Gregg Masters 00:06
This is PopHealth Week on HealthcareNOW Radio. I’m Gregg Masters Managing Director of Health Innovation Media and the producer co-host the show joining me in the virtual studio is co-founder and principal co-host at PopHealth Week. Fred Goldstein, president of Accountable Health, LLC PopHealth Week engages industry leadership and stakeholder voices spanning payer provider patient, vendor and regulatory communities in population health best practices and strategy connect with us via www dot pop up studio dot productions or follow in direct message me on Twitter via at Gregg Masters, mph. And that’s Gregg with two G’s. On today’s episode, our guest is Carolyn Yang M. D, attending physician home hospital program at Brigham and Women’s Hospital. Dr. Yang is interested in the intersection between healthcare policy, business and innovation. Her academic background is in neuroscience and entrepreneurship and management via Johns Hopkins University with extensive leadership and research experience. Our goal is to ultimately improve patient outcomes and care delivery, reducing costs and innovate better solutions. And with that brief introduction, Fred, over to you.
Fred Goldstein 01:26
Thanks so much, Gregg and Dr. Yang, welcome to PopHealth Week
Caroline Yang 01:30
Thanks. Happy to be here.
Fred Goldstein 01:31
Yeah, it’s a pleasure to finally get you on the show here we met at HIMSS. It was an interesting thing as you were doing some stuff around that. So tell us as I understand your first time at HIMSS, what were some of your thoughts?
Caroline Yang 01:42
Yeah, well, I think it was really exciting just to see everyone from different industries and different stakeholders in the healthcare industry come together and talk about really hot topics, and what’s new and different challenges and brainstorming, you know, different solutions that are creative and novel. So that was like a really great forum to see all that to witness all of that and to talk to everybody who is in that space that I typically don’t get to interface with on a regular basis.
Fred Goldstein 02:11
Yeah, I agree. I thought it was, it was very good. This year, I really enjoyed the opportunity, one to get together with people obviously, and to, to look at some of the new tech in it, etc. But before we get into this really cool topic on taking hospital care and moving things like that into the home, why don’t you provide our audience with a little sense of your background?
Caroline Yang 02:28
Yeah, so I’m currently a practicing hospitalist physician at the Brigham. I practice part time in the traditional hospitalist model where I see patients who are acute level of care in the hospital. But I also work part time in the Brigham home hospital program, which is a newer program where we do hospital level care, but in the home. And so it’s two different environments doing the same type of medical care. And so it’s been really exciting to see the common the common ground, and also the differences in the way that we deliver acute care. So that’s what I do great. Currently, my background and interested in health tech and innovation, digital health, which has been been a much more busy space these days in the industry. And so I’ve been excited to see the different solutions that people are coming up with to make healthcare more affordable and more accessible for all those players who are involved, including patient and provider.
Fred Goldstein 03:32
So Caroline, what what made Brigham decide to sort of go into that direction with home hospital work?
Caroline Yang 03:40
Yeah, I mean, I think initially, it was an academic curiosity of, you know, we weren’t the first to come up with it. Actually, back in 94, Johns Hopkins had a similar idea and begin to execute it in practice, albeit a smaller model. And, you know, I think what the Brigham was looking for sort of something innovative, but that was cost effective. And while you know, the finances of it initially may have been more challenging just given reimbursement. And such, it was a much more enticing option for patients and providers alike to be able to provide care where the patient is asked more literally,
Fred Goldstein 04:21
and I find it interesting. I remember when I first mentioned it to you, I said something to the effect hospital at home. And you said no, this is home hospital. It’s an interesting play on the words. Can you sort of discuss the differences that you see them?
Caroline Yang 04:36
Yeah, I mean, I think the technical term for all the programs is referred to as hospital at home, but everyone calls it home hospital. I actually think you could argue both are pretty similar, but the idea of hospital at home is that the the hospital is existing within the home. And so you kind of envision all of the resources a hospital has I just like stuck in the home. But in reality, we’ve created our own ecosystem of hospital in the home, in the sense that the home hospital is actually somewhat different when it comes to the resources, and the, and the build of our structure of how we deliver care, that acute level at home. So it’s not a mirror, which might be implied by hospital at home. But it’s kind of a unique model that does the same thing. But in a different environment.
