Getting prepared for new trends in at-home models of care with Rob Stoltz, senior business development director, and Kathy Piette, co-founder and CEO of Corstrata

Episode 76 December 12, 2023 00:40:48
Getting prepared for new trends in at-home models of care with Rob Stoltz, senior business development director, and Kathy Piette, co-founder and CEO of Corstrata
The Post-Acute POV
Getting prepared for new trends in at-home models of care with Rob Stoltz, senior business development director, and Kathy Piette, co-founder and CEO of Corstrata

Dec 12 2023 | 00:40:48


Show Notes


In this episode of the Post-Acute POV podcast, our host, Diana Eastabrook, staff writer for McKnight’s Home Care, is joined by Rob Stoltz, senior director business development director, and Kathy Piette, co-founder and CEO of Corstrata, to discuss new trends and innovations in at-home healthcare models.

Join the duo as they outline the different types of emerging at-home care models, explore evidence showing positive outcomes in at-home care programs, and discuss key challenges providers face while getting started with these models. Rob and Kathy offer expert knowledge for post-acute providers looking to participate, or even build partnerships, in this growing area of healthcare. Listen to their conversation.

Topics discussed during today’s episode:

  1. [00:34 – 01:30]: Introduction to the episode's topic, presenters, and background information on both guests.
  2. [02:11 – 04:19]: Rob outlines the objectives for the episode and discusses why the industry is moving towards at-home care models.
  3. [04:48 – 06:02]: Rob examines the rise in different types of at-home care models since the pandemic.
  4. [06:18 – 08:15]: Kathy defines and compares the different forms of at-home care models.
  5. [08:42 – 11:38]: Kathy explains CMS’s Hospitals Without Walls program, which allowed for hospital-level care at home during the pandemic.
  6. [12:09 – 16:52]: Kathy identifies the key components needed to enable at-home care models and gives examples of how to manage specific patient needs.
  7. [17:32 – 18:43]: Kathy discusses the importance of getting the necessary medical equipment/ medication and having properly trained staff providing care in at-home care models.
  8. [19:19 – 24:08]: Rob talks about staffing and recruitment problems, technology infrastructure challenges, issues with family/caregiver engagement at home, and other key challenges in at-home models of care.
  9. [24:33 – 27:56]: Kathy describes possible roles post-acute providers can play in hospital-at-home, primary care-at-home, and SNF-at-home models.
  10. [28:31– 32:43]: Kathy details evidence that shows at-home models achieving positive outcomes and the steps post-acute providers can take to participate in these models.
  11. [34:03 – 35:47]: Rob introduces key steps and areas of focus for preparing technology and exploring possible partnerships for at-home models of care.
  12. [36:13 – 38:20]: Rob goes into more detail about how to get started with different organizations and partnerships.
  13. [38:45 – 39:49]: The duo wraps up the discussion with major goals discussed and the importance of staying on top of the latest industry developments.



The content in this presentation or materials is for informational purposes only and is provided “as-is.” Information and views expressed herein, may change without notice. We encourage you to seek as appropriate, regulatory and legal advice on any of the matters covered in this presentation or materials.

