Dr. Matthew Richards (00:00):
It is a complex business, but it's not insurmountable, and the complexity really lies in the ability to coordinate the logistics.

Abby Burns (00:11):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. I'm Abby Burns. We've talked a lot recently about site of care shifts, moving services outside the four walls of the hospital. But I'll be honest, one site of care we haven't really talked about in those conversations is the home.

(00:35):
It's been four years since Medicare passed the acute care hospital at home payment waiver in response to the pandemic. And while a lot of us expected to see a radical shift to home-based care, the numbers tell a different story. This week I've invited Dr. Matt Richards, Senior Medical Director of Medically Home, to help unpack the misconceptions preventing home-based care from playing a bigger role in care delivery. Matt, welcome to Radio Advisory.

Dr. Matthew Richards (01:02):
Thanks for having me.

Abby Burns (01:03):
Matt, to start us off, I don't want to assume that our listeners know exactly what Medically Home is and what you do. Can you tell our listeners a little bit about Medically Home and how you fit into the broader home-based care landscape?

Dr. Matthew Richards (01:20):
Medically Home is a company that was started, gosh, coming up on 10 years ago, and really with the goal of trying to think of there has to be a different way to deliver care than the traditional brick-and-mortar model. Our founders were people who worked in engineering and logistics and thought there's going to be a way to do this better, right?

Abby Burns (01:45):
Not what you might think right off the bat for a healthcare company.

Dr. Matthew Richards (01:47):
No, certainly not what you would expect somebody to start a healthcare company, but I think it was the combination of that engineering and logistics background, but also it was paired with unfortunately an adverse event that happened in a brick-and-mortar hospital to one of our founder's family members. And I think through that there was a realization of there has to be a way to do this in an environment where patients can be in a setting that they choose, that they prefer, but still deliver high-quality safe care.

(02:16):
And so Medically Home really set out to do that and with a goal of not just decentralizing care that's being delivered for hospital level, but also then thinking about how to decentralize care that is across the entire spectrum. And so when we think about what our ultimate goals are for our company and what we'd like to bring broadly to American healthcare is the ability to say, we can deliver care in the home really at the preferred site location, but can also change the level of acuity.

(02:45):
So that could look like an episode, like an urgent care visit or an emergency visit, but that could also translate into a hospitalization And then subsequently could also then transition into longer chronic disease management, so seeing somebody for 30, 60, 90, or even indefinitely. The best analogy would really be like, let's build the car. I'm going to use the DeLorean because I was a Back to the Future fan. So build the DeLorean to go to 88.

(03:13):
That way we know that whenever we slow the DeLorean down to 55 or 33 or 10 miles an hour, we already know it did great going to 88. And so we've built it to really engineer and deliver on that high acuity model so that then as we take that speed dial and just dial it down a little bit, we know we've already got high reliability at high speeds.

Abby Burns (03:37):
Matt, I think that makes a lot of sense, having essentially the options on the table for where the patient and the clinician decide it makes the most sense or maybe matching patient preference to where they want to receive care. I think a lot of people, myself included, really expected home-based care to take off in the wake of the pandemic.

(03:57):
We had Medicare pass the Acute Hospital Care at Home Waiver in and I think it was November of 2020. Credit where credit is due, there are, I think, more than 300 hospitals that are operating a hospital at home program. That's a lot more than the 20 hospitals that were doing so before the pandemic, but it's still only about 5% of hospitals total. What is your read on why we haven't seen this take off at scale?

Dr. Matthew Richards (04:23):
I think what the waiver did was the waiver gave us a payment mechanism for a small portion of patients through the Medicare beneficiaries, and then we've seen some adoption from some of the larger national payers. But then I think what we're still dealing with is that was still an episode of care and it's payment for that episode of care.

(04:44):
So paying parity for the DRG for hospitalization just like they would in a brick-and-mortar with a DRG bundle payment, then allows for you to get the reimbursement that lets you operate this program. And it's just that your costs have shifted. Instead of having to put bricks and mortar together and wiring and technology, you've coordinated a network of people and you've hired a different process to get hospital at home care delivered.

(05:10):
But then when you go beyond that, we still deliver care in a transactional healthcare space by and large. So once they discharge from the hospital, we still have there's a home health episode of care and that has a start and an end and is paid with that start and end in a transactional way. Then you've got follow-up primary care visits still bundled as one visit billed at that visit's time.

