<v Jordan Cooper>Next in Health podcast with your host Jordan Cooper, we are here today joined by Doctor Chang Kai Cau, Chief Clinical Informatics, Informatics Information Officer at the University of Chicago Medicine. Kai, thank you for joining us. How you doing today?</v>

<v Jordan Cooper>Thanks.</v>

<v Cheng-Kai Kao>Pretty good. Nice to meet you, Jordan. And have. Hello everyone.</v>

<v Jordan Cooper>So today we're gonna be speaking about University of Chicago Medicines Hospital at home program to get us started off Kai, would you tell us a little bit about the program? It's background and your involvement in it.</v>

<v Cheng-Kai Kao>Yeah. So and you use Chicago, Madison, we are launching this very exciting program. We are still in the planning phase, but we plan to officially launch the program in January and we'll start to see our very first page and as soon as next month. So it's a lot of work really around how do we actually provide inpatient level care to the patient's home and I'll be leveraging more details about the programming itself, but.</v>

<v Cheng-Kai Kao>Not very sure that there's a lot of desire from the patient to be able to actually be seeing at home, especially over the pandemic. There's a lot of going trend about, you know, is this something I can just take care of myself at home with doctors and nurses coming to my house so.</v>

<v Cheng-Kai Kao>Very excited that we are working together internally and then also working with a lot of partners across the nation to work on this project.</v>

<v Jordan Cooper>Just so that we can align with our listeners on the definition of what we're talking about, the American Hospital Association defines hospital at home as a program that enables some patients who need acute level care to receive care in their homes rather than in the hospital. This care delivery model has been shown to reduce costs, improve outcomes and enhance the patient experience. Again, that's from the AA Kai. Is that a fair definition that aligns with you Chicago's efforts?</v>

<v Cheng-Kai Kao>Yes, I think that's a very fair definition. But beyond just hospital at home, we are essentially looking at overall this home care based model where you know can we spend our services to the pensions home, not just the inpatient stay. So for example, can we do urgent care at home, can we do more like sniff at home, rehab at home? Can we include our existing home health services and really expand that to become providing a spectrum of different services to the patients home.</v>

<v Cheng-Kai Kao>Rather than just focusing on acute care.</v>

<v Cheng-Kai Kao>But.</v>

<v Jordan Cooper>Sure. What kind? What are some of the? What's the impetus for University of Chicago Medicine to start moving care from the actual facility to care at home? Is it, is it patient demand or is there another reason?</v>

<v Cheng-Kai Kao>That's a great question. So I think we see the trend of the patient demand that's one of the reason, I mean the traditional there has been a lot of home based services, you know, home dialysis, home Hospice, you know and obviously home health. But I think more and more we see the trend overall towards the home based model like we talk about the retreat, the patient with the right service at the right place rather than compared with the traditional model where it's more like episodic care patients come to the hospital or clinics.</v>

<v Cheng-Kai Kao>Regalos impatient outpatients only when they are sick. But what we really are aiming to do is be able to provide this spectrum of care they really have provide better monitoring, better support to improve patients health, not just.</v>

<v Cheng-Kai Kao>You know, within these episodes, but for the institution, there's obviously a couple of other reasons too. First, in the our capacity and access as being an issue, our hospitals almost always fall. So any given time, there's an issue around how can we actually create more capacity. So we can actually see more patients because otherwise they are waiting in the emergency room. So expanding the capacity and access, this is one of the top reasons why they do it for institution. Secondly, we also are looking at a lot of benefits.</v>

<v Cheng-Kai Kao>That's been proven in its program in other pilot programs, in other institutions, there has been studies showing that this program reduced the cost, reduced readmissions, and also reduce Ed visits. And also it really improve the patient experience by reducing delirium, allowing them to have more activities and actually sleep better at home compared with the experience within brick and mortar. And third, really, we wanted to take this opportunity to examine the social determinants of health.</v>