©2023 by MatrixCare

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Episode Transcript

Speaker 1 (00:02): Welcome to the Post-Acute Point of View podcast, our discussion hub for healthcare technology in the out-of-hospital space. Here we talk about the latest news and views on trends and innovations that can impact the way post-acute care providers work. We'll also dive into how technology can make a difference in today's changing healthcare landscape for home and facility-based workers and the people they care for. Let's dive in. Diane Eastabrook (00:34): Hello and welcome to this session of McKnight's Home Care Expo entitled Get Prepared: New Trends in At Home Models of Care. I'm Diane Eastabrook, staff writer for McKnight's Home Care Daily, and I'll be your moderator today. Let's meet our presenters. Rob Stoltz serves as the Senior Director, Strategic Initiatives Home and Hospice at MatrixCare. Rob is a longtime veteran in the home-based healthcare IT industry with deep experience in EMRs, care transitions, patient engagement, predictive analytics, and interoperability. (01:06): Most recently, Rob has been focused on technology partnerships, leveraging interoperability to benefit all stakeholders involved with patient care while enhancing provider efficiency through effective workflows. Kathy Piette is CEO and Co-founder of Corstrata, a specialized telehealth company offering virtual access to certified wound and ostomy specialists to improve patient outcomes and lower costs. (01:30): As a 20 plus year post-acute healthcare executive, Kathy has extensive executive management experience serving in quality and operational leadership roles. She brings extensive experience in telehealth, continuous process improvement, project planning and organizational redesign for care management of high opportunity, high cost patient populations in a range of care settings including home care, hospice, long-term care, and new in-home models of care like hospital at home. She received her graduate degree from the University of North Carolina at Charlotte. Now let's get started. So Rob, we see a lot of care moving into the home these days, but there are some challenges, right? Rob Stoltz (02:11): Well, it does not go without its challenges, that's for sure. So we'll kind of get started on this. I think we'll talk about maybe what objectives we're going to try to hit today as we go through here. So as we look at the objectives that are in play today, then what we're going to try to do is address those challenges by talking about some industry research and the results of that that we've done in conjunction with McKnights to really understand kind of those challenges that are facing some of those adopters because it is a challenging space. (02:45): Everything that's new presents its own challenges. And this is certainly a lot of things that we hear about, but the actual execution of many of these things are new to the industry. And then we're going to look and really try to say, "Okay, now that we understand some of the challenges, how do we explore kind of practical steps for organizations to get into this for an at home strategy?" (03:07): And then really help to give some information onto how you and your organization can lean in and say, "Hey, I want to be part of this. What steps do we take the lean in and get engaged in it?" And so those are really going to be the objectives that we're going to try to do today. And I think by doing that, we should probably start off by just kind of summarizing and setting the stage for the environment. (03:29): So if we stop for a minute and kind of think of why did we end up doing this study. It's because everyone knows there's this continual move to patients who want to be cared for into the home and getting outside of the four walls of the traditional care settings that many people are accustomed to. And you can see pressure on the administration. It's actually kind of refreshing to see bipartisan support for care in the home, which is great. (03:54): And timing is right. I mean, everybody talks about what change kind of was brought on by the COVID-19 move and how people had to get used to remote care, but there's really a lot more kind of going on than just that. Right? So as a result of that, of course the patients and the providers are well more set to go into this than they were say a couple of years ago. Right? (04:19): So when you look at the statistics, I was looking at some the other day from the AMA and the number of seniors, elderly patients who now engage with telehealth is well over 50%. Obviously it still has challenges and the providers themselves more comfortable with, "How do I do the right kind of assessment and the right kind of visits?" Those kinds of things that are impactful. So there's definitely a world now that we live in that both parties, the patient, providers are more amenable and kind of used to this. (04:48): So that's kind of a known result of where we were through the pandemic. But there's also a component of this that when you think about some of the initiatives that have been funded for rural access to high speed internet and things like that, those are ongoing and those are going to be ongoing for quite some time. But I can tell you as somebody who lives in a rural part of the country, it's crazy for me to think after many years of not having access, I now have two high-speed providers to connect with where I live. (05:18): And so there's definitely trending towards a lot of