One of the biggest concerns with this program, jeff, is that this waiver is supposed to expire at the end of December of this year. Well, just yesterday, some of the healthcare heavyweights, the American Medical Association, the American Telemedicine Association, they joined with some of the big health systems sending a letter to Congress saying can you put a five-year extension on this? Because the systems, I think, are really starting to see the value that this brings, the cost savings. One of the biggest things today is about whole person care, patient-centered care. We hear that a lot. Where does a patient want to recuperate, want to get better? It’s in the home.
Jeff Howell:
Welcome to the Home Health 360 podcast, where we speak with leaders in home care and home health from across the globe. Guy Tomasi brings more than four decades of on the ground expertise in private duty non-medical home care. As part of the Corcoran Consulting Group, Guy has served for 13 years as managing director of Connecticut-based Lifetime Care at Home and under his leadership, Lifetime Care at Home was one of the first non-medical care agencies in the country to incorporate the Centers for Medicare and Medicaid Services quadruple aim, value-based care pillars and in this coordinated care model they were an early adopter as a non-medical provider within a hospital at home model administered by Yale Health System and managed by Medically Home. So I’m really looking forward to diving deep today on the non-medical piece of how all of that works within this episode. Guy, thank you for joining us today.
Guy Tommasi:
Hi, jeff, thank you for inviting me on today. I’m looking forward to this discussion. What did I miss from your background? Actually, you pretty much nailed it. You covered four decades in 30 seconds, which was great, but it really did. You took it and really encapsulated it really well. And I am one who really enjoys being innovative, using technology, using data to really support what we do, and I’ve been able to do that and had the good fortune, even when I started my career, in a hospital environment where I’ve had opportunities to work within the community and bring care where people want it in the home, and I’ve really had that fortune of doing that throughout my career and actually the last 25 years in the non-medical space and 13 specifically with my recent provider status. You covered it and I’m excited about sharing that understanding and expertise, especially in the hospital at home environment.
Jeff Howell:
So it’s exciting, yeah the big thing that jumped off the page to me was that hospital at home really exploded or was really revived from the urgency to take people out of overloaded hospitals during COVID. And I think a lot of people don’t have much of an understanding around hospital at home to begin with. But in particular, how does the personal care, non-medical care side of things fit in? So what’s your take on the existing landscape of hospital at home and how does the non-medical piece fit in?
Guy Tommasi:
Sure, the whole concept, jeff, isn’t new. It’s been around for a while. It actually started back in the 1970s in the United Kingdom where they were doing trials. They were doing different models of hospital at home. Johns Hopkins School of Medicine and Public Health developed the hospital at home care here in the United States, so the history of it isn’t brand new.
Guy Tommasi:
What really kicked it off was COVID and it was CMS the Centers for Medicare and Medicaid’s answer to and in response to the hospital acute patients but those who may not have needed that level of care. What CMS did was that they granted this waiver called the Acute Hospital Care at Home Waiver, and what it essentially did was, in the conditions of participation, there’s a specific regulation that requires 24-hour on-site nursing care. That essentially got waived and they said you know what, let’s begin to set these programs up, we will institute this waiver and we will reimburse those programs at the DRG rate. So it really started to establish programs that hospitals began to look at. Hospitals began to look at third party like a medically at home or a dispatch. Health began to incorporate and, as a result, we really in an interdisciplinary team and with an interdisciplinary team that’s very unique for the non-medical space.
Guy Tommasi:
Typically it’s the caregiver by themselves in the home taking care of the patient with those activities of daily living. Taking care of the patient with those activities of daily living. This allowed the opportunity to really work side-by-side with other healthcare professionals physicians, nurses, therapists. Mobile technology with remote monitoring using a tablet to sign in and to log in the tasks. This was really an opportunity for the non-medical space to really step up Because, when we look at what they’re looking to do is really to provide those activities of daily living, the personal care to ensure that client, that patient, was receiving that level of care on a 24-hour basis that didn’t necessarily need a medical intervention.
Guy Tommasi:
In our case, when we were allowed to participate, this really elevated our caregivers and brought recognition to them that they never really had from the broad scope of a health care hospital environment. So it really did open up doors for the non-medical. And again, every program is different. Right now, jeff, actually, as of the first of this month, there’s over 315 hospitals in 37 states that have been approved for this waiver and each one runs, you know, independent of each other. They all have their different requirements based on who’s managing it and, just as a contrast, before the waiver there was only 20 programs. Today we’ve got 315 programs. That in itself, I think, is a statement that this is a program that provides good outcomes, that provides the care at a much lower cost in an environment where a patient thrives the most in the home.
