April 15, 2024 • 36 mins
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.
Episode Resources:
If you liked this episode and want to learn more about all things home-based care, you can explore all our episodes at alayacare.com/homehealth360.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Guy Tommasi (00:00):
One of the biggest concerns with this program, jeff
, is that this waiver issupposed to expire at the end of
December of this year.
Well, just yesterday, some ofthe healthcare heavyweights, the
American Medical Association,the American Telemedicine
Association, they joined withsome of the big health systems
(00:21):
sending a letter to Congresssaying 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 costsavings.
One of the biggest things todayis about whole person care,
patient-centered care.
We hear that a lot.
Where does a patient want torecuperate, want to get better?
(00:45):
It's in the home.
Jeff Howell (00:56):
Welcome to the Home Health 360 podcast, where we
speak with leaders in home careand home health from across the
globe.
Guy Tomasi brings more thanfour decades of on the ground
expertise in private dutynon-medical home care.
As part of the CorcoranConsulting Group, Guy has served
for 13 years as managingdirector of Connecticut-based
(01:16):
Lifetime Care at Home and underhis leadership, Lifetime Care at
Home was one of the firstnon-medical care agencies in the
country to incorporate theCenters for Medicare and
Medicaid Services quadruple aim,value-based care pillars and in
this coordinated care modelthey were an early adopter as a
(01:38):
non-medical provider within ahospital at home model
administered by Yale HealthSystem and managed by Medically
Home.
So I'm really looking forwardto diving deep today on the
non-medical piece of how all ofthat works within this episode.
Guy, thank you for joining ustoday.
Guy Tommasi (01:58):
Hi, jeff, thank you for inviting me on today.
I'm looking forward to thisdiscussion.
What did I miss from yourbackground?
Actually, you pretty muchnailed it.
You covered four decades in 30seconds, which was great, but it
really did.
You took it and reallyencapsulated it really well.
(02:19):
And I am one who really enjoysbeing innovative, using
technology, using data to reallysupport what we do, and I've
been able to do that and had thegood fortune, even when I
started my career, in a hospitalenvironment where I've had
opportunities to work within thecommunity and bring care where
(02:45):
people want it in the home, andI've really had that fortune of
doing that throughout my careerand actually the last 25 years
in the non-medical space and 13specifically with my recent
provider status.
You covered it and I'm excitedabout sharing that understanding
(03:05):
and expertise, especially inthe hospital at home environment
.
Jeff Howell (03:10):
So it's exciting, yeah the big thing that jumped
off the page to me was thathospital at home really exploded
or was really revived from theurgency to take people out of
overloaded hospitals duringCOVID.
And I think a lot of peopledon't have much of an
understanding around hospital athome to begin with.
(03:32):
But in particular, how does thepersonal care, non-medical care
side of things fit in?
So what's your take on theexisting landscape of hospital
at home and how does thenon-medical piece fit in?
Guy Tommasi (03:44):
Sure, the whole concept, jeff, isn't new.
It's been around for a while.
It actually started back in the1970s in the United Kingdom
where they were doing trials.
They were doing differentmodels of hospital at home.
Johns Hopkins School ofMedicine and Public Health
(04:06):
developed the hospital at homecare here in the United States,
so the history of it isn't brandnew.
What really kicked it off wasCOVID and it was CMS the Centers
for Medicare and Medicaid'sanswer to and in response to the
(04:29):
hospital acute patients butthose who may not have needed
(04:49):
that level of care.
What CMS did was that theygranted this waiver called the
Acute Hospital Care at HomeWaiver, and what it essentially
did was, in the conditions ofparticipation, there's a
specific regulation thatrequires 24-hour on-site nursing
(05:12):
care.
That essentially got waived andthey said you know what, let's
begin to set these programs up,we will institute this waiver
and we will reimburse thoseprograms at the DRG rate.
(05:33):
So it really started toestablish programs that
hospitals began to look at.
Hospitals began to look atthird party like a medically at
home or a dispatch.
Health began to incorporate and, as a result, we really in an
(06:09):
interdisciplinary team and withan interdisciplinary team that's
very unique for the non-medicalspace.
Typically it's the caregiver bythemselves in the home taking
care of the patient with thoseactivities of daily living.
Taking care of the patient withthose activities of daily
living.
This allowed the opportunity toreally work side-by-side with
(06:32):
other healthcare professionalsphysicians, nurses, therapists.
Mobile technology with remotemonitoring using a tablet to
sign in and to log in the tasks.
This was really an opportunityfor the non-medical space to
really step up Because, when welook at what they're looking to
(07:00):
do is really to provide thoseactivities of daily living, the
personal care to ensure thatclient, that patient, was
receiving that level of care ona 24-hour basis that didn't
necessarily need a medicalintervention.
In our case, when we wereallowed to participate, this
really elevated our caregiversand brought recognition to them
(07:25):
that they never really had fromthe broad scope of a health care
hospital environment.
So it really did open up doorsfor the non-medical.
And again, every program isdifferent.
Right now, jeff, actually, asof the first of this month,
(07:47):
there's over 315 hospitals in 37states that have been approved
for this waiver and each oneruns, you know, independent of
each other.
They all have their differentrequirements based on who's
managing it and, just as acontrast, before the waiver
there was only 20 programs.
(08:08):
Today we've got 315 programs.
That in itself, I think, is astatement that this is a program
that provides good outcomes,that provides the care at a much
lower cost in an environmentwhere a patient thrives the most
(08:33):
in the home.
Jeff Howell (08:35):
That was going to be.
My next question is what doesthe data tell us about how
effective these programs are atreducing costs?
Guy Tommasi (08:41):
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 atdata.
There's still a lot of datathat is surfacing Medical
Association.
(09:01):
They've all shown that theoutcomes have been positive
without any adverse effects.
Now you're going to getchallenged, I think.
The reality is there's thosewho will provide studies and
data to support why this shouldcontinue and there's those that
(09:24):
I'm sure are going to havepushback for that reason that
they are not comfortable yetwith the program.
They feel it hasn't been aroundlong enough, but there is
enough coming out that certainlysupports this program to stay
the way it is.