that. And when I drive around in those areas, you can see quite a difference. So that infrastructure has certainly made a change in some of the accessibility. And then there's this blending initiative of all the payers at this point to really control the healthcare cost. And that means getting into the lowest cost setting at the right time. Right? (05:41): So it's been an ongoing project. People are trying to kind of get better at that and make the determination of what is the right time so we don't have adverse outcomes from that. But it's an ongoing initiative and because people know that patients want to be cared for in the home, that just kind of lends itself to being the right time to engage in these emerging models. (06:02): And I think there's such a proliferation of the terms, I guess, for SNF at home, hospital at home, primary care at home, all these different at home. And it takes a minute to say, "Hey, what do they mean? Can we kind of categorize them, define them a little bit?" (06:18): I'm so happy that Kathy's here with me because Kathy and the group of Corstrata are engaged in this remote wound care and ostomy management, and they're participating in so many of these models that I think I'm going to ask her if I could kind of talk about them in a little bit more detail on how they get structured just so that we can do more than just say the terms. We can put some meaning and solidification to them for the people who are listening. Kathy Piette (06:43): Yeah. So when we think about at home models and this whole new evolving movement, let's talk about the different types. So of course, the one I think everybody has been talking about the most is acute care at home. And it's really where the patient no longer exists in the four walls of the hospital, being provided hospital level care in their home. It goes by different names, so it goes by hospital at home, advanced care at home, they have all the same meaning. Right? (07:13): So these patients have to be supported and cared for at the same level of care. And we'll get in a little bit more later about what that care actually looks like. And then we've kind of gotten what is termed continuing care at home. So what happens after this patient is no longer in an acute care episode? Well, they're in home health at home. Right? So our traditional home health model is hospice at home, rehab at home. (07:42): Let's say they just had an orthopedic joint replacement, they need rehab at home. And then also we're starting to see can we bring the same skill sets that are demanded for in skilled nursing facilities into the home to support that? And that would include both the skilled care as well as that non-skilled care to help take care of that patient. Then we can go more to what is being termed on demand care at home. This is like urgent care. (08:15): This patient is at risk of going to the hospital. Someone identifies, perhaps it's a home health agency, that this patient is susceptible and they call in these companies that make at home urgent care visits. They bring in physicians and physician extenders in order to look at this particular patient and see if they can triage this patient at home rather than them going back into the four walls of the hospital. (08:42): So this also includes these new mobile units that are out there providing lab testing and other kinds of special programs for mobile x-ray units, et cetera. And then we come to what is so familiar in the majority of, overwhelming majority of Medicare aged patients, right? Which is how do we manage longitudinally chronic care at home? And so we've had care settings, for example, renal care at home where they're actually bringing dialysis into the home as opposed to having to take patients into the dialysis centers. (09:22): We have infusion at home. Home health has been doing that for a long time, but now we actually have mobile units that are coming in and doing infusions at home. And that would of course also include all of these new mobile primary care physicians where they're sending physicians, nurse practitioners, PAs, et cetera, into the home to actually do a primary care visit rather than that patient have to be transported into the physical office. (09:52): COVID really produced these overwhelming tailwinds that are really driving this movement into at home care. And we'll talk a little bit later about the results of those and what's driving some of this, which a lot of it is patient satisfaction. Patients want to be cared for in their homes. So in March of 2020, CMS knew that hospitals were being flooded by all the COVID patients and they knew they needed to do something to get some of the less high acuity patients out of those four walls of the hospital into their own homes to be taken care of. (10:30): So they quickly, which is unusual for CMS, evoked the Hospitals Without Walls program, right? And they put it in place to end with the public health emergency. Well, of course, we all know that that public health emergency has recently ended, but in December, because of so much favorable feedback about this program, the waiver itself was extended for two more years by the Omnibus Bill. During this two years there's, CMS is really going to be looking at outcome measures to measure the success of this program. (11:05): Today, you can actually access this on the CMS website. There are over 123 health systems, 277 hospitals in 37 states approved for this Hospital Without Walls program. So how is this particular program