Jeff Howell:
That was going to be. My next question is what does the data tell us about how effective these programs are at reducing costs?
Guy Tommasi:
This is one of those programs that, even though it’s been around for a while, the real attention came in 2020. So they’re still looking at data. There’s still a lot of data that is surfacing Medical Association. They’ve all shown that the outcomes have been positive without any adverse effects. Now you’re going to get challenged, I think. The reality is there’s those who will provide studies and data to support why this should continue and there’s those that I’m sure are going to have pushback for that reason that they are not comfortable yet with the program. They feel it hasn’t been around long enough, but there is enough coming out that certainly supports this program to stay the way it is. I was reading just yesterday one of the biggest concerns with this program, jeff, is that this waiver is supposed to expire at the end of December of this year.
Jeff Howell:
Which would affect all 315 hospitals.
Guy Tommasi:
Correct that waiver Association, the American Telemedicine Association. They joined with some of the big health systems sending a letter to Congress saying can you at least extend this by five years? Can you put a five-year extension on this? Because the systems, I think, are really starting to see the value that this brings, the cost savings and it’s addressing. One of the biggest things today is about whole person care, patient-centered care. We hear that a lot. Where is the best place? That takes place? In the home. Where does a patient want to recuperate, want to get better? It’s in the home. Unfortunately it’s not in brick and mortar anymore. That’s for the most acute Right now. The home environment is where people want to be and, for good or for bad, that’s where COVID came in. Covid really opened the eyes of the rest of the healthcare system. It opened the eyes of the payers that the home is where people want to be, where they recuperate the best.
Jeff Howell:
And Guy to that end. Do we have evidence that there’s a higher level of patient and family satisfaction?
Guy Tommasi:
Yes, yes, again, there are studies that come out to show that there is a high level of satisfaction. And you know, what we tend to forget sometimes, jeff, is the emotional stress level of going into a hospital. Now, I worked in a hospital for 15 years, so I’m not here to say anything negatively, but there’s a stress level that people go through when they have to go into a hospital or they’re in a hospital room. Family is separated, so the level of satisfaction. We tend to forget that there’s a stress level, an emotional level, that is also involved in the overall health outcome of that individual.
Guy Tommasi:
The other thing that the Hospital at Home program offers is Kaiser Family Foundation said that 80% of health outcomes are medical. There is a direct correlation to the social determinants of health. We’ve heard this. There’s more attention being given to the social determinants of health, which is nutrition, transportation, the education environment.
Guy Tommasi:
The hospital at home program affords an opportunity that never existed before from a nurse inpatient perspective. It allows that clinician to have his or her eyes on the patient in an environment that they’ve never seen the home. So now they could start to look at and see what are the risks that this patient deals with every day the flow risks, the nutritional risk, the transportation obstacles, all of which are non-medical but have a significant bearing on their health, overall health outcome. So now you’ve got a clinician who’s in that home and is saying wait a minute, I never knew that Mrs Jones had transportation issues which made it difficult for her to get her medications, which made it difficult to go out and get groceries. Those are those social determinants that have significant implications of a person’s overall health that when you’re in a hospital the clinical side of that doesn’t really get seen.
Jeff Howell:
Yeah, I’ve always said the number one cause of hospitalizations is actually loneliness, if you go far enough up the stream.
Guy Tommasi:
That’s true. And again, to really drive that home, look at COVID, look what happened during COVID, with isolation and loneliness and families not being able to reach out and see a family member and the hardship that really had, which was difficult. And again, loneliness is one of those we tend to not always think about if you’re not there. And again, from a non-medical perspective, we’re in the home many times 24-7. We see all of that 24-7. We see all of that. We see if there’s a change in the status from morning to evening because we’re there and you can report that to now a clinical, a home health agency for some intervention to avoid that hospitalization.
Jeff Howell:
So if I were to ask you what types of patients are best suited for hospital at home, it sounds like it’s far more broad than the acute use cases that most people’s minds would automatically default to.
Guy Tommasi:
Yeah, I think so the process, if I can share what in our situation, a patient would come into the emergency department and there was a physician there who was dedicated and identified as the physician for the hospital at home program and that physician basically did an evaluation and an assessment and made the decision this patient can really utilize the services at home by basically bringing a mobile hospital room to that patient’s home and that decision is made at that time and within two hours, again using ours as an example, within two hours that patient was home and a team was already deployed nurses, physicians, monitors, ivs within a two-hour period of time, by having that physician in the emergency department doing the on-site assessment and evaluation and making that determination which really allowed that patient to go back home with all the services, maybe without the anxiety of being in a hospital, which then allowed for those who needed to be in an ICU type environment to have access to those beds, to have access to that staff.