I was reading just yesterdayone of the biggest concerns with
(09:45):
this program, jeff, is thatthis waiver is supposed to
expire at the end of December ofthis year.
Jeff Howell (09:53):
Which would affect all 315 hospitals.
Guy Tommasi (09:56):
Correct that waiver Association, the American
Telemedicine Association.
They joined with some of thebig health systems sending a
letter to Congress saying canyou at least extend this by five
(10:17):
years?
Can you put a five-yearextension on this?
Because the systems, I think,are really starting to see the
value that this brings, the costsavings and it's addressing.
One of the biggest things todayis about whole person care,
patient-centered care.
We hear that a lot.
(10:38):
Where is the best place?
That takes place?
In the home.
Where does a patient want torecuperate, want to get better?
It's in the home.
Unfortunately it's not in brickand mortar anymore.
That's for the most acute Rightnow.
(11:02):
The home environment is wherepeople want to be and, for good
or for bad, that's where COVIDcame in.
Covid really opened the eyes ofthe rest of the healthcare
system.
It opened the eyes of thepayers that the home is where
people want to be, where theyrecuperate the best.
Jeff Howell (11:22):
And Guy to that end .
Do we have evidence thatthere's a higher level of
patient and family satisfaction?
Guy Tommasi (11:29):
Yes, yes, again, there are studies that come out
to show that there is a highlevel of satisfaction.
And you know, what we tend toforget sometimes, jeff, is the
emotional stress level of goinginto a hospital.
Now, I worked in a hospital for15 years, so I'm not here to
(11:54):
say anything negatively, butthere's a stress level that
people go through when they haveto go into a hospital or
they're in a hospital room.
Family is separated, so thelevel of satisfaction.
We tend to forget that there'sa stress level, an emotional
level, that is also involved inthe overall health outcome of
(12:17):
that individual.
The other thing that theHospital at Home program offers
is Kaiser Family Foundation saidthat 80% of health outcomes are
medical.
There is a direct correlationto the social determinants of
health.
We've heard this.
There's more attention beinggiven to the social determinants
(12:39):
of health, which is nutrition,transportation, the education
environment.
The hospital at home programaffords an opportunity that
never existed before from anurse inpatient perspective.
It allows that clinician tohave his or her eyes on the
(13:02):
patient in an environment thatthey've never seen the home.
So now they could start to lookat and see what are the risks
that this patient deals withevery day the flow risks, the
nutritional risk, thetransportation obstacles, all of
(13:23):
which are non-medical but havea significant bearing on their
health, overall health outcome.
So now you've got a clinicianwho's in that home and is saying
wait a minute, I never knewthat Mrs Jones had
transportation issues which madeit difficult for her to get her
(13:45):
medications, which made itdifficult to go out and get
groceries.
Those are those socialdeterminants that have
significant implications of aperson's overall health that
when you're in a hospital theclinical side of that doesn't
really get seen.
Jeff Howell (14:05):
Yeah, I've always said the number one cause of
hospitalizations is actuallyloneliness, if you go far enough
up the stream.
Guy Tommasi (14:12):
That's true.
And again, to really drive thathome, look at COVID, look what
happened during COVID, withisolation and loneliness and
families not being able to reachout and see a family member and
the hardship that really had,which was difficult.
And again, loneliness is one ofthose we tend to not always
(14:35):
think about if you're not there.
And again, from a non-medicalperspective, 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 inthe status from morning to
(14:55):
evening because we're there andyou can report that to now a
clinical, a home health agencyfor some intervention to avoid
that hospitalization.
Jeff Howell (15:07):
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 casesthat most people's minds would
automatically default to.
Guy Tommasi (15:20):
Yeah, I think so the process, if I can share what
in our situation, a patientwould come into the emergency
department and there was aphysician there who was
dedicated and identified as thephysician for the hospital at
home program and that physicianbasically did an evaluation and
(15:40):
an assessment and made thedecision this patient can really
utilize the services at home bybasically bringing a mobile
hospital room to that patient'shome and that decision is made
(16:03):
at that time and within twohours, again using ours as an
example, within two hours thatpatient was home and a team was
already deployed nurses,physicians, monitors, ivs within
a two-hour period of time, byhaving that physician in the
(16:26):
emergency department doing theon-site assessment and
evaluation and making thatdetermination which really
allowed that patient to go backhome with all the services,
maybe without the anxiety ofbeing in a hospital, which then
(16:47):
allowed for those who needed tobe in an ICU type environment to
have access to those beds, tohave access to that staff.
Jeff Howell (16:57):
I remember seeing on 60 Minutes, I think over a
decade ago, a look at France'shealth system, and I remember
the term.
The phrase that they used atthe time was that the North
American has more of a reactive.
You get sick, you go to ahospital, you get cared for,
there, behind the curtain, allthese doctors making proactive
(17:18):
house calls.
It sounds like what you'redescribing, I think, what most
people think of hospitals big,clunky, expensive equipment.
And what you just describedsounds more like nurses and
doctors acting like an EMR fieldstaff that have their caseload,
but they're really out in thefield with mobile technology to
be able to bring the hospitalinto the home, absolutely,
(17:42):
absolutely.
Guy Tommasi (17:43):
And I was one of those who was literally in awe
of the mobile equipment that wasdispatched to someone's home.
It looked like a SWAT teamcoming into the driveway or into
that residence Very organized,but what you would typically
think of seeing in a hospitaland trying to say, geez, how
(18:04):
would this fit into someone'shome?
The reality when they showed upat the door was, wow, this is
pretty advanced technology.
And what it made me think ofwas it was a modern mobile
technology with kind of oldschool service like the house
(18:25):
call, where the doctor made thehouse call, and now you have a
team that's available 24-7 tocome in and really set up a
mobile hospital room and takecare of that patient.
And granted, like I saidearlier, there is pushback to
(18:48):
this program.
You're going to have those whoare going to continue to
question the level of care, thelevel of service, but everything
that I've read and continues tocome out all points to this
program being favorable.
The outcomes are there, thecost is there, there's a reason
why 315 hospitals have signed upfor this.