(05:37):
What it's going to take is actually the thing that is starting to take, I think, foot in American healthcare, which is moving away from fee for service into more of risk or bundled payment type models. And in those systems that are starting to get more and more of their value-based care dollars or having more and more lives that they're taking risk for, then what you can then say is this actually makes sense if you think of it less as transactional and episodic.

Abby Burns (06:08):
I think it just goes to show what we can achieve in a world where we have realized home-based care at scale. One of the first things that you were saying when we were first talking was people don't really know what it is. We say home-based care. What I hear when we say home-based care might look totally different from what Jane Doe says when she hears home-based care. Is that something you've run into a lot?

Dr. Matthew Richards (06:35):
I think it's exactly what you describe. We see a lot of either misperceptions or maybe just inferring. So what you may see is you start to describe hospital at home to someone and they may say, "Oh, well, I had a family member that had home health."

(06:53):
And you have to say, "Wait, it's very different than home health. Much higher acuity. Home health is only going out in the home twice a week for an hour at a time, and this is 24/7 monitoring, multiple visits a day in the home, nursing monitoring at a high level of acuity and high skilled care being provided."

Abby Burns (07:14):
When I think of your DeLorean example, it's maybe you're talking about home health as the 50 miles an hour versus the 88 miles an hour.

Dr. Matthew Richards (07:20):
Exactly. Exactly. And so you'll see people infer their own thing, but again, that also speaks to the episodes and the fractionation and the siloing that we talked about. All of those still appear episodic, and that's I think one of the other challenges as we look to get this to scale, which is just a understanding of shifting from it's fractionated silos to it's actually a continuum of care.

(07:47):
And honestly, Abby, the best thing to think about it is from the patient's perspective. A great example I always think of in that perspective is congestive heart failure being a patient population that certainly has a high return to hospital rate. So some systems have rates 25 to 30% of patients are returning to the hospital, But what's bringing them back into the hospital is not necessarily a mystery.

(08:15):
This is a disease that people will battle for years. It is something where meds have to be tweaked. The thing I always use when talking to patients is we are tweaking the radio dial here just a little bit with your diuretic and your other medicines. But even then, the signal could get out of focus there with even the best intentions.

(08:37):
And so when you think about patients who have a high propensity to return to the hospital, if you could then think of a way to monitor them, have instant access to where they could reach in and get reporting, oh, I've gained more weight, or my shortness of breath has certainly got a lot more profound in the last few days, and again, deploying something out into the home that could either get ahead of the next exacerbation and/or have higher frequency touch bases for that level two on the volume knob or the 10 mile an hour version of the DeLorean, they can then start to provide some of that chronic education, figuring out what are you cooking in the home?

(09:19):
What are you feeding yourself? One of the things I really love about hot pot home care is actually getting to have a lens into people's homes.

Abby Burns (09:29):
That's exactly where my mind went, Matt, is the social determinants of health that play such a huge role in I won't say determining, but influencing certainly individual's health, but a lot of times don't make it into the brick-and-mortar office.

Dr. Matthew Richards (09:41):
Yeah, exactly. I think social determinants and even then it may just be that there's just an air in communication a lot of ways. I think of one example where we had a program who had had a patient. I think they'd had two emergency department visits, a hospitalization, two cardiology clinic visits all within the span of about four or five months. And then during the last admission, they got transferred into the hospital at home model. And so then they're in the home and they had received multiple times education about sodium restriction, fluid restrictions, staying on...

Abby Burns (10:14):
The discharge planning, all of that.

Dr. Matthew Richards (10:17):
All of the standard heart failure stuff. But what had been overlooked was these individuals weren't from America, and so at home what they were doing is they were cooking their traditional foods from their home country. And when we got them into the hospital at home model, we were able to actually see what they were cooking in their home.

(10:33):
And then found that even though they'd been told, restrict your sodium, restrict your fluid, their traditional foods that they were cooking were heavily laden in sodium. So then by doing a little bit more targeted education, they were able to advise the husband who was cooking for the wife, "Hey, we actually need to switch to this low sodium alternative, or let's find within your culinary choices something that has less sodium."

(10:57):
And the great success story of that patient is they went another 12 months before needing an urgent care or hospitalization.

Abby Burns (11:04):
Huge change.

Dr. Matthew Richards (11:05):
Huge change. So there's the ability for us to get an eye into someone's home and maybe find out, yes, they're food insecure, or they're having trouble paying the rent. There's caregiver burden challenges, all of those things. But even then, it just could be a matter of, I know we told you to reduce your sodium, but somehow we didn't translate that to...