Jeff Howell:
I remember seeing on 60 Minutes, I think over a decade ago, a look at France’s health system, and I remember the term. The phrase that they used at the time was that the North American has more of a reactive. You get sick, you go to a hospital, you get cared for, there, behind the curtain, all these doctors making proactive house calls. It sounds like what you’re describing, I think, what most people think of hospitals big, clunky, expensive equipment. And what you just described sounds more like nurses and doctors acting like an EMR field staff that have their caseload, but they’re really out in the field with mobile technology to be able to bring the hospital into the home, absolutely, absolutely.
Guy Tommasi:
And I was one of those who was literally in awe of the mobile equipment that was dispatched to someone’s home.
Guy Tommasi:
It looked like a SWAT team coming into the driveway or into that residence Very organized, but what you would typically think of seeing in a hospital and trying to say, geez, how would this fit into someone’s home? The reality when they showed up at the door was, wow, this is pretty advanced technology. And what it made me think of was it was a modern mobile technology with kind of old school service like the house call, where the doctor made the house call, and now you have a team that’s available 24-7 to come in and really set up a mobile hospital room and take care of that patient. And granted, like I said earlier, there is pushback to this program. You’re going to have those who are going to continue to question the level of care, the level of service, but everything that I’ve read and continues to come out all points to this program being favorable. The outcomes are there, the cost is there, there’s a reason why 315 hospitals have signed up for this.
Jeff Howell:
I would imagine the length of episode of care or patient stay is also reduced when you’re able to recover in the comfort of your home.
Guy Tommasi:
Exactly, and part of the requirements is this has to be treated like it’s a hospital stay.
Guy Tommasi:
So the average length of stay that we were involved with was three to five days.
Guy Tommasi:
That was the average length of stay had to follow a lot of the same requirements as in the hospital. On the non-medical side, we were able to in many cases be invited to stay on after the discharge because families started to see how a loved one was being taken care of and, even though that episode or that acute stay came to an end and discharged, their mom or dad still may have needed some of those personal care activities. They still may have needed to get dressed in the morning and food prepared, possibly, and just personal care of their loved one that continued bringing them that positive, good outcome. I would strongly encourage to seek out these programs and participate, because you may look at it and say that’s a hospital program, that’s not for us. The opportunity for these programs, or I should say the opportunity for the service to continue after discharge, is a great opportunity. That thing goes into a private pay mode, a different type of a mode, but it generates that revenue. It generates awareness and recognition.
Jeff Howell:
And right now you said everything is just under the one acute hospital at home waiver.
Guy Tommasi:
That’s correct. Right now CMS has the reimbursement is based on this acute hospital care at home waiver and again it’s hoping they extend it by a five-year extension. And I really do, jeff, believe that so far it’s bipartisan support and I think they see that the reality is people are recovering and are choosing to be there. What we have to be careful is people still have choices and we want the patient and family to make the best possible choice for where that loved one, that patient, is going to recuperate, is going to be taken care of and the home is the place to be. It’s not Guy Tomasi saying that’s the best place to be.
Guy Tommasi:
I think every piece of literature you want to read and every survey AARP. Almost 90% of people they surveyed want to receive services in their home. I think the government is seeing that and CMS in particular is seeing that this is a movement where we could keep the most acute in the hospital, where they should be, and those who don’t need that level can be taken care of in their home, and to allocate resources accordingly. Unfortunately, the home health is not a reimbursed area right now. That’s a different topic and different subject.
Jeff Howell:
But those are some of the things that still need to be worked out as we go forward and for the listeners who have a loved one that needs care in the home, I would presume the best way to go about it, as you’re searching for a home care provider, would be to ask them if they participate in the personal care side of the acute hospital home waiver, because to my understanding, they’re going to get a higher standard of care. Number one for that agency to be handpicked by that hospital or health system to be their non-medical partner. But secondly, I would imagine that the degree of responsiveness is going to be at a higher standard and there’s going to be cases where the home health aid has to be deployed within the hour or something like that, as opposed to reactive scheduling in conventional home care. Is that right?