Jeff Howell (19:11):
I would imagine the length of episode of care or
patient stay is also reducedwhen you're able to recover in
the comfort of your home.
Guy Tommasi (19:20):
Exactly, and part of the requirements is this has
to be treated like it's ahospital stay.
So the average length of staythat we were involved with was
three to five days.
That was the average length ofstay had to follow a lot of the
same requirements as in thehospital.
On the non-medical side, wewere able to in many cases be
(19:44):
invited to stay on after thedischarge because families
started to see how a loved onewas being taken care of and,
even though that episode or thatacute stay came to an end and
discharged, their mom or dadstill may have needed some of
those personal care activities.
They still may have needed toget dressed in the morning and
(20:09):
food prepared, possibly, andjust personal care of their
loved one that continuedbringing them that positive,
good outcome.
I would strongly encourage toseek out these programs and
(20:29):
participate, because you maylook at it and say that's a
hospital program, that's not forus.
The opportunity for theseprograms, or I should say the
opportunity for the service tocontinue after discharge, is a
great opportunity.
That thing goes into a privatepay mode, a different type of a
(20:50):
mode, but it generates thatrevenue.
It generates awareness andrecognition.
Jeff Howell (20:57):
And right now you said everything is just under
the one acute hospital at homewaiver.
Guy Tommasi (21:03):
That's correct.
Right now CMS has thereimbursement is based on this
acute hospital care at homewaiver and again it's hoping
they extend it by a five-yearextension.
And I really do, jeff, believethat so far it's bipartisan
support and I think they seethat the reality is people are
(21:28):
recovering and are choosing tobe there.
What we have to be careful ispeople still have choices and we
want the patient and family tomake the best possible choice
for where that loved one, thatpatient, is going to recuperate,
is going to be taken care ofand the home is the place to be.
(21:52):
It's not Guy Tomasi sayingthat's the best place to be.
I think every piece ofliterature you want to read and
every survey AARP.
Almost 90% of people theysurveyed want to receive
services in their home.
I think the government isseeing that and CMS in
particular is seeing that thisis a movement where we could
(22:17):
keep the most acute in thehospital, where they should be,
and those who don't need thatlevel can be taken care of in
their home, and to allocateresources accordingly.
Unfortunately, the home healthis not a reimbursed area right
now.
That's a different topic anddifferent subject.
Jeff Howell (22:35):
But those are some of the things that still need to
be worked out as we go forwardand for the listeners who have a
loved one that needs care inthe home, I would presume the
best way to go about it, asyou're searching for a home care
provider, would be to ask themif they participate in the
(22:56):
personal care side of the acutehospital home waiver, because to
my understanding, they're goingto get a higher standard of
care.
Number one for that agency tobe handpicked by that hospital
or health system to be theirnon-medical partner.
But secondly, I would imaginethat the degree of
(23:16):
responsiveness is going to be ata higher standard and there's
going to be cases where the homehealth aid has to be deployed
within the hour or somethinglike that, as opposed to
reactive scheduling inconventional home care.
Is that right?
Guy Tommasi (23:30):
Absolutely, You're absolutely correct and if I can
share our experience, theselection, if you will, of
providers and partners is prettythorough.
There are requirements that areneeded.
They looked at our agency inparticular and they wanted to
make sure that we had a CNA orHHA level caregiver.
(23:54):
When that doctor that Imentioned earlier makes the
decision that this patient canreceive services in the home,
the physician notifies thecommand center and the command
center is then charged withassembling that team to be out
there.
Now, when they called us, wehad one hour to respond.
(24:17):
Actually, as the program wenton, it was reduced to 45 minutes
.
So that call came to our officeand we had to respond within an
hour that we would be able toservice that.
And you know, with the way thework shortages is out there
today, it's amazing how fast anhour goes by when you're trying
(24:42):
to find coverage and you knowyou're under the gun.
You could see that clockticking Because, in fairness to
the patient, the command centercan't wait forever and they have
to have a plan B and a plan C,which they did.
We were not the onlynon-medical provider.
They had to have two and theyhad to have three.
In the event, we couldn't dothat, couldn't meet the need.
(25:06):
So what I would say to thosehome care agencies, the
non-medical once you find aprogram in your respective area,
reach out, be part of it, havea plan in place.
We've learned how to build thisprogram.
Every day was a learningexperience because it was brand
(25:28):
new.
If I had to start it all overagain, I know exactly the plan I
would want to put in placebecause I've gone through that
experience.
So I would encourage thenon-medical listeners out there
do not be afraid of this program.
You will be doing exactly whatyou've been doing every day.
(25:50):
You'll be providing theactivities of daily living.
Be proactive, Educate thehospital, the managing team, on
the services that you can bringto the table.
The opportunity is there.
You got to do some looking andyou got to do some finding.
(26:10):
But and I'll go one stepfurther, Jeff, from a
recruitment standpoint, you knowwe're all struggling.
How can we attract the best,the brightest?
How can we get them all on ourteam?
Track the best, the brightest.
How can we get them all on ourteam?
This program became a greatrecruiting tool.
We were able to say be part ofa multidisciplinary team, Work
(26:32):
alongside physicians, nurses,while still doing non-medical
care.
When you look at what motivatesour caregivers, when you look
at what motivates our caregiverspay isn't always the driver.
It's the opportunity to betrained in new things and in
really being professional.
Yeah, sure, being part ofsomething, yeah, being part of
(26:53):
something bigger, that's whatthey like and that's when you
become that employer of choice.
Jeff Howell (27:00):
I love that, especially since the best
caregivers they're in it,because this is a calling, so
for them to be part of amulti-disciplined care team,
that is super exciting.
We are just up against our timehere, guy, so I'll get you out
of here.
On this last question how doyou see hospital at home
evolving over the next fiveyears?
Guy Tommasi (27:20):
Within five years, especially if that waiver gets
extended.
The payers are going to jump onthis bandwagon because it's a
cost-effective way to bringpositive outcomes.
So the payers, who right now arestill I want to know a little
bit more are going to jump onthis.
(27:42):
I see this as the next care inthe 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 andas we've learned from this,
(28:03):
programs are going to gettweaked, they're going to get
refined so that it's going to bea 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, thedeterminations will be that this
patient can certainly have thislevel of care in the home.
