Dr. Bruce Leff is a professor of medicine at the Johns Hopkins University School of Medicine, holding a joint appointment in the department of health policy and management in the Johns Hopkins Bloomberg School of Public Health. He is also an internationally recognized leader and researcher in the development, evaluation and dissemination of novel models of care for older adults, including the Hospital-at-Home, Guided Care, geriatric service line models and medical house call practices.
Through the Vision Series, Dr. Leff shares his vision for a health care system that meets the person where he or she lives. He discusses the surging social movement toward age-friendly health systems, and he also provides a unique framework to better depict what this movement will look like on a national level. In addition, Dr. Leff explains how individual providers fit into the equation, and how the transformation of the existing health care system will impact patients’ lives.
I think there are a few different ways to think about approaching that. You can think about nouns and verbs and types of care and attitudes and culture toward care. What’s coming into the vernacular is called “age-friendly.” The John A Hartford Foundation of New York and the Institute for Health Care Improvement has been working for the past few years at a national level to develop a social movement toward creating age-friendly health systems. They identify by basically doing a very substantial review of literature and health models that focus appropriately on older adults, and they came up with something they called the “four Ms” that helps focus systems at all levels.
Those four Ms are first what “matters” to people; trying to get a good sense of what people’s preferences for health care are. The next M is “mentation”; that is a good health system that’s age-friendly and is really addressing the needs of older adults who recognize that older adults experience a higher rate of memory disorders, that is dementia. They’re also more vulnerable to important conditions like delirium, that is having acute confusional episodes, especially when they’re in the hospital. You have what matters, you have mentation. The third M is “medications”; the use of medications in older adults is critically important. The issue of poly-pharmacy and making sure that people are on the meds that they need to be on, and are not on medications that they should not be on, or that can cause harm.
Then the last of the four Ms is “mobility.” An age-friendly system should be able to pay attention and optimize the ability of older adults to get around and assess that on a regular basis and make sure that when older adults are experiencing trouble with that, that it can be addressed through physical therapy or through optimizing medicines or getting them what they need. Then some folks have added a fifth M to the list, and that is the notion of “multi-morbidity” or “multi-complexity.” That is acknowledging the fact that older adults tend over time to accumulate more conditions, illnesses, diseases, and that when you’re taking care of older adults, that multi-complexity, multi-morbidity needs to be managed in the total holistic sense, as opposed to focusing on a single condition.
Older adults who have heart failure very, very rarely only have heart failure. They might have heart failure, hypertension, diabetes, chronic kidney disease, and those conditions need to be managed together in accordance with what matters. Thinking about those four or five Ms is one way health systems can be age-friendly. I think another way systems can be age-friendly is by thinking about how and where care gets delivered. That’s been of special interest to me over the years. My own point of view is that much of what happens currently in facilities, whether it’s in ambulatory clinics or hospitals or skilled nursing facilities, can, and I think much of it should, happen at home, which is simply a much more friendly environment for older adults and can be associated with substantial advantages.
There’s a robust literature on hospital at home, which provides acute hospital-level care in the home and [can be a] substitute for the care traditionally provided in the brick-and-mortar hospital. A lot of the evidence suggests that patients want that kind of care, that it’s associated with better care experience and that it’s associated with lower rates of important complications, including things like delirium and the like, and as well as lower rates of mortality — and it costs less. I think there’s been starting work on the ability to do rehabilitation or skilled nursing facility level care in the home instead of the bricks and mortar of the skilled nursing facility. Then for patients who are too frail to come into our traditional ambulatory clinics, home-based primary care and home-based palliative care are also quite powerful models. I think those models tend to honor the wishes of patients to get care in their comfortable, familiar environment, and that kind of care tends to promote age-friendly care in that the providers who provide that kind of care are more attentive to what matters to patients and their medications and issues related to mentation and mobility.
You’re forced to do that when you see people in their own environment.
