“We know that rehospitalizations in this country have historically occurred far too often — upwards of 20% to 30% — for Medicare beneficiaries,” Dr. Marc Rothman, Signify’s CMO, told Home Health Care News “And this is something we’ve known for a solid 20 years. And over that time, the evidence basis for what allows people to stay at home safely and avoid rehospitalizations has been nicely built out by leaders in medicine and research.”
The program allows Medicare patients to receive clinical and social care support as they transition from the hospital to the home, and is designed to reduce avoidable in-patient readmissions and ER visits.
The Dallas-based Signify arranged the program’s pilot with that research and understanding in mind, coupled with its existing capabilities, which include advanced analytics and technology.
Its Transition to Home clients thus far include Ardent Health Services, Beaumont Health, Cape Fear Valley Health and Premier Health, among others.
Signify works with the Centers for Medicare & Medicaid Services (CMS) on its Bundled Payments for Care Improvement (BPCI) Initiative, which is a Center for Medicare & Medicaid Innovation (CMMI) creation. Broadly, the BPCI initiative consists of organizations entering into payment arrangements that measure financial and performance accountability for Medicare beneficiaries’ episodes of care.
“We wanted to bring that evidence basis together in a scalable, sustainable fashion to members of the BPCI program, who have transitioned to home and really want to avoid rehospitalization,” Rothman said. “That’s sort of the nidus of the program.”
Transition to Home was launched before the COVID-19 crisis hit, and it has gone through a few iterations since. Signify began doing on-the-ground work in the Midwest specifically, but once the virus took hold, it became a virtually focused solution.
Signify first identifies beneficiaries that are a part of the bundled payment program. Afterwards, they follow patients once they are discharged from acute care, then reach out to those patients to find out how they’re doing at home — and what challenges they are facing there.
Those challenges could include ones relating to social determinants of health or clinical issues, and Signify then aims to fill those gaps in care in the home. To do so, social care coordinators, social workers, nurses, nurse practitioners, physicians and pharmacists are all enlisted, depending on the issues. It’s a solution that has become coveted among health care providers and others, especially during the public health emergency.
“We’re seeing a lot of interest in rehospitalization-reduction strategies across the board, whether that’s with at-risk providers, hospital systems or physician groups,” Rothman said. “Health insurance organizations are interested in this as well because they’re looking at the total cost of care. And for them, readmissions are also undesirable. And the patients, of course, are the ones who want the service the most because the least satisfying outcome for a patient who goes home after being hospitalized is to be hospitalized again.” While the program is virtual now, that is not how Rothman nor Signify views it permanently. As things move forward, the hope is that more in-person visits can be conducted to improve the model further.
When that happens, home-based care providers will likely have the chance to help reduce the unwanted hospital visits. “I see in-person, face-to-face visits as part of the future, especially where there is really a need and demand for it,” Rothman said.
Over time, Signify is hoping to not just expand the program’s offerings, but also scale it to more providers and payers across the country. “We expect that rapid growth we’ve seen to continue,” Rothman said. “Many transitional care programs I’ve seen in my career have been too local and are dependent on a very small number of providers. They’re often not scalable. I think it’s such an important component of our program that we’ve managed to successfully scale it, and I think that’s a great sign for our future.”
“So what we’re trying to do is triage those needs and provide virtual services where that suffices, and we’ve learned during the pandemic that the Medicare population is willing to adopt technological and virtual solutions,” Rothman said. “But where needed, I see a [forthcoming] gradual increase in face-to-face visits, because there are some situations that really do require them in the home, because getting to see a primary care provider is not always an option for these patients.” The challenge of face-to-face visits is that applying it to everyone, Rothman said, makes the program unsustainable from a cost perspective.
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