Fred Goldstein 05:29
It kind of I think you explained it perfectly. And it really made a lot more sense to me. And when you did that, this is a different place. It’s not a hospital dropping into the home. And I thought that that was really a good way to look at it, and probably will help as we try to develop this out further in the future. It is its own unique environment. So when you think about that, and another a lot of places we can go into there’s some studies that have been done, etc, that we can talk about. But how do you select? Firstly, how it says how do you select patients for that?
Caroline Yang 05:59
Yeah, I think every hospital model is different. In in that you know, the diagnoses that each program is capable of caring for differs based on their staffing based on is different based on what specialty support, they might have to take different diagnoses, differs based on the radius in which they make decisions at home. Because it changes the time that it takes care for somebody in an acute situation. And so all those factors will change what diagnoses are taking care of at home. But for example, for Brigham, we do it based on a variety of factors, including geography. So we do 10 miles around the hospital, and anybody outside of that wouldn’t qualify, we do it based on social situation. So like, if someone homeless, we can’t safely care for them at home, if they’re in a group home, sometimes that’s not an option. So for rehab, there’s a lot of different environments that a patient might live, that is not a good fit. I like to say not a good fit, because who knows, in the future, depending on resource changes and other things, there may be room for diagnoses and situations that we don’t care for now that we could care for in the future. But for right now, based on the medical piece, you know, we care for lower acuity. And that makes sense because we are not bedside all the time. But we do monitor them remotely all the time. And we have access to them all the time. So that that asset is definitely a pro, but it does make it so that more acute patients are not as safe in the home hospital model as we have it right now.
Fred Goldstein 07:43
And you talked about this remote patient monitoring. Is there a certain did you build that system? Are you running it on top of somebody else’s platform? What did you use for the remote patient monitoring?
Caroline Yang 07:53
Yeah, I think it started out more as a hodgepodge. So we kind of found third party applications, and we did not home grow any remote monitoring or platforms. So the device, the hardware, and the software is third party, and we contract with them to some degree to make our ecosystem of remote monitoring. So you know, so we use different vendors. And I think that’s always in flux. And, you know, depends on all this new stuff that comes out day by day, we are always reevaluating kind of what tech is the best for our model.
Fred Goldstein 08:31
And I assume you’ve integrated that into your electronic health record system, etc.
Caroline Yang 08:37
That is a goal. There’s a lot of different software solutions that do offer that. And so like it’s like I said, we’re constantly looking for, you know, big and better, bigger and better solutions as we grow ourselves. And so while something may have worked and been feasible when we had a smaller census, or a smaller team, or less complex patient, as we grow, I think we are constantly needing to look at what solutions were using. But ideally, we do integrate, you know what data comes from those remote monitoring devices and onto the platform that we use, and having the data from that platform integrate with the EMR, even if it’s just unidirectional, so that all the data is in one place. Because I think the biggest challenge with all this tech is that there’s just so much data. And it’s hard to really track down where one piece of data came from dependence, integrity to make sure that it’s securely being transmitted and accurately being transmitted. And so there is still redundancy. I think, right now as we transition to different solutions. The redundancy is sort of a failsafe, but at the same time it does create opportunity for more error. So it’s all things to consider but I think yeah, ultimately less solutions. More integration, more interoperability is really where we had.
Fred Goldstein 10:01
And and I noticed you have this team of folks on the website that are in this home hospital program physicians, I think it was like a nurse practitioner or someone at that level. And then you also had EMTs, which I thought was interesting is that because these people are at a house, you might have to run out and do something, or?