Abby Burns (11:26):
To make it real.

Dr. Matthew Richards (11:27):
Yeah, that your Tostito chips and your pretzels that you eat are actually heavily laden in sodium, so we've got to avoid those. So that ability to look inside someone's home is also very, very helpful in terms of that chronic management.

Abby Burns (12:44):
I think getting that perspective, Matt, into what's going on in the patient home is so important and a pretty clear win from a patient perspective and from a clinician or a health system perspective. But when care is taking place inside the home, I think it's also important that we acknowledge another stakeholder, which is the caregiver. You mentioned the husband that's cooking dinner for his wife. How does home-based care affect caregivers?

Dr. Matthew Richards (13:15):
The caregiver burden in this country is something that's obviously huge. Unpaid caregiving for family members is something that's profound here, but I think there's a few points to make sure that are always known, one of which is patients are never forced into this option. It's always something where we talk to them, we consent them, and we want to make sure that they're on board.

(13:38):
And if they had a caregiver, we always usually check in with the caregiver as well, partly because we need to understand what have they been doing to support the patient, but also just to understand that they're going to be okay and they've got a clear explanation of the process. So I think that's helpful. And my experience as a hospital who practices in this model, what I see is a bimodal population.

(14:02):
There are some caregivers who unfortunately are overstretched and overburdened, and in some ways, a hospitalization becomes a form of respite to them.

Abby Burns (14:13):
Right. They're no longer solely responsible for taking care of their loved one.

Dr. Matthew Richards (14:18):
Exactly, exactly. And when you approach them with this idea, it's hard to necessarily encapsulate that we could provide some assistance with them because all the programs that we operate we usually have home health aid availability so that we can provide that as a supplement or in some ways a replacement for some care. But sometimes they just say, "It's just been a rough few days and I can't do it."

(14:43):
But I also find that there is a pretty significant population that exists in the other portion of the bimodal group, which is those who would say, "I'd absolutely love for my patient family member caregiver person that I'm caring for to be back at home because I know they're going to do better at home." But then additionally, making sure we understand, is it impacting?

(15:03):
I think some early signs in the literature actually showed that this isn't increasing the burden for patients and caregivers compared to. A study that came out of the group at Mass General found that when they surveyed caregivers, they found that really the brick-and-mortar has its own burden that is really unaccounted for, and the hospital at home has a burden as well, but was not perceived to be more severe or increased compared to the brick-and-mortar.

Abby Burns (15:35):
Wow.

Dr. Matthew Richards (15:35):
When you think about it, I mean, a brick-and-mortar hospitalization still carries with it its own challenges, commuting back and forth to the hospital.

Abby Burns (15:45):
That's exactly where my mind went, especially we talked about social determinants of health earlier, and I think it's something in the realm of 5% of adults say that they have foregone medical care because of transportation issues. And when we're thinking about a higher acuity population, we can all think of family members that have needed rides to medical appointments, and maybe that's the middle of the workday and they don't have caregivers that can help them with that.

(16:10):
Matt, this brings me to another question or concern frankly that I hear, which is is it really safe to take people that need, for example, inpatient care, out of the hospital? Is it safe to deliver care in the home?

Dr. Matthew Richards (16:25):
Yeah, I think it's a good question. And really what I would rely on to help answer that is, A, I've seen it with my own eyes, but that's me and that's an N of one, right? But really when you look at the body of literature that's piling up here, that's what supports the safety and efficacy of being able to take care of patients in the hospital at home. For those who may not be aware, hospital at home has been operated in Europe and Australia and parts of the world outside of the United States for decades, as early as the '60s.

Abby Burns (16:58):
Wow.

Dr. Matthew Richards (16:59):
There's a bound in the literature from those areas that show there is a portion of patients who can be cared for safely. And understandably, they've moved to that more in countries where they've got national healthcare systems. So the payer mechanism has not been the barrier there. Here in America, since the waiver, we've now got more and more literature coming out that, again, support the same types of outcomes.

(17:23):
And so what we see in the literature at a broad stroke is cost of care is no different than a brick-and-mortar hospitalization for the acute episode itself. And we may actually be trending towards a significant savings on the 30-day total cost of care from the start of the admission through 30 days.

(17:42):
And that's mostly through a couple things. One, patients in hospital at home are more mobile, so they're less likely to stuck in bed with button to press and all their meals being brought to them. They're actually moving around in their home. They're going back and forth to the restroom. They're going to their kitchen to get food when they're ready, or they may just be simply moving from the couch to the bedside commode.