We’re starting to see some innovative systems move in those directions. I think we’re also starting to see disruptions from underneath those health systems starting to push them in that direction. For instance, the Mount Sinai health system, which had a Center for Medicare and Medicaid Innovation demonstration study of hospital at home that they did between 2014 and 2017, which they built off of a foundation of a very robust home-based primary care program has started to move in that direction. They even took out full page ads in the New York Times, starting around 2015. I think the title read, “If our beds are full, it means we’ve failed.” That is, [if] they haven’t started to push more care that can be done outside the bricks and mortar of the hospital to the community, and to the home, [then] they’ve failed in their mission. I think they saw hospital at home and home-based primary care and rehabilitation at home as tools in the toolbox to start to move care toward the community in a way that’s more congruent with the needs of older adults, especially frail older adults. I think they’ve also started to reduce their in-patient footprint in Manhattan. There was a hospital in the system that was a 900-bed hospital. I think they tore it down, but only replaced it with a 300 bed-hospital. Hospital at home and home-based primary care were two of probably a dozen tools [within] multiple approaches and strategies and tactics to try and keep care in the home, in the community and not in the hospital.
I think [we’re] starting to see those sorts of movements. [We’re] starting to see the improvements in remote patient monitoring and technology enable more care outside of the hospital. I would be very keen to say that technology is rarely, if ever, a solution, but it’s a really important tool to enable care outside the facility. I think that’s only going to get better. I think the algorithms sitting behind remote patient monitoring and hopefully the artificial intelligence behind the data will really also enable more care to happen outside the facility. I think you’re going to start to see more of that kind of work as well.
A few things. The whole notion of culture and leadership in health care is really quite important. I think the culture of American health care has been one that’s quite focused on the facility. The culture is focused on the facility, it’s built around the facility, payment is built around the facility, regulations and accreditation is built around the facility. At some level, home-based care is a bit of a square peg in the round hole of American health care delivery.
At some level, home-based care [or] non-facility-based care is really a bit of a backward bicycle. The hard wiring really lends itself to and promotes facility-based care. Those things are very hard-wired into the system. Those things are hard to change. For example, about a year ago, the world changed. I know at Hopkins and a lot of other places, the ambulatory clinics shut down and systems that [had been] taking years to do telemedicine tried to stand it up, and many stood it up within a number of days or weeks. In my own clinic, we went from 100% outpatient in-person to 100% telemedicine visits. That went on for a while. [As of March 2021] we are almost 100% back to in-patient clinic visits. I think that’s happening in a lot of other places, too, because that’s familiar. That’s [where] the hard wiring and payment took over again. I think a lot of health systems were missing the facility fees associated with in-person visits. Many of them shifted back to the familiar and it made a lot of CFOs happy.
That culture of health care and health care delivery and health care leadership is a hard-wired thing. That really does take some change. Another is the infrastructure for moving care outside of facilities. The supply chain, the logistics, all of those things are geared towards facility-based care and the ability to move that out of a facility mindset and get it hard-wired and supported and developed for a more home- and community-based model will take some time. Also, in an economic sense, some health systems in some areas are the main economic drivers of the local economy. I think until those systems see the shift out of the facility and into the community, it’s something that would not necessarily result in loss of jobs and loss of local economy. That’s part of the shift that needs to happen. I think that can happen. You’re going to need people to do things more outside of facilities. I think that will also create jobs and help people get the care that they need.
I think another barrier is how clearly health care gets paid for and how the quality of care gets evaluated. A lot of the quality metrics that are appropriate for older adults don’t always apply well to patients who are high-need, high-complexity. They really haven’t been developed for that population. We did a study two or three years ago where we looked at all of the MIPS [Merit-Based Incentive Payment System] measures in the CMS measure set. We were interested in how applicable those measures were for old, frail people who were homebound. What we found was that fully half of the measures that could even remotely be applicable to that group of patients did not include home visit codes in the measured denominator. They couldn’t even be used for home-based care, for people who are getting home-based primary care. That poses a barrier as well, especially if payment is linked to quality by metrics that are being employed by the Medicare program.