Caroline Yang 10:23
Yeah, exactly. Again, like we’ve changed and grown so much in the past year, as many programs has to keep up with the demand and the full hospitals. And so a lot of our model has changed over the past year. So to give a little hit, initially, we weren’t using EMTs at all it was me and a nurse. So that was pretty much it. And at nighttime, we would have access EMTs were exactly what you were explaining. In that we if we had an emergency call the nurses worked on during the night, and we needed extra support or hands on, we did contract with a third party paramedic team that would go out and sort of see the patient in an acute situation. Then, fast forward to our current model, we basically integrate EMTs as an equivalent to our nursing staff. So we see patients on are rounding during the day with both EMTs and nurses. So they’re equivalent in that regard. And then we still have the nighttime paramedics that go out for emergencies. And now you know Brigham has an internal team at Spaulding. So now we have Spaulding folks who are also taking that role. And it’s been challenging, as you know, in the healthcare system the past year and probably beyond staffing shortages has been a big problem. And so we are not, you know unique in that we don’t have that problem, we very much had to be, you know, to improvise and to be creative about how we fulfill the staffing needs of our team to care for the patients in the census that we had, which was growing. And so that’s how we’ve gotten sort of creative and using the paramedics, our nursing team, obviously our MD team has grown as well. So yeah, that’s our model. We don’t have NPS or APS right now, the MGH team, actually, they have a whole hospital team that runs very differently. But they do utilize ATP. So like I said, every home hospital model is, is different from the way that they’re structured.
Fred Goldstein 12:27
How have you been able to compare between models and see any differences in outcomes costs or things like that.
Caroline Yang 12:35
So I’ve looked at a lot of data from different groups like Johns Hopkins, and they’ve done a lot of meta analyses and stuff like that across different programs. Again, the data was pretty sparse before 2020. Because, you know, as we started the pandemic, and I started before the pandemic, there were a handful of programs that were running at it, you know, at a census that was sort of sustainable, and then as the waiver from CMS came out to reimburse inpatient care, the same as home hospital inpatient care, then we saw this huge growth of different home hospital programs. So now we’re over 200, just in like 18 months, we went from, you know, under 10, to over 200. Hospitals are programs in the model from hospitals that are taking this waiver. So it’s, like I said, in healthcare generally change happens pretty slow. But in this case, we definitely had both a financial and like philosophical motivation to, to take advantage of these types of innovative programs. So it’s been exciting to see them grow. And I imagine in the next couple of years, we’ll see even more research and data, looking outcomes and cost reduction than we have. But to go back a little bit like Brigham did two RCTs were the first in hospital space. And the more recent one back in 2020, you know, really showed that there was a cost reduction that the like, adjusted mean, cost of the acute care episode was 38%, lower for home patients, or home hospital patients and control patients who were in the hospital. And that’s looking just at direct costs. So meaning like, you know, the physician, non physician labor supplies, medications, testing, but that’s not even looking at the like opportunity cost of opening up beds for more patients that are sicker, that may build higher and those types of cost saving. So I think there’s a lot of data already that is very supportive of, you know, cost reduction opportunities and such for home hospital. But I imagine in the coming years with all these new programs, there’s going to be way more
Gregg Masters 14:47
and if you’re just tuning in, you’re listening to pop Health Week on healthcare now radio, our guest is Carolyn Yang, MD, attending physician home hospital program at the Brigham and Women’s Hospital. In Boston, Massachusetts,
Fred Goldstein 15:02
so And you had mentioned that these, you know, is allowed to open up these services at the same rate as inpatient. So, obviously, with a 38% relative cost, I would assume at some point, we can, you know, we can see these costs come down by using services like that.
Caroline Yang 15:18
Yeah, I imagine. And I think, you know, a real big factor in that is reimbursement. And we have gotten lucky with the CMS waiver. But again, that is technically only going to last till the end of the public health emergency, which has been pushed, you know, as we know, quite a bit. And so it does look like you know, come July, that there may be an end waiver. And so there’s a lot of advocacy happening around trying to extend it. So that can give us some time to really put together a good policy that will last and hopefully be permanent, so that different home hospital programs can continue to be sustainable. And so I think, you know, different hospital programs will come up because it’s financially sustainable. And I think that’s going to be the biggest barrier to getting more programs. And I really hope that losing the waiver, if it ends up worst case scenario, that we don’t have a lot of programs kind of dissolve, and I do think that may be an unintended consequence of of that loss.