Guy Tommasi:
Absolutely, You’re absolutely correct and if I can share our experience, the selection, if you will, of providers and partners is pretty thorough. There are requirements that are needed. They looked at our agency in particular and they wanted to make sure that we had a CNA or HHA level caregiver. When that doctor that I mentioned earlier makes the decision that this patient can receive services in the home, the physician notifies the command center and the command center is then charged with assembling that team to be out there. Now, when they called us, we had one hour to respond. Actually, as the program went on, it was reduced to 45 minutes. So that call came to our office and we had to respond within an hour that we would be able to service that. And you know, with the way the work shortages is out there today, it’s amazing how fast an hour goes by when you’re trying to find coverage and you know you’re under the gun. You could see that clock ticking Because, in fairness to the patient, the command center can’t wait forever and they have to have a plan B and a plan C, which they did. We were not the only non-medical provider. They had to have two and they had to have three. In the event, we couldn’t do that, couldn’t meet the need.
Guy Tommasi:
So what I would say to those home care agencies, the non-medical once you find a program in your respective area, reach out, be part of it, have a plan in place. We’ve learned how to build this program. Every day was a learning experience because it was brand new. If I had to start it all over again, I know exactly the plan I would want to put in place because I’ve gone through that experience. So I would encourage the non-medical listeners out there do not be afraid of this program. You will be doing exactly what you’ve been doing every day. You’ll be providing the activities of daily living. Be proactive, Educate the hospital, the managing team, on the services that you can bring to the table.
Guy Tommasi:
The opportunity is there. You got to do some looking and you got to do some finding. But and I’ll go one step further, Jeff, from a recruitment standpoint, you know we’re all struggling. How can we attract the best, the brightest? How can we get them all on our team? Track the best, the brightest. How can we get them all on our team? This program became a great recruiting tool. We were able to say be part of a multidisciplinary team, Work alongside physicians, nurses, while still doing non-medical care. When you look at what motivates our caregivers, when you look at what motivates our caregivers pay isn’t always the driver. It’s the opportunity to be trained in new things and in really being professional. Yeah, sure, being part of something, yeah, being part of something bigger, that’s what they like and that’s when you become that employer of choice.
Jeff Howell:
I love that, especially since the best caregivers they’re in it, because this is a calling, so for them to be part of a multi-disciplined care team, that is super exciting. We are just up against our time here, guy, so I’ll get you out of here. On this last question how do you see hospital at home evolving over the next five years?
Guy Tommasi:
Within five years, especially if that waiver gets extended.
Guy Tommasi:
The payers are going to jump on this bandwagon because it’s a cost-effective way to bring positive outcomes.
Guy Tommasi:
So the payers, who right now are still I want to know a little bit more are going to jump on this. I see this as the next care in the home, hospital care at home being the future of care, Because all the tea leaves point to home-based care. And as this program grows and as we’ve learned from this, programs are going to get tweaked, they’re going to get refined so that it’s going to be a seamless transition from that emergency room to the home. It’s going to get to the level, too, that even before they get to that emergency room, the determinations will be that this patient can certainly have this level of care in the home. So this is the future it really is. And I think when like minds work together and keeping the patient at the center of this, then like minds should not be disagreeing and I think once they see the feedback, if they look at the satisfaction feedback, that in itself is going to be a driver, because that’s where people want to recuperate, want to be taken care of, want to stay.
Jeff Howell:
All signs are pointing in that direction. It is something that reduces costs, improves outcomes and improves the satisfaction of the patients and families. Let’s hope that the letter to Congress gets approved and there’s enough data from the 315 hospitals for Congress to extend the acute hospital at home waiver. My favorite line that you’ve delivered, guy, is when you talked about a modern standard of care that is at a bespoke level, but it’s also delivered in the comforts of the home. So that is what gets me excited about the future of not just care in the home, but hospital in the home. And I did leave out one thing you are also a nationally recognized speaker with enough humility to not mention it. So Guy has actually given presentations to more than two dozen organizations. And, guy, I’ve learned so much, I take so many notes here and, as always, I steal all of the best lines from my guests to make myself appear smarter. So thank you again for being on today.
Guy Tommasi:
Jeff, it’s been my privilege to be here and to be able to share this and feel free to take all the information and continue to use it wisely and to promote what we want to promote and carry in the home.
Erin Vallier:
Hey listeners. This is your host, Erin, with a very important podcast announcement. Jeff Howell, my fellow host that you know and love, is moving on to another exciting season in his career, so this is a really bittersweet moment for me. I have really enjoyed working with Jeff over the years. It’s sweet because I get to interview him for once, but bitter because it’s his last few moments on the podcast. Jeff you’re going to make me cry. Oh, so I’m really curious, Jeff are there any standout moments from recording the podcast over the years?