paid for? Well, it's paid for by traditional Medicare. Hospitals bill the DRG and daily rates. This was a very attractive to hospitals. There was parity in payment, correct? (11:38): I mean, they were being paid the same thing in the hospital as they're being paid to take care of home. But this waiver program had some specific stipulations around what you needed in the home in order to support that level of care, right? So you had to have a physician that saw that patient daily. That could be done virtually, and that's what the model has matured into. These physicians, usually hospitalists employed by the hospital visit these patients virtually. (12:09): There also has to be two in-person clinical visits a day. That can be by an RN, can be by an LPN, a PA, an advanced practice nurse, or even in some cases paramedics are being used if that particular function of paramedics is allowed in the practice act of a particular state. You also have to be able to, like you do in the hospital, monitor vital signs. So remote patient monitoring was added to the model, right? (12:38): In addition, if these patients experience an event or escalation of their acuity and need to be returned to the hospital, they cannot live more than 30 minutes away from that particular hospital. And there has to be emergency on-demand transport available. And then of course, you need all those services that you have in the hospital. You've got to provide them with food, you've got to provide them with therapists if needed, specialty nurses like wound and ostomy care, which is what we do at Corstrata, social work, et cetera. (13:14): So it really is this, how do you bring to bear the technology, the staffing into the home to provide this level of care? Let's delve into those key components of these programs. At the roof level, at the peak up here, we have consumers, consumers and patients are driving this demand. They prefer home as their location of care. Many of these patients find it very difficult to be transported to outpatient clinics, to physician offices, et cetera, for their care. (13:47): And the care coming into the home is a much more preferential setting. Interesting about the home setting, it also unlocks the clinicians visiting that home [inaudible 00:14:00] into what that home looks like and what the challenges of this patient truly are. So you think about home health, for years the home health nurses have, home health has acknowledged this, but you go into the home and there you find maybe there's not enough food. (14:18): Maybe they have horrible COPD, but they have no air conditioning in the hot sweltering summer. So you really find out the challenges. Maybe the house is cluttered and there's risk for falls. So really getting into the home allows insight into that home and how you can support that patient to be better cared for within their surroundings. We also know that patients heal better in their own homes if all possible. (14:50): So there is demand there. So let's look then at the care models we talked about. We went through, we looked at SNF at home, physician at home, hospital at home. All of those, you really need to know what the population needs are. You need to understand what the nonclinical and clinical skills are that need to be brought into that home. And then you've got to have integrated care. Right? You're sending teams into the home. (15:23): You have to have a way in order to care manage that patient. A command center per se. Whether it's your EHR that's serving as that, how do we actually coordinate the care through multiple people coming in the home ensuring that we have all the supports needed, both clinical and nonclinical? And so this is really starting to talk about the infrastructure. In addition, we've got to look at the technology. What technology has to be in that home to support? (15:53): Does that patient need remote patient monitoring? We understand that monitoring those vital signs remotely can lead to great knowledge is when to actually go in and see that patient. So how do we get that patient's home equipped technology wise in order to support that care level? There are lots of other types of sensors that that home can be manned up with. Think about the sensors that actually monitor activities of daily living. (16:23): Is that patient opening the refrigerator door? Are they opening the oven door? Are they going in and out at odd times at night? Are they sitting in their chair? Are they frequent toilet? Could they possibly have a UTI? So there's all sorts of technologies that can man up the home that allow this at home management of these patients. The other thing that's very critical is the supply chain. How do we get the medical equipment that this patient needs? (16:52): Do they need antibiotics? So they need infusion pumps, et cetera. What medications do they need? What kind of supplies like wound supplies, gloves, et cetera. So what is the mechanism for getting into the home? The same supplies you might find in an outpatient clinic or within a physician's office, right? In order to actually treat that patient. And then what about, how do we do blood tests, imaging, all of those to ensure that we don't have to take that patient out of their home, take them to a lab or take them to an outpatient center to get those tests. (17:32): So all of, as we talked previously, all of these mobile units are arising that are actually going out and making these visits. And then workforce, we've got to have the staff, both clinical and