Eldercare Voices: Whatever It Takes - Building a Healthcare System like

Steven M. Stein, MD

Fragmented care delivered by fragmented providers with fragmented documentation during fragmented hours in fragmented settings through fragmented funding has not provided person-centered care. “Whatever It Takes” is an attempt we are undertaking in Michigan to change that narrative in an incremental way for that person or family member who is concerned that they are experiencing an emergency.

The “Whatever It Takes” program brings together Trinity Health At Home, St. Joseph Mercy Hospital – Ann Arbor (SJMH-AA), Integrated Health Associates (IHA) and Huron Valley Physician Association (HVPA) physician groups, Emergency Physicians Medical Group, Huron Valley Ambulance (HVA), and some key community agencies such as the Area Agency on Aging 1B to consistently assess situations considered by a patient (or a family member or formal caregiver) receiving skilled home care services to be urgent and then deliver an immediate response in the manner that is the most appropriate and cost-effective for each situation. “Whatever It Takes” accepts the fact that patients and families often reach out in different ways when they have concerns. They may call their physician's office. They may call their home care agency. Those with a personal care response system may press their pendant button. The home care agency might identify an urgent situation through remote monitoring (e.g., major gain in weight in someone with a history of heart failure who also documents that they are feeling more short of breath).  The person or family member may call 911. 

The program rests on four major pillars:

The first pillar is establishing a minimum common data set (MCDS) that gives providers immediate access to some key information that is always on hand when a patient believes he or she is experiencing a medical emergency and calls for help. The provider will know certain elements of that person's history: contact information for the patient’s physician, physician practice case manager, and “in case of emergency" person; chronic conditions, allergies, history of recent hospitalizations; some key social determinants of health (e.g., transportation issues, living alone, history of elder abuse, etc.); Durable Power of Attorney for health care/advance care plan/DNR status; and any risk stratification categorization (i.e., high, medium, low risk) that has been previously done on the patient. We call the MCDS the "Cheers" Form – as it is one incremental step toward building a health care system like Cheers – where everyone knows your name.

The second pillar is that when there is an initial reach out by the patient, the home care or physician office triage nurse assesses the situation by utilizing physician-approved telephone triage protocols. If the situation is not an emergency that requires an immediate in-person assessment, the patient is reassured and coached on an approach to symptomatic relief. A follow-up visit with their doctor is arranged, if needed. In a true emergent or urgent situation, the triage nurse dispatches a community paramedic or home care nurse who immediately drives to the home and assesses the patient; the patient and paramedic or nurse video-conferences with the physician (either the primary care physician or covering provider or an emergency room physician), obtains orders for stat diagnostics (e.g., labs, oximetry, EKG, etc.) that are done right there in the home and then treats the patient under the telehealth supervision of the physician. If the treatment (e.g., IV dose of Lasix for heart failure, nebulizer treatment for asthma, first dose of IV antibiotics for a pneumonia, etc.) is effective and thus does not require an immediate transfer to the ER, a follow-up appointment with the relevant physician will be arranged for the same day or next day by the home care agency. Other times, the in-home treatment may be unsuccessful and the physician will make the decision to have the community paramedic bring the patient to the physician's office, an urgent care center or, when required, to the ER. Of course, if the situation requires a transfer to the ER right away, the transport would occur in the usual way via an advanced life support ambulance.

The third pillar will ensure that each clinical incident is well-documented and that the information related to both the assessment and treatment of the patient is sent to the primary care physician immediately. The primary care physician is thus able to use this information for assessment of the patient during the next office visit, which may very well be the same day. For example, the documentation of an event that happened at 2 a.m. will be in the hands of the physician should the patient come into their office for a same day appointment at 11 a.m.

The fourth pillar is "see something, do something."  If we identify any other needs (e.g., a need for meals on wheels, a more thorough home safety evaluation or a follow up mental health visit, etc.), the home care agency or area agency on aging will ensure that the patient is connected to the relevant community resource and that those needs are subsequently addressed by that agency.

Initially, the program serves only Medicare FFS home care patients who are enrolled in St. Joseph Mercy Home Care and Hospice in Washtenaw County (Ann Arbor/Ypsilanti/Chelsea). The two-year goal is to serve all patients in the Medicare Shared Savings Program and CPC+ practices affiliated with SJMH-AA. That will take us from serving many hundreds of patients to serving many thousands of patients. The majority of the funding received from Trinity Health, the Michigan Health Endowment Fund and Huron Valley Ambulance will be used to pay for care that is presently uncompensated (e.g., paramedic services that do not result in a transfer of the patient to the ER, physician telehealth services, fixing a broken ramp, etc.) 

Going forward, it is our expectation that beneficial outcomes in this approach will drive different payers to request entry for their members. This would not only include traditional payers such as health plans, ACOs, Bundled Payments for Care Improvements (BPCI) Model 2 hospitals, government payers (such as Medicaid and the VA) but also monthly or yearly subscription fees from retirement communities, nursing homes and even individuals. We even expect that progressive physician offices may choose to have the “Whatever It Takes” team serve as an after-hours answering service as value-based purchasing requires a different kind of response than "If you believe that you have an emergency, go to the ER or call 911."

Yes, the “Whatever It Takes” group of providers is committed to doing Whatever It Takes and building a health care system like "Cheers" – where everyone knows your name.

Dr. Steven M. Stein is the Chief Medical Officer for Trinity Health Continuing Care. He has oversight for Trinity Health's home care agencies, hospices, nursing homes, PACE organizations and senior housing complexes. Dr. Stein received his Bachelors in Computer Science at Columbia, his medical degree at Cornell and did his residency at Montefiore Medical Center. He did his geriatrics fellowship at Harvard where he also received a Masters in Health Services Administration at the School of Public Health and subsequently served on the faculty of the Medical School as a member of the Division on Aging. His career has placed him in leadership positions in both managed care and on the provider side – consistently advocating for our most vulnerable citizens receiving high quality, cost-effective health care that is targeted to what matters most to the specific individual served.