Jeff Howell:
Some days it feels like forever. Some days it feels like forever, aaron. Back in 2017, I had brought up the idea internally, like let’s do a podcast, and the head of the department said, hey, just so you know, no one has ever put home care and podcast in the same sentence before, and we had other priorities. And we put it on the shelf at the time, as we should have at that time, and it kept circling back, and the reason why we ended up bringing it back was a couple of things is that we did want to raise awareness of the sliver of health care that we call home care and home health, and we wanted to be a part of that conversation, and it’s really the only truly passive medium where you can listen to your favorite podcast on a walk or washing dishes or in the car. And a couple of the really standout things about the impact of the podcast that we’ve had and you will continue to have is that Kevin Mystery would tell me hey, I’m going on a road trip. I’ve listened to every episode. Can you just send me a few of the really good ones that you really remember? And this is how I keep inspired in our industry, and we hired someone named Jessica Lindsay who in the interview process said, hey, I’ve listened to every episode and she had soundbites to use and it’s been rewarding. I’m sure, as you have felt the people that have circled back and said that this podcast and I take no credit for this it’s all about making sure that our guests try to speak 90% of the time, and there’s so much. I wouldn’t single out any one thing except that my biggest takeaway from it is that it’s truly been an honor and a privilege to meet the biggest difference makers in the industry and to learn from them and each episode most of the episodes. It almost probably sounds like a cliche that I’ve written so many pages of notes. I can’t tell you how much I’ve learned in the industry by having the good fortune of sitting in the seat so that I get to chat with some of the brightest minds in the space.
Jeff Howell:
I do want to give a shout out some of the brightest minds in the space. I do want to give a shout our producer Ryan, who does a lot of the hard work behind the scenes and is an invisible face here on the podcast, just like Kati, who does our road mapping, and Monika that runs our social channels. And then you, Erin, of course. In the last five plus years that we’ve known each other, I don’t think that you’re actually capable of having a bad day. You are always in this constant state of Zen, and I know that you, with your relationships in the business, you’ve landed some of the biggest names that have come on as guests, and I can’t think of a better person to take over full-time responsibility of being the host on the pod and bringing this podcast to the next level, and I’m going to look forward to listening to the episodes and they’ll come as a complete surprise to me and not being involved in the planning.
Erin Vallier:
It means a whole lot, jeff, coming from you. So I have always admired you and respect the talent that you have and the creativity that you have. You are really going to be missed. And I have a final question for you, and I think it’s just only fair, since you ask all of your guests this question, so I got to toss it back to you. Give us a reason to be optimistic about the care provided in the place where patients call home.
Jeff Howell:
What a fitting last question. Well, the easy answer is the theme that I’ve picked up on from all of the guests is that it makes both more financial sense to deliver care in the home versus in buildings, and that it makes more sense from a humanitarian standpoint, given that this is where 99% of people, where they want to age in place, is in the place where they’ve created all their memories. And from a technology standpoint, there are innovations every day that are helping us all make this closer to reality and the new normal. With that combination of these three things, I think it’s going to be an unstoppable force that care will become the new normal. But what makes me even more optimistic is the unstoppable force of guests that we’ve had on this show and the colleagues that I’ve been able to work with. The talent, the grit, the passion, the purpose and the mission I’ve seen from all the people that I’ve met in the industry has been both humbling and inspiring. So in a final sign-off, I do want to acknowledge and thank you all and keep up the noble work.
Jeff Howell:
Home Health 360 is presented by AlayaCare and hosted by Jeff Howell and Erin Vallier. First, we want to thank our amazing guests and listeners. Second, our episodes air twice a month, so be sure to subscribe today so you don’t miss an episode.
Erin Vallier:
And last but not least, if you liked this episode and want to learn more about all things home-based care, you can explore all of our episodes at alayacare. com/ homehealth360 or visit us on your favorite podcast platform.
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Episode Description
Home Health Consultant and CEO of Corcoran Consulting Group, Guy Tommasi, joins this episode with our host, Jeff Howell, to discuss hospital-at-home care models’ growing potential. They explore sustainable, patient-centered approaches to transforming recovery, demonstrating that innovative care models surpass conventional hospital treatment by enhancing patient satisfaction and lowering expenses. Tommasi foresees a smoother fusion of traditional health care, opening new avenues for payers, providers, and patients. Listen as we reflect on our progress and anticipate the growing significance of home care in the health care sector.