nonclinical staff to go into these homes and they have to be trained up to whatever model they're delivering. Right? So let's say they're delivering hospital at home. Well, they have to be nurses, paramedics, et cetera, that understand hospital level care and can provide that within the home setting. (18:08): So the staff have to be trained. They have to understand what their role is in the home, and we have to have enough of them because we all know there's a shortage of nurses. And then finally, if you are considering going into these models and playing in these models, you have to understand all the different reimbursement methodologies. Right? So we talked about the waiver program that allows traditional Medicare to pay the DRG or the hospital rate for hospital at home. (18:43): But then Medicare Advantage plans, all of these insurers are opening up Medicare Advantage plans to allow for providers like nursing homes, home health, hospices to participate in these new models and a risk bearing methodology. So you have to understand before you go in here, what those reimbursement models are and what your approach, how you will price this out, and are you willing to go at risk with some of these payers in order to make this happen? So you've got to understand your cost. Rob Stoltz (19:19): Yeah. There's a lot going on there, Kathy, right? So some of the challenges, so when we get the complexity, kind of those models and then we kind of turn back to the study for a minute, it's probably not going to surprise anybody that some of the top challenges, the top challenges that we heard from for these early adopters is staffing and recruitment. And you talked about this. (19:40): If we look at what people are talking about, they're talking about this mindset of, "Hey, I'd never have done this before, but I now might have to do these house calls." Look at that a little bit differently. And for some people that may be great, that may be liberating something different to their life. And then some people, that may be a real challenge. So it's not only just about getting them, but it's understanding the mindset of when I start into these at home services, how comfortable are each of the people that we're used to working with, dealing with that situation? (20:11): When you get in the home, it's a totally different environment. There's less control than when you're in a facility. And so those kinds of things come into play. When we hear of staffing, it's always about the shortage, but this is really about the job itself. And we saw so many people move from an office to a work at home model just during the pandemic. (20:31): And some people adjusted great and other people hated it. Right? And I think it's the same kind of mentality that we see with this kind of transition going back and forth. You just named a whole bunch of stakeholders, and we'll try to hit on this a little bit later as well. But when you think about it, there's a big difference for some of the people because they're used to working in this controlled environment where they're always connected. And so the timeliness of the data is always real. (20:57): And you may be in a patient's home that has no wifi, that has no cell signal, and all of a sudden it changes how do we think about dealing with them from a technological and a documentation and tool standpoint. The second half is really important too, because once you get in the home, there is a far bigger engagement of the family and the family caregiver. And for anybody who's ever gone through this on a personal level, you know we talk about the caregivers a ton because they're so critical to the success of the patient. (21:28): But it's a really different mindset to say, "How am I going to interact with them and have them involved in the care if needed and make use of that resource to help take care of that patient?" So going back to the middle is there's this technology infrastructure and some of the study information later on talks about this again, so we'll hit it again. But the segment that we all know is that the post-acute care community is, the out of hospital kind of networks are hard to connect. Right? (21:59): They've been a challenge. A lot of different isolated EHRs. We talked about in the survey results earlier, people using their segment specific technologies. And what that means is you have to bridge those technologies so that the people who are in this care and collaborating on them really have the information that they need. And so the early adopters really called these three things out as the most challenging things that they're facing. (22:26): Now, they identified a few other challenges as well. So as we take a look at those, there's some educational challenges tied to them. So proper documentation for home care. And the real trick of this too is qualified patients. Kathy talked earlier about all the things we have to do for them. There's all sorts of companies out there who are using these analytics to identify who are the right patients that can leverage this model and you can have a good impact on. (22:52): And so that's a real challenge getting to that and seeing how effective it is and making sure that the people that you're moving into these programs are the ones that can really benefit for it. So certainly a challenge that people are seeing on the front side of this. And Kathy talked about this, but reimbursement models are, this is all new. I mean, if you think of the home and hospice industry and what we've