(28:25):
So this is the future it reallyis.
And I think when like mindswork together and keeping the
patient at the center of this,then like minds should not be
disagreeing and I think oncethey see the feedback, if they
look at the satisfactionfeedback, that in itself is
(28:48):
going to be a driver, becausethat's where people want to
recuperate, want to be takencare of, want to stay.
Jeff Howell (28:56):
All signs are pointing in that direction.
It is something that reducescosts, improves outcomes and
improves the satisfaction of thepatients and families.
Let's hope that the letter toCongress gets approved and
there's enough data from the 315hospitals for Congress to
extend the acute hospital athome waiver.
(29:19):
My favorite line that you'vedelivered, guy, is when you
talked about a modern standardof care that is at a bespoke
level, but it's also deliveredin the comforts of the home.
So that is what gets me excitedabout the future of not just
care in the home, but hospitalin the home.
And I did leave out one thingyou are also a nationally
(29:40):
recognized speaker with enoughhumility to not mention it.
So Guy has actually givenpresentations 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 thebest lines from my guests to
make myself appear smarter.
So thank you again for being ontoday.
Guy Tommasi (30:00):
Jeff, it's been my privilege to be here and to be
able to share this and feel freeto take all the information and
continue to use it wisely andto promote what we want to
promote and carry in the home.
Erin Vallier (30:14):
Hey listeners.
This is your host, Erin, with avery important podcast
announcement.
Jeff Howell, my fellow hostthat you know and love, is
moving on to another excitingseason in his career, so this is
a really bittersweet moment forme.
I have really enjoyed workingwith Jeff over the years.
(30:38):
It's sweet because I get tointerview him for once, but
bitter because it's his last fewmoments on the podcast.
Jeff you're going to make mecry.
Oh, so I'm really curious, Jeffare there any standout moments
from recording the podcast overthe years?
Jeff Howell (30:58):
Some days it feels like forever.
Some days it feels like forever, aaron.
Back in 2017, I had brought upthe idea internally, like let's
do a podcast, and the head ofthe department said, hey, just
so you know, no one has ever puthome care and podcast in the
same sentence before, and we hadother priorities.
And we put it on the shelf atthe time, as we should have at
(31:20):
that time, and it kept circlingback, and the reason why we
ended up bringing it back was acouple of things is that we did
want to raise awareness of thesliver of health care that we
call home care and home health,and we wanted to be a part of
that conversation, and it'sreally the only truly passive
(31:40):
medium where you can listen toyour favorite podcast on a walk
or washing dishes or in the car.
And a couple of the reallystandout things about the impact
of the podcast that we've hadand you will continue to have is
that Kevin Mystery would tellme hey, I'm going on a road trip
.
I've listened to every episode.
Can you just send me a few ofthe really good ones that you
(32:01):
really remember?
And this is how I keep inspiredin our industry, and we hired
someone named Jessica Lindsaywho in the interview process
said, hey, I've listened toevery episode and she had
soundbites to use and it's beenrewarding.
I'm sure, as you have felt thepeople that have circled back
and said that this podcast and Itake no credit for this it's
(32:24):
all about making sure that ourguests try to speak 90% of the
time, and there's so much.
I wouldn't single out any onething except that my biggest
takeaway from it is that it'struly been an honor and a
privilege to meet the biggestdifference makers in the
industry and to learn from themand each episode most of the
(32:45):
episodes.
It almost probably sounds likea cliche that I've written so
many pages of notes.
I can't tell you how much I'velearned in the industry by
having the good fortune ofsitting in the seat so that I
get to chat with some of thebrightest minds in the space.
I do want to give a shout outsome of the brightest minds in
the space.
I do want to give a shout ourproducer Ryan, who does a lot of
(33:06):
the hard work behind the scenesand is an invisible face here
on the podcast, just like Kati,who does our road mapping, and
Monika that runs our socialchannels.
And then you, Erin, of course.
In the last five plus yearsthat we've known each other, I
don't think that you're actuallycapable of having a bad day.
You are always in this constantstate of Zen, and I know that
(33:30):
you, with your relationships inthe business, you've landed some
of the biggest names that havecome on as guests, and I can't
think of a better person to takeover full-time responsibility
of being the host on the pod andbringing this podcast to the
next level, and I'm going tolook forward to listening to the
episodes and they'll come as acomplete surprise to me and not
(33:52):
being involved in the planning.
Erin Vallier (33:54):
It means a whole lot, jeff, coming from you.
So I have always admired youand respect the talent that you
have and the creativity that youhave.
You are really going to bemissed.
And I have a final question foryou, and I think it's just only
fair, since you ask all of yourguests this question, so I got
(34:16):
to toss it back to you.
Give us a reason to beoptimistic about the care
provided in the place wherepatients call home.
Jeff Howell (34:25):
What a fitting last question.
Well, the easy answer is thetheme that I've picked up on
from all of the guests is thatit makes both more financial
sense to deliver care in thehome versus in buildings, and
that it makes more sense from ahumanitarian standpoint, given
that this is where 99% of people, where they want to age in
(34:47):
place, is in the place wherethey've created all their
memories.
And from a technologystandpoint, there are
innovations every day that arehelping us all make this closer
to reality and the new normal.
With that combination of thesethree things, I think it's going
to be an unstoppable force thatcare will become the new normal
(35:08):
.
But what makes me even moreoptimistic is the unstoppable
force of guests that we've hadon this show and the colleagues
that I've been able to work with.
The talent, the grit, thepassion, the purpose and the
mission I've seen from all thepeople that I've met in the
industry has been both humblingand inspiring.
(35:29):
So in a final sign-off, I dowant to acknowledge and thank
you all and keep up the noblework.
Home Health 360 is presented byAlayaCare and hosted by Jeff
Howell and Erin Vallier.
First, we want to thank ouramazing guests and listeners.
Second, our episodes air twicea month, so be sure to subscribe
today so you don't miss anepisode.
Erin Vallier (35:53):
And last but not least, if you liked this episode
and want to learn more aboutall things home-based care, you
can explore all of our episodesat alayacare.
com/ homehealth360 or visit uson your favorite podcast
platform.