(18:05):
But that mobility in and of itself is still above what they're getting in the hospital brick-and-mortar setting. On top of that, we see less infections. So hospital fire infections go dramatically down. Obviously you're not in the environment exposed to all the other pathogens. And then on top of that, we see things like delirium rates go down because they're in familiar settings.

(18:25):
I can remember a case where someone was taken care of in their adult foster home where they had pretty progressive dementia and had multiple prior hospitalizations with high frequency of delirium requiring restraints and medications to control the delirium and hospitalizations that lasted weeks to let that really clear. And then with this one, they never got delirium. They were cared for by their same caregivers, familiar faces, familiar routines, all led to a better outcome.

(18:54):
So I think what we see is quality is better than the brick-and-mortar. Total cost of care for 30 days probably trending towards better and through less need for post-hospitalization, subacute rehab or skilled nursing facility stays and less debility that results in a need for more home health PT, more debility and less infections as well. So all of those pointing towards really the model of care for the right type of patient is better.

Abby Burns (19:26):
I'm glad that you added that in because again, it's tough to make broad sweeping statements. But when we're looking at patients that qualify for hospital at home specifically, I think the range of benefits that you just pointed out are really important to understand. The other thing, Matt, that you were making me think of as you were talking about, there's an opportunity as more hospitals do operate hospital at home programs, a lot of these programs, which you can attest to better than I, are highly tech enabled.

(19:56):
When we think about the opportunities that big data sets, that large language models have, I think we have a huge opportunity moving forward to understand what really works, what are the key enablers of driving some of the outcomes that you're talking about in the way that we set up hospital at home programs or home-based care programs?

Dr. Matthew Richards (20:16):
Yeah, I think you're right there. I think the space where either large language models or processing models, even generative AI could potentially help in twofold. One of which is I think understanding who are the right types of patients. That's one of the nuts that's often hard to crack is to get to the syrup as opposed to just the water and sugar. And then additionally, what we need to do is understand what are the outcomes from perspective of the patient outcomes.

(20:47):
But even then, when you think about the logistics and the coordination, using machine learning to help with that is something that I think will also be a space where this moves, because you have to predict the utilization of this network of individuals that's going to go out into the home and to be able to get visits timed at the right time, but distributed evenly so that you're not concentrating all your resources in one portion of the day.

(21:12):
So using tools like machine learning and predictive analytics and borrowing things like Amazon and UPS and all of those companies that have been trying to innovate in the space of being efficient while having to travel across cities.

Abby Burns (21:27):
Yes. Matt, I'm so glad that you brought us back here, which is where you actually started us off. You said Medically Home was started by engineers, people who really understand the logistics side of solving these challenges. One thing we hear at Advisory Board a lot of times from hospital leaders is home-based care, hospital at home seems too hard, too expensive, too inefficient relative to delivering hospital care. How do you want leaders to think about that?

Dr. Matthew Richards (21:55):
What I'd want them to think about is it is a complex business, but it's not insurmountable. And the complexity really lies in the ability to coordinate the logistics. And if you can, find a way to coordinate those logistics, and that could be through the assistance of our company or just trying to figure out a way to do so with a homegrown system or really honestly another competitor.

(22:23):
It is about trying to make sure that that network can be used effectively and efficiently. And I think that's where maybe some of the fear comes in is you've got this network of providers where it's a mixture of maybe some internal resources you have with your health system and then some community organizations that you're working with, and then the combination they're in and using.

(22:45):
70% of the visits are going to your internal, and 30% are going to this external, and how are you distributing visits? All of that I think is not impossible to figure out, but it's complex.

Abby Burns (22:57):
Yep. Yeah, I like that. I like the complex, not insurmountable is a helpful way to think about it. Matt, Medically Home has worked with, I believe, over 20 health systems to stand up hospital at home programs, right?

Dr. Matthew Richards (23:10):
Mm-hmm.

Abby Burns (23:12):
As you think across them, what themes can you pull out for us about how these health systems have overcome the logistical complexity? What do they have in common?

Dr. Matthew Richards (23:23):
So our support provides a lot of the benefit to get over that logistics hurdle. Obviously, that's one of our superpowers, and I'm not shy to brag on our capabilities there, but I think what we also see is when a system or an organization commits and really puts this as it's a priority initiative, this isn't a pilot, this a toe in the water, this is something that we need. And when those programs have a leader that's leading the program that really has accountability and driving to that success, that's where we see programs take off.