<v Cheng-Kai Kao>We have been really try very hard try to connect the patients, especially those with lower social economical status with the support they can have you know.</v>

<v Cheng-Kai Kao>You know, with the city, with the government or with the NGO's. But so far there's been, you know, limited to a screening when the patient is in in the hospital. But now we have the opportunity to actually look at the patients home and they actually do something more by actually looking at what do you mean by you really have trouble getting around? How many flights of stairs you actually have, how many obstacles do you have between your home to your food supply and your transportation? And how can we actually help you with those?</v>

<v Cheng-Kai Kao>And make sure you get to the right appointment. Make sure you get to the dialysis on time.</v>

<v Jordan Cooper>A new client you raise a lot of interesting points about the impetus for starting this hospital at home program. One thing I'm noticing is some of our listeners may be CFOs, CEOs, individuals who may be concerned with generating revenues in the health care delivery system when traditionally in a fee for service model. When you say you want to reduce readmissions and ER visits, that may translate into lost revenue for healthcare delivery systems. So clearly, I think what you're implying by trying to shift care into the community.</v>

<v Jordan Cooper>Is that there's been a transition, at least that University of Chicago, to maybe some sort of bundled payments, risk sharing, accountable care organization networks that enable you to care for population health over the long term. Can you speak to some of these different payment models, these new innovations and may be the result of the Affordable Care Act and how you're financially able to?</v>

<v Jordan Cooper>Should the transition to caring for a population and and Wellness and preventive health, instead of kind of reactionary fee for service medicine?</v>

<v Cheng-Kai Kao>There's a great question, Jordan and you are right. One of the biggest limiting factor for you know halfway home program or even overall telehealth before the pandemic has been the reimbursement, there's technologies out there we can FaceTime with our family members, right ten years ago. But the challenge has been who is gonna be paying for these services when we provide them at home or provide them remotely. So this pandemic, if there's any silver lightning, one of which is really.</v>

<v Cheng-Kai Kao>Expedite the the system level change around the payment model for telehealth. So actually in October 2020, Dcmh actually launched a program which they call a waiver program. They wait for the rights to see the patient within the four walls of the hospital. If the institution can provide reasonable plan and get approved. So with this waiver which we obtained about one year ago.</v>

<v Cheng-Kai Kao>We are now allowed to actually read actually.</v>

<v Cheng-Kai Kao>Appeals to CMS for fever service for patients at the Middle House, the home program, so there is definitely some components and some insurance will pay even under People's service model for these patients. But on the other side, as you mentioned, this program is very aligned with all the value based programs like Medicare Advantage and couple of other value based policies with other payers. So I think there's a lot of.</v>

<v Cheng-Kai Kao>You know excitement and and I will see the pairs are gradually sort of moving the needles, trying to think about what their strategy look like. If this is really the future where the patients really want to be treated at home. So we're happy to see in a lot of movements including a build that's being introduced to the Congress hopefully will be discussed and passed by next January to add really extend the payment for halfway home program by CMS for standard for two more years. And I think with that change.</v>

<v Cheng-Kai Kao>We have which will really encourage more payers like a primary insurance to really continue falling in line in terms of supporting this type of new care model.</v>

<v Jordan Cooper>If some of our listeners are tuned into this episode and are considering potentially rolling out a hospital at home program at their hospitals, to what extent do they have to be aware? To what extent must they collaborate with payers and in order to what extent do they need cooperation from payers? Do they need a partnership with payers? Do they need to have these sort of value based payment policies already established in their hospitals or these things they can do wherever regardless of?</v>

<v Jordan Cooper>Where they are.</v>

<v Jordan Cooper>Yeah.</v>

<v Cheng-Kai Kao>That's a great question. So I would suggest for those who are considering this, I mean, if you know your first step, if looking at all the payers, CMS is obviously the one that has currently a waiver program. So CMS people service will be your first starting point. So looking at your patient population, identify how big their population is and do a very candid analysis internally around.</v>