One of the biggest concerns with this program, jeff
, is that this waiver issupposed to expire at the end of
December of this year.
Well, just yesterday, some ofthe healthcare heavyweights, the
American Medical Association,the American Telemedicine
Association, they joined withsome of the big health systems
(00:21):
sending a letter to Congresssaying 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 costsavings.
One of the biggest things todayis about whole person care,
patient-centered care.
We hear that a lot.
Where does a patient want torecuperate, want to get better?
(00:45):
It's in the home.
Jeff Howell (00:56):
Welcome to the Home Health 360 podcast, where we
speak with leaders in home careand home health from across the
globe.
Guy Tomasi brings more thanfour decades of on the ground
expertise in private dutynon-medical home care.
As part of the CorcoranConsulting Group, Guy has served
for 13 years as managingdirector of Connecticut-based
(01:16):
Lifetime Care at Home and underhis leadership, Lifetime Care at
Home was one of the firstnon-medical care agencies in the
country to incorporate theCenters for Medicare and
Medicaid Services quadruple aim,value-based care pillars and in
this coordinated care modelthey were an early adopter as a
(01:38):
non-medical provider within ahospital at home model
administered by Yale HealthSystem and managed by Medically
Home.
So I'm really looking forwardto diving deep today on the
non-medical piece of how all ofthat works within this episode.
Guy, thank you for joining ustoday.
Guy Tommasi (01:58):
Hi, jeff, thank you for inviting me on today.
I'm looking forward to thisdiscussion.
What did I miss from yourbackground?
Actually, you pretty muchnailed it.
You covered four decades in 30seconds, which was great, but it
really did.
You took it and reallyencapsulated it really well.
(02:19):
And I am one who really enjoysbeing innovative, using
technology, using data to reallysupport what we do, and I've
been able to do that and had thegood fortune, even when I
started my career, in a hospitalenvironment where I've had
opportunities to work within thecommunity and bring care where
(02:45):
people want it in the home, andI've really had that fortune of
doing that throughout my careerand actually the last 25 years
in the non-medical space and 13specifically with my recent
provider status.
You covered it and I'm excitedabout sharing that understanding
(03:05):
and expertise, especially inthe hospital at home environment
.
Jeff Howell (03:10):
So it's exciting, yeah the big thing that jumped
off the page to me was thathospital at home really exploded
or was really revived from theurgency to take people out of
overloaded hospitals duringCOVID.
And I think a lot of peopledon't have much of an
understanding around hospital athome to begin with.
(03:32):
But in particular, how does thepersonal care, non-medical care
side of things fit in?
So what's your take on theexisting landscape of hospital
at home and how does thenon-medical piece fit in?
Guy Tommasi (03:44):
Sure, the whole concept, jeff, isn't new.
It's been around for a while.
It actually started back in the1970s in the United Kingdom
where they were doing trials.
They were doing differentmodels of hospital at home.
Johns Hopkins School ofMedicine and Public Health
(04:06):
developed the hospital at homecare here in the United States,
so the history of it isn't brandnew.
What really kicked it off wasCOVID and it was CMS the Centers
for Medicare and Medicaid'sanswer to and in response to the
(04:29):
hospital acute patients butthose who may not have needed
(04:49):
that level of care.
What CMS did was that theygranted this waiver called the
Acute Hospital Care at HomeWaiver, and what it essentially
did was, in the conditions ofparticipation, there's a
specific regulation thatrequires 24-hour on-site nursing
(05:12):
care.
That essentially got waived andthey said you know what, let's
begin to set these programs up,we will institute this waiver
and we will reimburse thoseprograms at the DRG rate.
(05:33):
So it really started toestablish programs that
hospitals began to look at.
Hospitals began to look atthird party like a medically at
home or a dispatch.
Health began to incorporate and, as a result, we really in an
(06:09):
interdisciplinary team and withan interdisciplinary team that's
very unique for the non-medicalspace.
Typically it's the caregiver bythemselves in the home taking
care of the patient with thoseactivities of daily living.
Taking care of the patient withthose activities of daily
living.
This allowed the opportunity toreally work side-by-side with
(06:32):
other healthcare professionalsphysicians, nurses, therapists.
Mobile technology with remotemonitoring using a tablet to
sign in and to log in the tasks.
This was really an opportunityfor the non-medical space to
really step up Because, when welook at what they're looking to
(07:00):
do is really to provide thoseactivities of daily living, the
personal care to ensure thatclient, that patient, was
receiving that level of care ona 24-hour basis that didn't
necessarily need a medicalintervention.
In our case, when we wereallowed to participate, this
really elevated our caregiversand brought recognition to them
(07:25):
that they never really had fromthe broad scope of a health care
hospital environment.
So it really did open up doorsfor the non-medical.
And again, every program isdifferent.
Right now, jeff, actually, asof the first of this month,
(07:47):
there's over 315 hospitals in 37states that have been approved
for this waiver and each oneruns, you know, independent of
each other.
They all have their differentrequirements based on who's
managing it and, just as acontrast, before the waiver
there was only 20 programs.
(08:08):
Today we've got 315 programs.
That in itself, I think, is astatement that this is a program
that provides good outcomes,that provides the care at a much
lower cost in an environmentwhere a patient thrives the most
(08:33):
in the home.
Jeff Howell (08:35):
That was going to be.
My next question is what doesthe data tell us about how
effective these programs are atreducing costs?
Guy Tommasi (08:41):
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 atdata.
There's still a lot of datathat is surfacing Medical
Association.
(09:01):
They've all shown that theoutcomes have been positive
without any adverse effects.
Now you're going to getchallenged, I think.
The reality is there's thosewho will provide studies and
data to support why this shouldcontinue and there's those that
(09:24):
I'm sure are going to havepushback for that reason that
they are not comfortable yetwith the program.
They feel it hasn't been aroundlong enough, but there is
enough coming out that certainlysupports this program to stay
the way it is.
I was reading just yesterdayone of the biggest concerns with
(09:45):
this program, jeff, is thatthis waiver is supposed to
expire at the end of December ofthis year.