Then payment is another big deal. We’ve seen the recent, really excellent work that CMS has done with regard to the hospital-based waiver for hospital at home. Within two months of that waiver being implemented, about 100 hospitals applied for and got the waiver. It’ll be interesting to see how things go once the public health emergency is over, since all the telehealth waivers are tied to the public health emergency. I think what [we’re] seeing is tremendous interest in trying to move care toward the home and toward the community.
It’s a complicated problem, but I think the short answer would be, I would really like to find a way to reduce social isolation experienced by many older adults. It’s tied to many problems and it’s a common problem. As the economy has changed over the last 50 or 100 years and families have become dispersed, it’s just gotten more and more problematic. The community ties are different now than they were 30 or 50 years ago. If social isolation were something that could be solved, that would be a tremendous thing. It’s outside of payment. It’s outside of service delivery, but it is a huge issue.
The patient and patient family in collaboration with the patient’s primary care provider [should be responsible]. If that transition involves skilled home health care, then obviously the skilled home health care agency should be involved in that. That’s a very, very challenging thing. Actually one of my mentees has done a lot of research in that area, and it is very complicated with all sorts of challenges in terms of ambiguity and who’s supposed to do what and communication lapses and the like. I do think probably the patient; a hospitalist who’s handing off the patient; and the primary care physician need to be at the heart of that transition. It’s a very complicated issue. People don’t really appreciate how complex that is.
You need the primary hospital-at-home medical team and then there’s a slew of support services and the like that need to happen to make that model work. Everything from physician care, nursing care, home health aides, pharmacists involved, unique pharmacy services, skilled therapists and DME and medications. There’s a host of players to make that model work.
I may be paraphrasing here, but Milton Friedman said, “When there’s a crisis, people look for ideas that had been developed and scattered along the floor.” I think home-based care was one of those and telehealth was one of those. They were really not mainstream until the pandemic and then many of them were adopted quickly and then as the world shifts back to normal, there will probably be some regression back toward the status quo. I think innovative health systems and innovative providers and innovative entrepreneurs are going to take advantage of the new normal and try and push things forward, so it’ll be, two steps forward, a half step to a step-and-a-half back.
There will be progress. I think the biggest thing that’s come out of the pandemic is probably the attitudinal shift among patients who no longer view facility-based care as inherently safe, or inherently desirable. A lot of folks now say, “Well, why do I need to come? Why do I need to drive 10 minutes or 30 miles to come to my primary care doctor? Why don’t we just get on a phone call or get on a telemedicine call?” I think [we’re] going to see that attitudinal shift drive things. I think [we’ll] see within innovative health systems shift, and the innovative folks within the health systems start to push the envelope a bit.
Technology is a tool and it’s not the solution. I think a lot of it is still in its relatively early development. There are certainly a number of sensors that can get certain kinds of data. I think the real revolution will come when those data, through a lot of computing mechanisms and artificial intelligence that I have really very limited understanding of, are converted into dispositive data that clinicians can use to make actual decisions. And it’s not just clinicians [who can use the data], but social workers and physical therapists can also use it to understand what someone’s needs are, and how that they can intervene before something awful happens.
I think one of the more interesting innovations that [we’re] starting to see is the development of non-wearable sensors that are of high quality that can get physiologic data that could be useful — whether that’s heart rate, or someone’s had a fall or someone’s going to have a fall. Everyone is pitching that, but I have not seen great technology around the prediction of [a] fall; that’s really pretty darn hard. I think the non-wearable high-quality embedded sensor that can get to certain decision points is where things need to go. But it’s not easy. If it were easy, it would have been done already.
I think the most exciting thing is [we’re] just starting to see the entry of lots of smart, innovative people — both legacy and entrepreneurs — in the space. When capital starts to enter a space, it means that there is potential for development. If you’re going to do something at scale and really implement it on a citywide, regional or national basis, you need that kind of firepower behind you. Take the [recent announcement about the] coalition that included Amazon. The fact that Amazon’s getting involved in this … that’s interesting, that’s cool. The fact that you have companies at national scale that are getting interested in the space, I think is really a great indicator.
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