South Shore Health Leverages Telehealth, RPM in New 'SNF at Home' Program

South Shore Health is adding remote patient monitoring capabilities to its Mobile Integrated Health program, giving the one-year-old program telehealth and mHealth tools that aim to improve care management for more complex patients at home.

The southeastern Massachusetts health system recently partnered with Current Health to create a “SNF at Home” program, which provides in-person and virtual care at home for patients who might otherwise be housed in skilled nursing facilities. The in-person care is handled by specially trained paramedics who are employed by the health system.

“We’re providing the same kind of experience that you would get at a SNF, but doing it in the patient’s own home,” says Kelly Lannutti, MD, South Shore’s MIH Medical Director and Program Development and Clinical Innovation Physician. “It’s like Amazon Prime for our health system.”

The health system launched the MIH platform around March of 2020, just as the coronavirus pandemic was kicking into gear. Patients are screened while they’re in the hospital, and sent home if they fit the parameters for home-based monitoring and care. They’re visited at least five times a week by South Shore’s paramedic team, while other services are handled via telehealth and home healthcare.

Lannutti says the program keeps patients out of the hospital – an important factor during the COVID-19 crisis – and at home, where they’re more apt to be comfortable and respond to treatment better. The health system is able to track their progress at home through telehealth and the home visits, but they wanted to take the program further.

This past March, South Shore added RPM capabilities to the program. Through the partnership with Current Health, patients in the program are equipped with an mHealth wearable and wireless devices that passively capture biometric data, including respiration rate, oxygen saturation, mobility and step count, pulse rate and body temperature, and a telemedicine hub that provides internet connectivity and transmits the data back to care providers at South Shore.

Lannutti says the RPM platform allows South Shore to monitor patients around the clock, in between the video and in-person visits, and to spot trends and adjust care management when needed.

“This really allows us to take care of sicker patients” outside the hospital, she says. By combining the MIH program and its in-person elements with connected care monitoring, the health system is taking patients out of expensive and complex care centers and creating a personalized care program around them at home.

“We’re giving them an alternate setting, and giving them a much more multi-disciplinary team around them” to facilitate care, she adds.

The merging of MIH and RPM programs gives South Shore an opportunity to target more complex patients, and may be a model for other health systems looking to expand acute care opportunities outside the hospital.

RPM, which is riding a wave of popularity as a result of the pandemic, offers opportunities to care for certain patients at home, the benefit being that those patients don’t need to be in a hospital. That’s good for patients recovering from COVID-19 and other health concerns.

But if those patients develop problems that require hospitalization, the program isn’t working – outcomes are worse, costs shoot up and hospitals are penalized for rehospitalizations.

Adding an MIH platform that offers specialized, in-person care could reduce those health emergencies, as well as give the health system capabilities to treat more patients at home. An RPM program alone might not work for patients who’d otherwise be in a skilled nursing facility because they need more care, but a program combining RPM with MIH strategies might do the trick.

Lannutti says the SNF at Home program “really allows us to think about patient care in a different way.” The key is creating a plan that uses the health system’s paramedics, who go through hundreds of hours of specialized training, to the best of their capabilities. They’re providing care in a home that replaces care in a SNF or hospital setting.

“Starting an IV with 12 cats climbing over them is not unusual,” she says.

The challenge lies in making those services sustainable.

“The struggle of MIH is there’s not a lot of reimbursement in sending paramedics into the home,” she notes. “We have to create a care plan that works.”

To measure the program’s value, Lannutti says South Shore will focus on eliminating hospital admissions and rehospitalizations, and comparing cost of care in the hospital or SNF to home-based care. Add to that formula an expected boost in patient engagement and satisfaction – patients usually prefer to be treated at home than somewhere else – and the program will be sustainable if it proves that those patients recover better and faster at home.

“There’s not a lot to benchmark it against right now,” she says, noting there aren’t many programs like this in the country. “This gives us a chance to be flexible. And we’ve had a lot of buy-in across the system to support this.”

As the program evolves, Lannutti sees opportunities to integrate primary and specialty care services and open the platform to those with chronic conditions, especially those with multiple chronic conditions that require more complex care.

“COVID really propelled us into the remote monitoring sphere,” she says. “Now we’re finding new ways to take advantage of that.”