seen for the last several decades, none of it looks like this, right? (23:20): And now we're starting to see this. We're starting to see the MA programs come into play. There's a lot of those kinds of things that are coming in there. And so as you work with these organizations to get in, getting clarity around that reimbursement model, how you benefit as a provider in this model is critically important. And this is a real tricky one, which is the accountability of the partners. Right? (23:41): So if you're in one of these scenarios and it's a risk bearing scenario, then are all the partners accountable? And if so, how? Because you may do your part, that doesn't mean that in the end necessarily you're going to hit it. So you really have to be able to make sure that each of the people you're engaged with throughout this process are really held accountable for the process if there's going to be some shared reward and shared risk tied to this as well. (24:08): So a lot of different things there that people have kind of called out in the early advancement of, "Hey, here's some things you really have to be careful for." And so as you're thinking about this, and you start to think a little bit more about participating in them, now you know some of the things to look out for. And now maybe Kathy, you could talk about what's the roles that you need to be able to fill in these models as well. So maybe I can have you talk about that a little bit more. Kathy Piette (24:33): Absolute. So let's look at three of these models and then talk about what the needs are in terms of these models for care delivery. Right? So if you look at hospital at home, they are placed in the home in an acute care phase, and that averages four and a half days. Right? So what happens to these patients after those four and a half days? Well, then there's a recovery phase. So where could your post-acute team fit in to help care for these patients. In the acute care phase, think about it. They're going to need those boots on the ground we talked about, for nursing, for therapy. (25:18): So if you're a home care company or a skilled nursing facility and you have highly trained clinicians, could you send those into the home to provide that acute care to be that supply chain for the staff? But these are going to require these clinicians to be trained up in order to be able to deliver that acute care. So keep in mind that you could lend your care team as support for these in the acute care phase. If these particular hospital systems do not have those supports readily available and need assistance with that. (25:58): After that four and a half days in the recovery phase, that hospital doesn't want those patients going back to the hospital, right? We've got 30 day readmission penalties. So what happens during this post-acute care phase or recovery phase? Well, they're going to have to have clinical and nonclinical resources in there to support these patients. (26:20): Sometimes this is a traditional home health patient, but other times maybe this patient isn't going to be homebound and traditional services don't fit into there, but you could still be reimbursed for taking care of these patients from a clinical standpoint. So let's think about how you compliment both of those phases in hospital and home. (26:44): And then primary care at home. So you have mobile physician groups and physician extenders that are going to the home, looking at that patient, seeing the needs of that patient, and what if that patient needs therapy, needs additional skilled care? You could partner with one, be the preferred provider of one of those primary care mobile physician groups as the in-home resource for that skilled care. So that patient could then be put in a home health episode or even a hospice episode if that patient is appropriate for those services. (27:19): And then SNF at home. SNF at home, you have to think through how do your clinicians both skilled and non-skilled, how can they support that same level of skilled nursing care within the four walls of a home? So what skill sets do those clinicians need in order to provide that care? And how do you train them up in order to provide that? So you can see that you could fashion your particular services to compliment any of these models. (27:56): In the early days, what these post-acute providers are doing, it's really finding a niche and a partner in order to penetrate these new models. So next, let's look at what kind of results we're seeing. And this time, the most clear results are on hospital at home. I think there's some really good data out there that's showing the value these are presenting. They're presenting this value really as the quadruple aim that CMS has outlined. So the quality is improving. (28:31): There is a lower hospital readmission rate when these patients are cared for in their home. It drops to 7% versus 23% from patients that are discharged from the four walls of the hospital. That's significant. There's also lowering of the risk of admission to long-term care and skilled nursing facilities. Think about that. All of those are cost savings to these Medicare Advantage plans and ultimately to CMS and Medicare, correct? (28:58): And then cost savings. Studies indicate that 18% to 30% reduction in total cost by moving them out of the hospital. So they get fewer labs, that's sometimes the reason. Less diagnostic testing, et cetera. But and then overwhelmingly, there's improved patient satisfaction. The patient satisfaction scores