of years ago, PAs and others, what their forms of practice are going to look like as extension of the physician expert. So, I think we have the opportunity to completely transform the way medicine is practiced. It's so exciting because this isn't something that we learned in medical school or residency. Certainly our skill sets for how we take care of patients and illnesses, that's not changing, but the way we deliver it, that's completely changing.

Unger: It's really exciting. It is a quantum leap. And as you point out, so important for physicians to be driving that process unlike maybe things, other technology innovations of the past. So, it's really exciting that you and the Permanente system working with Mayo on this, and I'm eager to see the results. Thank you so much, Dr. Parodi for joining us and sharing your perspective on this topic. We'll be back with another COVID-19 update soon. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us. Please 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.