<v Cheng-Kai Kao>You know, UM, you know, when you see these patients at home, how big it of their senses would be? You can ready to calculate the total addressable patient volumes and then you also think about let's say if you see five patients at home, which doesn't sound like a lot, but in the meantime, you're freeing up five beds in house, right? So they will be backfilled revenues coming from those five patients. They will now be able to actually be admitted to the brick and mortar. So doing that financial analysis to really assess is this something worthy for you to continue.</v>

<v Cheng-Kai Kao>So this this answer may differ from institution to institution based on their patient population. Pair mix and such. But for us, when we look at not only just the short term finance revenue which we already for all we are not looking to sort of.</v>

<v Cheng-Kai Kao>You know, for example, again laugh for revenue from this program. Our intent was really to expand our capacity and access and also more for our long term vision of seeing all the digital health, all the patient care services expanding to home. We want to be able to have this program out saying able to enable all the other services like I mentioned earlier, urgent care homes near the home, rehab at home, home health and really becomes sort of home ECHO systems in the future state.</v>

<v Jordan Cooper>So Kai, you mentioned specific patient populations, are there specific patient populations that you Chicago medicine are targeting?</v>

<v Cheng-Kai Kao>Yeah, we have identified 5 patient conditions. So they are killing infections, which includes pneumonia, UTI, Cellulitis or covets. The second category would be half federal or fully overloaded. Third would be COPD or SMI acceptation, 4th will be acute kidney injury and the last will be DVD or pulmonary embolism that requires oral offering, transitioning or oxygen monitoring.</v>

<v Cheng-Kai Kao>And so these five patients are five group of patients are what we're going to start with. But I really see in a lot of other potentials in the future. So first, any general medicine patients who have a medical reason to stay in the hospital, maybe they're blood pressure, tie their blood sugar is high and these are the things you can monitor and treat safely at home. All these patients can be in the mining tool program. We also have seen other use cases in post surgical recovery sending some of these patients.</v>

<v Cheng-Kai Kao>Well, it's already been extradited to the charge from the surgical perspective, but now can marry even go home earlier if you have the right monitoring and sort of.</v>

<v Cheng-Kai Kao>Treatment programs at home and the third will be the chemotherapy. So we see a lot of oncology patients start to be actually treated at home. Traditionally, a lot of this IE chemotherapy will have to be given by in the hospital. But now we start to see some potential to actually do those at home as well. So we this program.</v>

<v Jordan Cooper>Got it. So now we've we've discussed somewhat the financial incentives. We discussed the operational challenges to some extent. What about the IT challenges with implementation or potentially since you mentioned that may not be such a great challenge, there may be with different data formats and integration of data. Also I'm interested in challenges with patient adoption and use, especially if you have a jury attric population, it's less familiar with technology.</v>

<v Cheng-Kai Kao>Now these are again awesome questions. You know Jordan so.</v>

<v Cheng-Kai Kao>I would say to set up house the home program. I think it's a relatively smaller piece of, you know, all the other elements because you have a lot of things to align, including what patients you are seeing, what doctors meaning you know typically helpless would would do. And one of the nurses, while the pharmacists work for you, essentially are reinventing the workflow of every service in the hospital to think about how we can provide those services at home. But that said, it is very important in enabler.</v>

<v Cheng-Kai Kao>And really can in the speed up the efficiency if we have a good system in place. So to start with, you need to have essentially a virtual patient floor in your ESR regardless of which one you use because you essentially these are still impatient. They're just the location is a room in their home, but everything else still inpatient stay. So you need to create sort of net virtual patient floor and there's quite a few different it builds around all those sets around, no templates.</v>

<v Cheng-Kai Kao>Around the building codes that need to be set up, you know if you are for example, scaling the patients medication at home, you need to have those scanners, laptop, mobile devices all set up. But I see more sort of a challenge around it. Space has been there's a lot of growth and desire to provide service in the space, but there hasn't been a lot of integrations between these mobile devices to the hospitals EHR. So for example, we are monitoring the patients heart rate temperature.</v>