Jeff Howell (09:53):
Which would affect all 315 hospitals.
Guy Tommasi (09:56):
Correct that waiver Association, the American
Telemedicine Association.
They joined with some of thebig health systems sending a
letter to Congress saying canyou at least extend this by five
(10:17):
years?
Can you put a five-yearextension on this?
Because the systems, I think,are really starting to see the
value that this brings, the costsavings and it's addressing.
One of the biggest things todayis about whole person care,
patient-centered care.
We hear that a lot.
(10:38):
Where is the best place?
That takes place?
In the home.
Where does a patient want torecuperate, want to get better?
It's in the home.
Unfortunately it's not in brickand mortar anymore.
That's for the most acute Rightnow.
(11:02):
The home environment is wherepeople want to be and, for good
or for bad, that's where COVIDcame in.
Covid really opened the eyes ofthe rest of the healthcare
system.
It opened the eyes of thepayers that the home is where
people want to be, where theyrecuperate the best.
Jeff Howell (11:22):
And Guy to that end .
Do we have evidence thatthere's a higher level of
patient and family satisfaction?
Guy Tommasi (11:29):
Yes, yes, again, there are studies that come out
to show that there is a highlevel of satisfaction.
And you know, what we tend toforget sometimes, jeff, is the
emotional stress level of goinginto a hospital.
Now, I worked in a hospital for15 years, so I'm not here to
(11:54):
say anything negatively, butthere's a stress level that
people go through when they haveto go into a hospital or
they're in a hospital room.
Family is separated, so thelevel of satisfaction.
We tend to forget that there'sa stress level, an emotional
level, that is also involved inthe overall health outcome of
(12:17):
that individual.
The other thing that theHospital at Home program offers
is Kaiser Family Foundation saidthat 80% of health outcomes are
medical.
There is a direct correlationto the social determinants of
health.
We've heard this.
There's more attention beinggiven to the social determinants
(12:39):
of health, which is nutrition,transportation, the education
environment.
The hospital at home programaffords an opportunity that
never existed before from anurse inpatient perspective.
It allows that clinician tohave his or her eyes on the
(13:02):
patient in an environment thatthey've never seen the home.
So now they could start to lookat and see what are the risks
that this patient deals withevery day the flow risks, the
nutritional risk, thetransportation obstacles, all of
(13:23):
which are non-medical but havea significant bearing on their
health, overall health outcome.
So now you've got a clinicianwho's in that home and is saying
wait a minute, I never knewthat Mrs Jones had
transportation issues which madeit difficult for her to get her
(13:45):
medications, which made itdifficult to go out and get
groceries.
Those are those socialdeterminants that have
significant implications of aperson's overall health that
when you're in a hospital theclinical side of that doesn't
really get seen.
Jeff Howell (14:05):
Yeah, I've always said the number one cause of
hospitalizations is actuallyloneliness, if you go far enough
up the stream.
Guy Tommasi (14:12):
That's true.
And again, to really drive thathome, look at COVID, look what
happened during COVID, withisolation and loneliness and
families not being able to reachout and see a family member and
the hardship that really had,which was difficult.
And again, loneliness is one ofthose we tend to not always
(14:35):
think about if you're not there.
And again, from a non-medicalperspective, 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 inthe status from morning to
(14:55):
evening because we're there andyou can report that to now a
clinical, a home health agencyfor some intervention to avoid
that hospitalization.
Jeff Howell (15:07):
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 casesthat most people's minds would
automatically default to.
Guy Tommasi (15:20):
Yeah, I think so the process, if I can share what
in our situation, a patientwould come into the emergency
department and there was aphysician there who was
dedicated and identified as thephysician for the hospital at
home program and that physicianbasically did an evaluation and
(15:40):
an assessment and made thedecision this patient can really
utilize the services at home bybasically bringing a mobile
hospital room to that patient'shome and that decision is made
(16:03):
at that time and within twohours, again using ours as an
example, within two hours thatpatient was home and a team was
already deployed nurses,physicians, monitors, ivs within
a two-hour period of time, byhaving that physician in the
(16:26):
emergency department doing theon-site assessment and
evaluation and making thatdetermination which really
allowed that patient to go backhome with all the services,
maybe without the anxiety ofbeing in a hospital, which then
(16:47):
allowed for those who needed tobe in an ICU type environment to
have access to those beds, tohave access to that staff.
Jeff Howell (16:57):
I remember seeing on 60 Minutes, I think over a
decade ago, a look at France'shealth system, and I remember
the term.
The phrase that they used atthe time was that the North
American has more of a reactive.
You get sick, you go to ahospital, you get cared for,
there, behind the curtain, allthese doctors making proactive
(17:18):
house calls.
It sounds like what you'redescribing, I think, what most
people think of hospitals big,clunky, expensive equipment.
And what you just describedsounds more like nurses and
doctors acting like an EMR fieldstaff that have their caseload,
but they're really out in thefield with mobile technology to
be able to bring the hospitalinto the home, absolutely,
(17:42):
absolutely.
Guy Tommasi (17:43):
And I was one of those who was literally in awe
of the mobile equipment that wasdispatched to someone's home.
It looked like a SWAT teamcoming into the driveway or into
that residence Very organized,but what you would typically
think of seeing in a hospitaland trying to say, geez, how
(18:04):
would this fit into someone'shome?
The reality when they showed upat the door was, wow, this is
pretty advanced technology.
And what it made me think ofwas it was a modern mobile
technology with kind of oldschool service like the house
(18:25):
call, where the doctor made thehouse call, and now you have a
team that's available 24-7 tocome in and really set up a
mobile hospital room and takecare of that patient.
And granted, like I saidearlier, there is pushback to
(18:48):
this program.
You're going to have those whoare going to continue to
question the level of care, thelevel of service, but everything
that I've read and continues tocome out all points to this
program being favorable.
The outcomes are there, thecost is there, there's a reason
why 315 hospitals have signed upfor this.
Jeff Howell (19:11):
I would imagine the length of episode of care or
patient stay is also reducedwhen you're able to recover in
the comfort of your home.