are sky-high. Patients are more comfortable in being cared for in their home, they're more confident in the quality of care they're getting, and they prefer to be there. (29:37): And then looking at how these models improve the overall health of populations. And they're really starting to address these social determinants of health, right? So as Rob referred to earlier, we can increase access to care in these rural areas through these new models. We can also lower socioeconomic situations. You can get in there and actually address those nonmedical needs. (30:04): Do they need nutrition? Do they need housing? Do they need a myriad of things that really kind of flattens the curve and addresses the health of these particular underserved populations? And then next, let's turn our attention to how do you as a home-based care provider get a seat at the table? What do you really need to do to engage with these? Well, first of all, you need to profile your geographies. (30:37): You need to go out there and see what new models of care are being delivered in your region or area. Right? And you've got to know who are doing those. And then you want to identify your competition. Are there other home health companies that are actually providing this care with some hospital systems? Are there physician groups that are working with other people and as preferred providers? So you need to do your initial research. Where are these new models happening in your particular locale? (31:13): And who's playing in them? What models are they? And then ask yourself, how could you play in these particular models? How could you lend your services and your expertise to carve out a niche in these models for your organization? And then once you've decided maybe you're better suited to offer SNF replacement at home, or maybe you think you would be good working with these mobile physician groups, you've got to develop a model framework. (31:47): And that framework would really define how you intended to work with these. So you can go out and sell yourself and your organization that you're the people to partner with to do this. You got to know your data too. Data in all of these models is invaluable because at the end of the day, it's proving the quadruple aim. Right? So you have to know your re-hospitalization rates, your ED visit rates. (32:15): You've got to be able to use that particular data to take out here to these organizations and convince them that you're the company to provide this particular care. You've got to know your patient satisfaction scores. Are you making them happy? All of these are going to be important. Do you have some disease specific programs that you have? Perhaps you have a CHF program or a diabetes program or maybe a wound specialty program. (32:43): Do you have those specific programs that are going to be needed in these new at home delivery models? And do you have results from those programs that show lower re-hospitalizations, improved care, shorter length of stay, or any related case studies? So get your data together that supports the care that you decide that you are best to partner with in these models. And then you've got to know your cost. Because as Rob said, Medicare Advantage has now penetrated over 50% of the over 65 population, and they are looking to go either at risk or at reward. (33:25): So you have to know your cost so you know how you can enter these arrangements. And then last, once you have all this developed, you need to really kind of make a target list. "I'm going to go after these models. These are the players. Here's my data. Here's a framework for that model to support them." And what we find the best way to do that is suggest a proof of concept. "Let us go in and play in a small little sandbox with some defined KPIs, key performance indicators, and really prove it to you. Let us show what kind of partner we can be." Rob Stoltz (34:03): So Kathy, those are great, actually very timely and very formative to say, how do we go about doing this, right? You just laid out a nice action plan. We'll talk about a few of the action plan as it relates to getting involved in these things. We'll address a couple of other action plans here just that really relate back to those primary concerns that the early adopters had, right? And the first one, if you remember thinking back, really focused on technology. (34:31): And so one of the other things that you really just need to do for as an action item is to evaluate the readiness of your technology and how it'll play in that infrastructure. So we think of the EHR traditionally as the center of any of these operations. But when we think about it, there's specific aspects of it that are incredibly important. And the first thing listed down below is interoperability. (34:55): And so what that really means is if you're going to partner with one of these primary care organizations or any of these others, what they don't want to do is have you part of that group, but lose the ability to then see what's going on with that patient. And so understanding what interoperability capabilities do you have so that your partners in these models can keep track of those patients and understand them is critical, right? (35:22): And that really uses things that are around advanced APIs. Those are ways to create interoperability and be easy to use. And I think we talked about it a little bit earlier, but being mobile ready is critical because we are working with people who sometimes are in this environment