“We don’t want to wait for symptoms. We can be proactive, before a complete exacerbation of a chronic disease,” says an ACO executive.

Editor’s Note: This article is part of HealthLeaders’ Mind the Gap series, a three-part exploration of how healthcare brings together information, patients, care and payment. Read the other articles on automation and real-time drug benefit checks.

Another benefit of the expansion of pandemic telehealth is more home hospital (HAH) and remote patient monitoring (RPM) programs. Integra Community Care Network, the responsible care organization (ACO) for Care New England Health System, is launching the two in partnership with tech company Biofourmis. And with the Centers for Medicare & Medicaid Services (CMS) expanding HAH exemption eligibility and reimbursement parity beyond the COVID personal health emergency, seek more payviders and health systems to provide home solutions.

Two programs for home care

The Integra HAH waiver program, according to the Biofourmis press release, “will admit” patients to their homes instead of a medical facility for hospital care. ”Data from the wearable sensors connects to the scan engine. Biovitals approved by the FDA to monitor the status of Medicare patients, who will also be connected via tablets, videos and in-person home visits as needed.

“It allows us to be so much more connected to patients and better able to help people feel comfortable 24/7,” says Ana Tuya Fulton, MD, MBA, Chief Medical Officer at Integra and CEO of Geriatrics and Palliative Care at Care. New England.

Integra’s second remote monitoring program applies to all of its ACO population – Medicare, Medicare Advantage, Medicaid, and commercial – with a focus on patients with congestive heart failure, COPD, asthma and other chronic diseases.

“Integra ACO offers remote monitoring for multiple populations,” says Fulton “with a focus on improving outcomes, reducing costs and improving patient / limb satisfaction”. In the Biofourmis statement, Fulton added, “From a clinical and cost perspective, keeping patients safe out of the hospital is certainly one of our goals as an at-risk ACO …”

A little help from CMS

Integra / Care New England’s HAH program and a growing list of hospitals have been made possible by the provision of acute hospital care at home from CMS. Announced in November 2020, the program is part of the larger initiative of the Hospital Without Walls agency. While the program is strictly for Medicare beneficiaries, Fulton notes that some states may be working on a similar solution for people enrolled in Medicaid. In December 2021, CMS released a revised fact sheet to help state and local governments develop “alternative care sites with information on how to request payments through CMS programs”.

The foundations of Integra

Fulton cites the foundations of Integra ACO as being strong for their current work. “We learned the care journey with our patients,” she says. “We started as the first ACO in community management of complex care with interdisciplinary teams supporting the most urgent needs, usually older patients. Noting that “we wanted to build a continuum to provide options,” Integra went from nurse practitioner to nurse. the care manager visits a home

Community Care Medicine Program in 2018 which added rapid response acute care at home. In 2021, Fulton says Integra has increased its remote monitoring capability with one goal: “We don’t want to wait for symptoms. We can be proactive, before a chronic disease has fully exacerbated.”

The role of patient identification

As for other means by which an ACO can develop operationally? “Correct identification of the patient is paramount,” says Fulton, adding, “No one has identified him 100% and everyone is looking for the secret recipe. Use and cost data to stratify risk is not sufficient. “

Fulton continues, “We spend a good deal of our time digesting data from claims-based payers reports, including Medicare. Who are our patients, what are their conditions, what complaints do they have? She adds, “We are looking at their clinical needs, our medical programs, community resources, social determinants of health. We spend a lot of time in an ACO analyzing data, perfecting programs – and that changes every year. I spend so much time living in the patient’s EHR. “

While Fulton manages the patient’s EHR, she helps create a situation where more patients can live at home. Integra’s HAH and RPM programs seek to transfer elements of care from a hospital setting to one where convenience and familiarity can help speed healing.

Laura Beerman is a contributing writer for HealthLeaders.