Guy Tommasi (19:20):
Exactly, and part of the requirements is this has
to be treated like it's ahospital stay.
So the average length of staythat we were involved with was
three to five days.
That was the average length ofstay had to follow a lot of the
same requirements as in thehospital.
On the non-medical side, wewere able to in many cases be
(19:44):
invited to stay on after thedischarge because families
started to see how a loved onewas being taken care of and,
even though that episode or thatacute stay came to an end and
discharged, their mom or dadstill may have needed some of
those personal care activities.
They still may have needed toget dressed in the morning and
(20:09):
food prepared, possibly, andjust personal care of their
loved one that continuedbringing them that positive,
good outcome.
I would strongly encourage toseek out these programs and
(20:29):
participate, because you maylook at it and say that's a
hospital program, that's not forus.
The opportunity for theseprograms, or I should say the
opportunity for the service tocontinue after discharge, is a
great opportunity.
That thing goes into a privatepay mode, a different type of a
(20:50):
mode, but it generates thatrevenue.
It generates awareness andrecognition.
Jeff Howell (20:57):
And right now you said everything is just under
the one acute hospital at homewaiver.
Guy Tommasi (21:03):
That's correct.
Right now CMS has thereimbursement is based on this
acute hospital care at homewaiver and again it's hoping
they extend it by a five-yearextension.
And I really do, jeff, believethat so far it's bipartisan
support and I think they seethat the reality is people are
(21:28):
recovering and are choosing tobe there.
What we have to be careful ispeople still have choices and we
want the patient and family tomake the best possible choice
for where that loved one, thatpatient, is going to recuperate,
is going to be taken care ofand the home is the place to be.
(21:52):
It's not Guy Tomasi sayingthat's the best place to be.
I think every piece ofliterature you want to read and
every survey AARP.
Almost 90% of people theysurveyed want to receive
services in their home.
I think the government isseeing that and CMS in
particular is seeing that thisis a movement where we could
(22:17):
keep the most acute in thehospital, where they should be,
and those who don't need thatlevel can be taken care of in
their home, and to allocateresources accordingly.
Unfortunately, the home healthis not a reimbursed area right
now.
That's a different topic anddifferent subject.
Jeff Howell (22:35):
But those are some of the things that still need to
be worked out as we go forwardand for the listeners who have a
loved one that needs care inthe home, I would presume the
best way to go about it, asyou're searching for a home care
provider, would be to ask themif they participate in the
(22:56):
personal care side of the acutehospital home waiver, because to
my understanding, they're goingto get a higher standard of
care.
Number one for that agency tobe handpicked by that hospital
or health system to be theirnon-medical partner.
But secondly, I would imaginethat the degree of
(23:16):
responsiveness is going to be ata higher standard and there's
going to be cases where the homehealth aid has to be deployed
within the hour or somethinglike that, as opposed to
reactive scheduling inconventional home care.
Is that right?
Guy Tommasi (23:30):
Absolutely, You're absolutely correct and if I can
share our experience, theselection, if you will, of
providers and partners is prettythorough.
There are requirements that areneeded.
They looked at our agency inparticular and they wanted to
make sure that we had a CNA orHHA level caregiver.
(23:54):
When that doctor that Imentioned earlier makes the
decision that this patient canreceive services in the home,
the physician notifies thecommand center and the command
center is then charged withassembling that team to be out
there.
Now, when they called us, wehad one hour to respond.
(24:17):
Actually, as the program wenton, it was reduced to 45 minutes
.
So that call came to our officeand we had to respond within an
hour that we would be able toservice that.
And you know, with the way thework shortages is out there
today, it's amazing how fast anhour goes by when you're trying
(24:42):
to find coverage and you knowyou're under the gun.
You could see that clockticking Because, in fairness to
the patient, the command centercan't wait forever and they have
to have a plan B and a plan C,which they did.
We were not the onlynon-medical provider.
They had to have two and theyhad to have three.
In the event, we couldn't dothat, couldn't meet the need.
(25:06):
So what I would say to thosehome care agencies, the
non-medical once you find aprogram in your respective area,
reach out, be part of it, havea plan in place.
We've learned how to build thisprogram.
Every day was a learningexperience because it was brand
(25:28):
new.
If I had to start it all overagain, I know exactly the plan I
would want to put in placebecause I've gone through that
experience.
So I would encourage thenon-medical listeners out there
do not be afraid of this program.
You will be doing exactly whatyou've been doing every day.
(25:50):
You'll be providing theactivities of daily living.
Be proactive, Educate thehospital, the managing team, on
the services that you can bringto the table.
The opportunity is there.
You got to do some looking andyou got to do some finding.
(26:10):
But and I'll go one stepfurther, Jeff, from a
recruitment standpoint, you knowwe're all struggling.
How can we attract the best,the brightest?
How can we get them all on ourteam?
Track the best, the brightest.
How can we get them all on ourteam?
This program became a greatrecruiting tool.
We were able to say be part ofa multidisciplinary team, Work
(26:32):
alongside physicians, nurses,while still doing non-medical
care.
When you look at what motivatesour caregivers, when you look
at what motivates our caregiverspay isn't always the driver.
It's the opportunity to betrained in new things and in
really being professional.
Yeah, sure, being part ofsomething, yeah, being part of
(26:53):
something bigger, that's whatthey like and that's when you
become that employer of choice.
Jeff Howell (27:00):
I love that, especially since the best
caregivers they're in it,because this is a calling, so
for them to be part of amulti-disciplined care team,
that is super exciting.
We are just up against our timehere, guy, so I'll get you out
of here.
On this last question how doyou see hospital at home
evolving over the next fiveyears?
Guy Tommasi (27:20):
Within five years, especially if that waiver gets
extended.
The payers are going to jump onthis bandwagon because it's a
cost-effective way to bringpositive outcomes.
So the payers, who right now arestill I want to know a little
bit more are going to jump onthis.
(27:42):
I see this as the next care inthe 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 andas we've learned from this,
(28:03):
programs are going to gettweaked, they're going to get
refined so that it's going to bea 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, thedeterminations will be that this
patient can certainly have thislevel of care in the home.