Abby Burns (23:56):
Is there any particular type of leader that needs to be at the helm here?

Dr. Matthew Richards (24:01):
Yeah, I think someone who's clinically driven and operationally focused is certainly going to be germane for this. But additionally, I would say you would need commitment from C-suite on down in order to be able to say, "This is the direction we're going. This is our priority."

(24:17):
Because then when you launch and you're three months in, if that month was a low month and we aren't getting the volume that we want to get, we want to understand who's going to be able to respond to the call that says, "Hey, how come we're not seeing the volumes in hospital at home that we not."

(24:33):
Because there's opportunity, there's volume in your hospital, and there's volume in the American healthcare system for patients who need to get hospital level of care and can have that delivered in the home. But then it's really about driving to the result. So if you have someone who's an operational and clinical leader driving towards results, then you're going to see that.

(24:52):
Where we've seen some challenges is when maybe that conviction hasn't been quite as strong or quite as clear as far as goals and accountability. That's where we've seen people maybe have a little bit of a stumble or take a little while to fully see things take off.

Abby Burns (25:10):
I have one final question for you, Matt, and it's actually born from a conversation you and I had a few weeks ago when we were planning for this conversation. We were talking about all of the content, all of the points that we were going to cover in the episode. And as we were getting ready to hang up, you told me you had one final request. Do you know where I'm going with this?

Dr. Matthew Richards (25:34):
It's a follow-up episode obviously.

Abby Burns (25:37):
You said we're going to have a great conversation, but home-based care is such an important topic and there is so much untapped potential for positive impact. Please do another episode on home-based care. And I will attest you, we're not shelling for speaking gigs. You said, "It doesn't have to be me. It doesn't have to be Medically Home."

Dr. Matthew Richards (25:54):
Does not have to be me. I don't care who does it as long as we keep talking about it more.

Abby Burns (25:58):
So my last question for you, Matt, is what did we not get to dig into deeply enough that you think listeners need to know more about? What should we cover next on Radio Advisory around home care?

Dr. Matthew Richards (26:10):
I think one that's really powerful is the patient's experience. And I think we touched on it some, but I can't say enough about how powerful it is. And so I'll share one story that I think for me provides I think the most powerful example. So while I was a clinician and working as a hospitalist, was caring for a patient at the program that I worked for. We had a patient who was transferring into the hospital at home model from the brick-and-mortar.

(26:36):
And they had spent a few days in the brick and mortar hospital, but still needed ongoing care with IV antibiotics. And they some pleural effusions and chest tubes that were draining those periodically. But unfortunately, this individual had advanced breast cancer that they had been battling for many years at this point.

(26:55):
And it was very clear to the patient, the family, and the patient's oncologist that this was an incurable disease and this patient was likely in the final months to a year of their life. And when we transferred her into the hospital at home model, the day that we got her in, nobody knew this prior to, but she shared with us, she said, "I'm so glad that I get to be home because tomorrow is my husband and I's 49th wedding anniversary."

Abby Burns (27:19):
Wow!

Dr. Matthew Richards (27:21):
And so it was her 49th wedding anniversary, but unfortunately, I don't think she was going to make it to her 50th. And so we were able to then take out some chocolate cake, a little bit of sparkling apple cider, and have this lovely moment with her and her husband celebrating their anniversary in their home in this beautiful veranda on the outskirts of the area where I live.

(27:45):
And really to have that moment with that patient being back in their home with what could be the last anniversary they experience with their partner for such a long time speaks to I think the power of how we can really give patients a positive care experience in this model.

Abby Burns (28:02):
Matt, thank you so much for sharing that story with us, and thank you for coming on Radio Advisory.

Dr. Matthew Richards (28:08):
Thank you. Happy to have you.

Abby Burns (28:16):
A few things I took away from the conversation with Matt. One, scaling home-based care is actually less of a clinical question and more of an operations question, and the opportunity for impact is huge. Home-based care can not only have a meaningful impact on patient lives, but on caregivers, clinicians, and provider organizations, and we're just scratching the surface on realizing all of the use cases. This is something we'll keep talking about on Radio Advisory. Because remember, as always, we're here to help.

(29:14):
New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Abby Burns, as well as Chloe Bakst, Atticus Raasch, and Paul Trigonoplos.

(29:33):
The episode was edited by Katy Anderson with technical support provided by Chris Phelps. Additional support was provided by Leanne Elston, Erin Collins, Patty Kenchen, and Matt Smith. We'll see you next week.