Fred Goldstein 16:26
You know, I think it makes sense to keep that moving forward. And, and allow that option of service, particularly if it can, it can generate, you know, similar or better outcomes and reduce costs, it’s the way to go for sure, we’ve been, you know, you talked about changes slow in healthcare, and Greg and I have been sitting here for quite a long time with that mantra, you know, trying to see when we’re going to flip the switch on this baby. And, and so it’s nice to see things like this, approximately, you talked about efficiencies, approximately, how many patients do you have at any given time in home hospital?
Caroline Yang 16:56
Yeah, so in our current situation, we are seeing about 15 to 16 patients a day. And, you know, with discharges and admitting that’s typically where we sit. So we’re taking like one to three new patients a day. And then, you know, like a typical hospital discharging, you know, here and there. So we’re generally taking care of 16. But just like, like I said, you know, 1824 months ago, we’re looking at maybe an average daily census looks like three to five. So it’s really grown quite a bit. And I imagine, you know, our ambitious goals for the entire NGB system and master Norberg EMS system is very ambitious, and will really expand the amount of patients that we care for at home. And so hopefully, like with the right tech solutions, and financial support from the organization, we will be able to make that happen. And again, it won’t be just with Brigham, you know, it will be a joint effort of Brigham and NASS general, and maybe Newton, Wellesley and Salem Hospital. So we’re really trying to get on that now to grow what we can offer in terms of home based care.
Fred Goldstein 18:04
Right. I was wondering, too, you know, this whole issue of equity. And, you know, when you think about home hospital, obviously, there are certain requirements for a home. And do you see ways or you begin to look at how you might address those inequalities?
Caroline Yang 18:24
Yeah, so I think it’s a multifaceted issue. I think technology, dissolving inequities and healthcare is, has arguments on both sides. I think, you know, obviously, technology, people don’t have to leave their home, if they do, you know, this idea of telehealth and providing care where the patient is at and via technology does increase access. I think that’s absolutely number one. But I also think that technology requires you to have good internet access for you to have, you know, a good connection for you to have the best technology available to you in terms of a phone or a computer to make that equitable for all those who are on the receiving end of digital health or digital health solutions or telehealth. And so I think that on that side, there’s a lot of work that needs to be done to ensure that those challenges are addressed, and that the needs of those who are less fortunate to afford technology solutions, you know, that that those people are not ignored? And so I think that yes, technology can meet people where they’re at and it can help provide care to those who maybe don’t typically, you know, have the means to meet you where you’re at, at the hospital or in the clinic, as a provider, that you can meet them where they’re at in their home, or on the street or in in the car wherever and Um, and it allows people who maybe work three jobs and, you know, just need to hop out to the break room and take a telehealth visit, like, I think, you know, that’s, that is the challenge, but also the blessing, an opportunity that exists within delivering care with different technology solutions. And as far as home hospital goes, and we really don’t discriminate, we we will take anybody who comes through the doors of the emergency room, or who’s in the hospital, and we don’t look at anything beyond those criteria that I mentioned earlier in terms of geography and, and it is challenging, like, we would love to deliver care to the homeless, but there’s just no safe way to do it. So I do think there’s limitations, but I think that overall, on the whole, we are serving, you know, this issue of health equity in a positive way. So
Fred Goldstein 20:49
as you look at this equity issue, obviously, you know, you look to get technology into the home, and there are different ways to do that. But are there you know, I imagine, you know, there may be certain home environments where you need to go in and just actually clean the house, to provide a safe bed, a clean bed and things like that, do you look at things like that, or, or provide food service in home, etc, as part of the program.
Caroline Yang 21:15
Totally. So we do our best beyond the four walls of their home, which we do rely on the patient to provide. We do provide additional supplementary services like meal delivery, and it doesn’t have to be for someone who doesn’t have access to food, but we help with people who don’t have access to the right food. So for patients who have heart failure, and they’re being admitted for a flare, or an exacerbation, and they don’t have anything but can soup at home, we will provide, you know, delivery to their homes of the food from you know, contracted organizations that can provide that type of food like community serving or other groups, we also provide home health aides to provide additional assistance in the home. And while we don’t provide them for the purpose of home cleaning, sometimes, you know, if there’s a small means that will really enhance their medical care, we will do you know, they are able to provide, you know, those services.