(28:25):
So this is the future it reallyis.
And I think when like mindswork together and keeping the
patient at the center of this,then like minds should not be
disagreeing and I think oncethey see the feedback, if they
look at the satisfactionfeedback, that in itself is
(28:48):
going to be a driver, becausethat's where people want to
recuperate, want to be takencare of, want to stay.
Jeff Howell (28:56):
All signs are pointing in that direction.
It is something that reducescosts, improves outcomes and
improves the satisfaction of thepatients and families.
Let's hope that the letter toCongress gets approved and
there's enough data from the 315hospitals for Congress to
extend the acute hospital athome waiver.
(29:19):
My favorite line that you'vedelivered, guy, is when you
talked about a modern standardof care that is at a bespoke
level, but it's also deliveredin the comforts of the home.
So that is what gets me excitedabout the future of not just
care in the home, but hospitalin the home.
And I did leave out one thingyou are also a nationally
(29:40):
recognized speaker with enoughhumility to not mention it.
So Guy has actually givenpresentations 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 thebest lines from my guests to
make myself appear smarter.
So thank you again for being ontoday.
Guy Tommasi (30:00):
Jeff, it's been my privilege to be here and to be
able to share this and feel freeto take all the information and
continue to use it wisely andto promote what we want to
promote and carry in the home.
Erin Vallier (30:14):
Hey listeners.
This is your host, Erin, with avery important podcast
announcement.
Jeff Howell, my fellow hostthat you know and love, is
moving on to another excitingseason in his career, so this is
a really bittersweet moment forme.
I have really enjoyed workingwith Jeff over the years.
(30:38):
It's sweet because I get tointerview him for once, but
bitter because it's his last fewmoments on the podcast.
Jeff you're going to make mecry.
Oh, so I'm really curious, Jeffare there any standout moments
from recording the podcast overthe years?
Jeff Howell (30:58):
Some days it feels like forever.
Some days it feels like forever, aaron.
Back in 2017, I had brought upthe idea internally, like let's
do a podcast, and the head ofthe department said, hey, just
so you know, no one has ever puthome care and podcast in the
same sentence before, and we hadother priorities.
And we put it on the shelf atthe time, as we should have at
(31:20):
that time, and it kept circlingback, and the reason why we
ended up bringing it back was acouple of things is that we did
want to raise awareness of thesliver of health care that we
call home care and home health,and we wanted to be a part of
that conversation, and it'sreally the only truly passive
(31:40):
medium where you can listen toyour favorite podcast on a walk
or washing dishes or in the car.
And a couple of the reallystandout things about the impact
of the podcast that we've hadand you will continue to have is
that Kevin Mystery would tellme hey, I'm going on a road trip
.
I've listened to every episode.
Can you just send me a few ofthe really good ones that you
(32:01):
really remember?
And this is how I keep inspiredin our industry, and we hired
someone named Jessica Lindsaywho in the interview process
said, hey, I've listened toevery episode and she had
soundbites to use and it's beenrewarding.
I'm sure, as you have felt thepeople that have circled back
and said that this podcast and Itake no credit for this it's
(32:24):
all about making sure that ourguests try to speak 90% of the
time, and there's so much.
I wouldn't single out any onething except that my biggest
takeaway from it is that it'struly been an honor and a
privilege to meet the biggestdifference makers in the
industry and to learn from themand each episode most of the
(32:45):
episodes.
It almost probably sounds likea cliche that I've written so
many pages of notes.
I can't tell you how much I'velearned in the industry by
having the good fortune ofsitting in the seat so that I
get to chat with some of thebrightest minds in the space.
I do want to give a shout outsome of the brightest minds in
the space.
I do want to give a shout ourproducer Ryan, who does a lot of
(33:06):
the hard work behind the scenesand is an invisible face here
on the podcast, just like Kati,who does our road mapping, and
Monika that runs our socialchannels.
And then you, Erin, of course.
In the last five plus yearsthat we've known each other, I
don't think that you're actuallycapable of having a bad day.
You are always in this constantstate of Zen, and I know that
(33:30):
you, with your relationships inthe business, you've landed some
of the biggest names that havecome on as guests, and I can't
think of a better person to takeover full-time responsibility
of being the host on the pod andbringing this podcast to the
next level, and I'm going tolook forward to listening to the
episodes and they'll come as acomplete surprise to me and not
(33:52):
being involved in the planning.
Erin Vallier (33:54):
It means a whole lot, jeff, coming from you.
So I have always admired youand respect the talent that you
have and the creativity that youhave.
You are really going to bemissed.
And I have a final question foryou, and I think it's just only
fair, since you ask all of yourguests this question, so I got
(34:16):
to toss it back to you.
Give us a reason to beoptimistic about the care
provided in the place wherepatients call home.
Jeff Howell (34:25):
What a fitting last question.
Well, the easy answer is thetheme that I've picked up on
from all of the guests is thatit makes both more financial
sense to deliver care in thehome versus in buildings, and
that it makes more sense from ahumanitarian standpoint, given
that this is where 99% of people, where they want to age in
(34:47):
place, is in the place wherethey've created all their
memories.
And from a technologystandpoint, there are
innovations every day that arehelping us all make this closer
to reality and the new normal.
With that combination of thesethree things, I think it's going
to be an unstoppable force thatcare will become the new normal
(35:08):
.
But what makes me even moreoptimistic is the unstoppable
force of guests that we've hadon this show and the colleagues
that I've been able to work with.
The talent, the grit, thepassion, the purpose and the
mission I've seen from all thepeople that I've met in the
industry has been both humblingand inspiring.
(35:29):
So in a final sign-off, I dowant to acknowledge and thank
you all and keep up the noblework.
Home Health 360 is presented byAlayaCare and hosted by Jeff
Howell and Erin Vallier.
First, we want to thank ouramazing guests and listeners.
Second, our episodes air twicea month, so be sure to subscribe
today so you don't miss anepisode.
Erin Vallier (35:53):
And last but not least, if you liked this episode
and want to learn more aboutall things home-based care, you
can explore all of our episodesat alayacare.
com/ homehealth360 or visit uson your favorite podcast
platform.
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