<v Cheng-Kai Kao>Wait.</v>

<v Cheng-Kai Kao>Ruth, breathing rate and all that through mobile devices and this will be synced to a tablets through a vendor that we work together for this program and this data will be ultimately sent back to the EHR, but there is still a lot of other vendors for example like if we do a chassis right, if we do an EKG. If you do a line placement.</v>

<v Cheng-Kai Kao>You know, Umm, you know, through different vendors and you know to provide to the patients at home. A lot of these vendors still haven't have integration with the EHR yet. So obviously there will be some efficiency loss when provider need to switch for example between different portals and EHR. Just try to place the order for example for traces, right. But I hope in the future state again as the program and overall the trend is continue to mature, we'll see more sort of the integration in the space.</v>

<v Cheng-Kai Kao>The last you mentioned a very important part about adoption. So I think one of the challenge you need to program is how do we making sure this service is equitable because we don't want to provide this to a certain well resource population. We certainly don't want to.</v>

<v Cheng-Kai Kao>You know, overlook our elderly population because a lot of them are actually the majority of patients who use CMS Medicare. So how do we make technology easier? How do we make ensure these tablets, for example, are cellular network enabled, so they are not actually reliable on the patients Wi-Fi at home because some of our patients don't even have Wi-Fi at home. So we don't want this to be a barrier for them to receive care. So a lot of the work has been around reaching out to the patients.</v>

<v Cheng-Kai Kao>We interview with quite a few patient advocates and also community patient panels to understand their perspective, to understand their barriers that may have and come up with support or resources until interest at least needs, including the tablets including a Wi-Fi, but also including, for example different languages, including sort of different way to introduce the material to help them quickly understand the care model.</v>

<v Jordan Cooper>Thank you, Kai, and I appreciate you going through the IT challenges with integrating mobile devices to hospital EHR challenges with adoption and ensuring an keeping in mind the potential challenges to HealthEquity that need to be addressed in this program. One thing I'd like to address which which is incredibly important, which is to what extent does this hospital at home program affect quality of care and health?</v>

<v Jordan Cooper>Outcomes compared to comparable inpatient care.</v>

<v Cheng-Kai Kao>Yeah. No, that's a great question. So we have some research, you know, study is done before and and most of them share, there's a very significant reduction of readmission rates. There's also study shows, there's reduction of length of stay by one to two days, there's in general. And I'm saying in general terms just because different study, quote, different numbers. But in general you see a code saving somewhere around 10 to.</v>

<v Cheng-Kai Kao>24% depending on which study you will quote. And like I mentioned earlier, for the patients the patient experience has been through the roof, there's a lot of patient satisfaction around now being able to be at home surrounded by their family and friends being a very familiar environment. And also again because they're familiar with the environment, we see there's a huge increase in terms of the time they are active, meaning that stand up work around much more often than in traditionally in a hospital stay.</v>

<v Jordan Cooper>Mm-hmm.</v>

<v Cheng-Kai Kao>Which again is in a more foreign environment to them. Patient also sleep better because now they don't have alarms and all these broadcasts that we have to do in hospital for some urgent cases, now they are at home sleeping sound piece and sound until the visit next day. So that really have more control. So what are usually frame this program to the patient is instead of you coming to us and sort of follow our schedule in the program is we bring the 32 you and actually.</v>

<v Cheng-Kai Kao>But adjust our services based on your daily routine you know, so I I think this is where, you know, like quite a few benefits we have seen in the program around the patient quality and safety and satisfaction.</v>

<v Jordan Cooper>Hi, the Commonwealth Fund has said quote hospital at home programs enable patients to receive acute care at home have proven effective in reducing complications while cutting the cost of care by 30% of or more. As you just mentioned leading to entrepreneurial efforts to promote their use but widespread adoption of the model in the US has been hampered by physicians concerns about patient safety as well as legal risk and by the reluctance of payers including Medicare to reimburse providers for delivering services at home. Now I know you mentioned.</v>