Fred Goldstein 22:26
And what’s been the response from the patients so far?
Caroline Yang 22:29
Oh, my gosh, every time they come back to the hospital, where’s home hospital, like, you know, Can you can you call them, I think a lot of them love being at home, being with their families, especially with the pandemic, both on the front of inpatients not often having the ability to have visitors or the visitor policy changing all the time. That is a big plus for them to be able to be with the ones that care for them and that they feel comfortable with. It helps them feel better being at home eating their own food that meets their cultural needs to I think that’s a huge thing that goes back to the health equity and, and cultural sensitivity is seeing that everyone’s diet is different at home than it is in the laboratory of a hospital that we have. Right we get to control when they get their medications. We control what they eat, we control you know how much activity they get. It’s, it’s like a laboratory. And so no wonder we get, you know, relatively satisfying results when we can control all those things, compared to in the home when we do leave our patients to really be autonomous and make those decisions with our support, but they’re still eating their home foods, they’re still you know, relying on their home support to help them take their medications and not relying on us to be there to remind them at every moment. What to do.
Fred Goldstein 24:04
So do you have or have you seen much of well, they were in home hospital, but we got to bring them in?
Caroline Yang 24:12
Yes. So we definitely have patients that they are doing okay and appropriate for home hospital when they come to us. But as everyone knows, different conditions evolve differently and sometimes people get worse or something that we couldn’t have predicted happen and they do meet a higher level of care and more acute attention and in those cases we will take somebody back to the emergency room and either they get you know a quick acute treatment in the IDI and come back to us or they get admitted back to the hospital and we may or may not take them home once they’re stable again.
Fred Goldstein 24:55
And you know in terms of the Quadruple Aim for you as a Physician, what’s been the physician response to this?
Caroline Yang 25:03
Yeah, I think a lot of us who are in the home hospital program, choose it because we really are invested in delivering the best care for the right patient at the right place and the right time. And so, the hospital may be and often is the best place for a hospital or a patient at a given moment. But there are patients that are in the hospital that actually would be equally or better served at home. And so I think that’s the physicians, the nurses, the EMTs, are all really invested in that goal of meeting the patient, where they’re at when they’re ready, and when they’re appropriate. And I think that the traditional model has not allowed that to even be an option. Before it was, well, if you require IV medicines, even if it’s once a day, or you’re just waiting for a test, that you really should stay monitored for that you need to stay in hospital because there’s no other option. And I think that this is great, because it gives that other option that may actually be more appropriate for the patient. And so as we’ve seen over the years, there are patients that are not appropriate at a given time, but as we have more capabilities, more staffing, then they do become appropriate. So I think moving forward, we’re gonna really see a growth in what capabilities home hospitals have.
Fred Goldstein 26:38
Well, Caroline, it’s been a pleasure to have you on PopHealth Week. It’s really nice to see this kind of innovation going on and hearing how it’s work, and also recognizing there are things that we obviously have to continue to work on. So thanks so much for joining us on PopHealth Week.
Caroline Yang 26:52
No problem. My pleasure.
Fred Goldstein 26:53
And back to you, Greg,
Gregg Masters 26:55
and thank you, Fred. That is the last word on today’s broadcast. I want to thank Carolyn Yang, MD attending physician Home Health Program at Brigham and Women’s Hospital for her time and insights today do follow Dr. Yang’s work on Twitter via at Brigham HMU at Mass Gen Brigham and at Brigham Women’s respectively, and on the web via www dot home hospital dot B W h.harvard.edu. And finally, if you’re enjoying our work at PopHealth Week, please like the show and the podcast platform of your choice. Do share with your colleagues and consider subscribing to keep up with new episodes as they’re posted. We live stream on health care now radio weekdays 5:30am 1:30pm and 9:30pm. Eastern, and for you left coasters 2:30am 10:30am and 630. Pacific for pop health week my co host Fred Goldstein. This is Gregg masters saying please stay safe everyone. Bye now.