where they're used to always being stable and having this stable environment to operate from an IT perspective. And it's just not the same once you get on the road. (35:47): And so obviously because of the different models of payment and so forth, you have to say, "Can I accept and understand how to recognize payments and billing?" So when you say, "Am I flexible enough to bill and be able to understand and fit the models because they are creative models that we may be participating in, can I do that and know from my organization where we stand in providing these in the health of this relationship that we're in?" (36:13): And then we talked about it earlier, but it is critical about now that you're involved with the family to expand kind of your infrastructure, be able to meet family caregivers and families kind of where they are in the technology. They can be great eyes and ears to be able to help you proactively manage these patients as well. But there has to be some technology there so that when you need authorizations from power of attorneys and actions to do that, can we engage with them in an effective way to make all of those happen? (36:43): Can we communicate with them and get early notice that somebody may not be feeling well, so that we can do those kinds of things to evaluate hospitalizations and avoid potential hospitalizations as well? So all of these different things or things that are related to those early identifiers said were challenging from a technology standpoint. And when you think about it, you have these different groups coming together to create care. (37:08): How do I make sure they're all aware of what's going on the patient and staying up to date on that so that we work together to prevent these adverse outcomes, in most cases, the re-hospitalization that we're trying to avoid? As we look at the next action step then, we're talking about exploring potential partners. And on this one, you can see that 76% of respondents are partnering with health systems, payers and or their referral sources. (37:31): And so this really goes back to what Kathy was talking about in terms of who's out there doing this and how do you get involved with them. It is definitely a piece of how do I provide this? Earlier in the year I kind of talked about in a blog about, I know so many good organizations who do these things, right? And they're so good at providing this care, but what they're not good about is kind of blowing their own horn, right? (37:56): And saying, "We do a great job with this," and bringing the data to the table. I think sometimes they think, "Hey, it's just the job we do. That's what we're used to," but it's not what these other organizations know or understand. So being able to really leverage what you do well and then go after those conversations in the way that Kathy was talking about and targeting who's doing it, is going to be absolutely critical to this. (38:20): And so those programs, maybe it's a CHF program, maybe it's different things that you've done in the past that you can identify where that success was. Maybe you have a great way to interact with the patients themselves from maybe a technology standpoint. You can bring that to the table where some of these people aren't used to doing that at all. So identify it, get to it, bring it to the table, and make sure other people know you do it. (38:45): And then finally, I think the last action step that we'll talk about here is just the ability to stay on top of all these things. People are going to look to you as a resource. You need to be a resource and an expert in this. And so there's lots of organizations out here that do a great job at bringing these topics to the forefront through industry experts. (39:06): And so just stay on top of them and look at them. When you read them, read them with a different eye and look at them with a different eye that say, "Okay, now this thing is required. How can I then use that? How can I solve that problem that is now required to help somebody that may not be able to do it themselves?" Right? (39:24): And the way you do that is just by staying on the leading edge of what you're talking about from that perspective. And so these organizations are accustomed to doing this already, but can really tie into this and continue to stay on the leading edge of these thought-provoking ideas and create solutions for them. So just to recap, I mean, we really shot with a few goals that we were trying to do. Hopefully we put check boxes by all of them. (39:49): We really wanted to kind of look at that and make sure you understood where the industry stands, how these doctors that are doing it now are facing challenges. We want you to be part of the 46% that are having financial success because we saw the benefits that Kathy talked about, that patients get from these, and we want to be able to continue to deliver success to people who want to be in their home and get this care. And you only do it by really trying to think these things through in advance and saying, "What steps can I do to make it successful?" Speaker 1 (40:20): That concludes the latest episode of the Post-Acute Point of View podcast. We have a lot of guests and topics coming up that you won't want to miss, so be sure to subscribe. To learn more about MatrixCare and our solutions and services, visit You can also follow us on LinkedIn, Twitter, and Facebook. Thank you for listening. Be well and we'll see you next time.

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