<v Jordan Cooper>That Medicare or you said CMS, which is the regulatory body that that runs the Medicare program has now begun reimbursing for these programs. I wonder if you have experienced any pushback against this model as just described by the Commonwealth Fund or if and if you have, how you've been able to overcome this pushback?</v>

<v Cheng-Kai Kao>Yeah. No, that's another great question. So the pair side, as we mentioned earlier, so now CMS have a waiver program to address some of the Medicare fee for service patients. So that's better. And for the value based payment models overall, this program really fit right well because really reduce a lot of readmissions and really provide care in the usually.</v>

<v Cheng-Kai Kao>Uh.</v>

<v Cheng-Kai Kao>Uh, more costs are being way compared with traditional brick and mortar stay, but All in all, we still are, you know, pending some of the other players to flip and and be on board with this new care model. So the concern around would more pairs fall in line or would this be sort of just stayed here and just with CMS waiver program and how long the program is going to stay even if this bill has passed with two more years. So there's always some of 30 here around the pairs.</v>

<v Cheng-Kai Kao>Uh, and reimbursement overall the other thing mentioned, you know as you curled around reluctance of the physicians around patient safety, I think that's also pretty real as well. I think so far we think user gargle medicine, I think we're lucky that pretty much everyone that I've encountered so far has been very excited about this kind of model. People believe this is something we can deliver and also people believe this is something really good for the patients and good for the health care system. But that's not to.</v>

<v Cheng-Kai Kao>Overlook the fact that there is actually always some resistance from the provider to a new care type of care model, especially something as drastic as to just move the care to the patients home. There's obviously concerned about traditionally in your Brigham order you have a lot more control over the patients, right. So you can say I want to get this lab and you click the order, you will be getting lab within an hour, you want to give the medication, you can do that in an hour. You want to see the passion. You can do that within a few minutes, but now everything's remote. So there is some level challenging around.</v>

<v Cheng-Kai Kao>We are sort of not having all these control and all these monitoring and and also potentially deliver these treatments within the time timely fashion like we typically do. So with that be an issue and would that jeopardize the patient safety. So a big chunk of I think the SuccessFactors around this broken would be around how do we care for these like the right patient population this patient need to be sick enough to be impatient level state observation level or outpatient level patients doesn't count.</v>

<v Cheng-Kai Kao>So they need to be sick enough to be admitted to a hospital. By the meantime, we're not meeting those patients who are going to like you. Next minute. We need to be carefully select the patient who of lower to intermediate acuity of care to be able to treat them safely at home. So I think these will remain challenges, but I remember optimistic that these are addressable challenges.</v>

<v Jordan Cooper>Kai, we're approaching the end of this podcast episode and I'd like to ask you to take 30 seconds and speak to your colleagues other CIO CMIO across the United States and speak, what message would you like to tell them about the hospital at home program?</v>

<v Cheng-Kai Kao>Yeah, I would say ohh. Driving innovation can be tough. You know, sometimes it can be really against the organizational culture to do something, you know, pretty innovative and also relatively have more risk involved. But I think for us at home, I really align well with the trend of telehealth growth align well with the digital health developments and also would be a very simple thing in enabler for many of these teacher health solution to come. So I really encourage.</v>

<v Cheng-Kai Kao>Through review, analyze and determine internally about whether it's something you want to adopt. But I think a lot of you will really find this as a very worthy program to invest.</v>

<v Jordan Cooper>And this has been Doctor Cheng Kai Kao as the chief Clinical Informatics Informatics Information officer at the University of Chicago School of Medicine. You've been listening to next in Health podcast with your host Jordan Cooper. Thank you very much for joining and we'll talk to you next time.</v>

<v Cheng-Kai Kao>Thanks everyone.</v>