Hospital at Home moves care where patients heal best

Joining us in this episode is Dr. Constantinos (Taki) Michaelidis, medical director of the Hospital at Home Program at UMass Memorial Health, alongside Susan Jarvis, chief operating officer at Sanford Health Fargo. Together they'll share how their organizations launched and scaled hospital at home programs in both urban and rural settings. The lessons they've learned and the impact they're seeing on patients, providers, and their respective health systems.

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Transcript

Alan Helgeson (announcer):

“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations, and real world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools, and partnerships advancing rural health care and strengthened care in communities across the country. 

Joining us in this episode is Dr. Constantinos (Taki) Michaelidis, medical director of the Hospital at Home Program at UMass Memorial Health, alongside Susan Jarvis, chief operating officer at Sanford Health Fargo. Together they'll share how their organizations launched and scaled hospital at home programs in both urban and rural settings. The lessons they've learned and the impact they're seeing on patients, providers, and their respective health systems.

Susan Jarvis:

Taki, thank you so much for joining us today. I'm really excited and I'm looking forward to talking with you about Hospital at Home. You have been instrumental in helping us here at Sanford and Fargo get our Hospital at Home program up and running. And you've been leading the Hospital at Home program at UMass Memorial since 2021.

So we've got a lot of experience, our program, we've only been going not even a year. But can you share with us, how did the Hospital at Home program there at UMass Memorial come to life? How did you decide to embark on Hospital at Home? And how does it work for you at UMass?

Dr. Constantinos (Taki) Michaelidis:

Yes, and Susan, and to the whole Sanford Home Hospital team, it's just such a privilege to be here with you today. So much of this important work only arises because of collaboration and supporting each other. And there's so many nuanced issues that arrive in home hospital that are unique to what we do in caring for vulnerable populations. So I hope this is only the second, third, or fourth of 20 or 30 conversations over the coming years and decades.

So just a step back for the moment, Susan, to your point. So my name is Taki, although it says Constantinos Michaelides. Everybody calls me Taki. I'm an internal medicine physician by training and have been privileged to work in home hospital for getting closer to 10 years, the last four at UMass Memorial Health. So a little bit about our health system and then we'll dive right into the question you asked, which is a really fun one and an important one. So we're the primary safety net provider health system in our central part of Massachusetts.

We are based in Worcester, Massachusetts and care for, we're the Level 1 trauma center, the NICU, the tertiary care center, the primary teaching affiliate of UMass Memorial Chan Medical School, and have about 1300 beds across our main academic medical center and our four partnered community hospitals. And where we were in, you know, 2021 was, you know, about a year, year and a half into the real challenge of the COVID pandemic.

And our health system had been operating the COVID field hospital for the state of Massachusetts. So providing excess surge capacity to care for our complex patients admitted with COVID. And then in November 2020, the waiver came along, the CMS waiver, which obviously underpins everything we do in home hospital. I'm sure we'll talk much more about that waiver because it is so important. 

That waiver came along and our health system leadership was looking at our main academic medical center, looking at our partner Community Hospitals and saying, holy cow, we have a capacity crisis still. It's not uncommon for us to start our morning with 90 patients boarding in our emergency department, 100 patients, 110 patients. And as all of us feel in our health system, I'm sure in your health system as well, we know that's not the experience we want for our patients, our family members, our loved ones. There's so many challenges with boarding in terms of quality and safety and cost.

We stood up our program to address that challenge. Started most of our planning in about January, February, 2021, launched the program in August of 2021. And now we're actually a little bit more than four years in. We've cared for getting closer to 3,900 patients and patients are doing great. And I'm looking forward to discussion around quality and safety and satisfaction.

But the short answer is it's been an incredible journey and looking forward to hearing more about your journey too and sharing things where we have many common challenges and where we might have solved them in unique ways.

Susan Jarvis:

Well, we looked at the Hospital at Home program when the waiver came out and we, like everyone, we were very challenged through COVID. But we did not embark on the Hospital at Home journey at that point. We focused more on we did have some, we had built a new medical center here in Fargo and we'd moved into in 2017. 

So we had a hospital, a different campus, where we had some beds that we were able to bring back online pretty quickly. And so through COVID, we were able to use hospital beds that we had planned to decommission and turn into clinic and other types of space for our cancer center. We had to delay that a little bit until Hospital at Home, until COVID was over. But then from the Hospital at Home standpoint, we though, you know, kind of post COVID, we've continued in Fargo to be very, very busy.

We have continued to bring other beds online and we built up all of the shell space that we had at our new medical center and we still have capacity challenges. So we do still almost on a daily basis have patients who are waiting for beds in our emergency department. We have various overflow areas and so we took another look at hospital at home.

And we said, you know, we know we're more rural than some of the programs that are out there, but we really want to give it a shot. And we want to see if this could help in some way with our capacity issues. And it was really our hospitalist group that came forward and said, hey, we think we have patients that would be great for this and we want to be really involved and we want to try this program. So with your help, with the help of the people in the industry that are doing it,

I've just found that the Hospital at Home kind of group is just very welcoming. They want to share what's happening, very helpful. And what you have done for our team has been very much appreciated and helped us get off the ground.

Dr. Constantinos (Taki) Michaelidis:

And such a kudos, because I think your word "journey" is exactly right. It is a journey and you folks are rocking it. And I love the perspective around your clinical team, your physicians coming and saying, you know, we believe in this. We want to get this off the ground. That is such an accelerant because as all of us know, there is culture and change management for sure in this work and having a really strong team of nurses and doctors and APPs working together who believe in the model upfront.

You're already years ahead of many other systems. So kudos to say the least.

Susan Jarvis:

And we are just at the beginning. And I want to talk a little bit in a minute about the bumps in the road. You have been very encouraging to help us understand, like it is going to build over time. But before we get to that, I would like to know a little bit more about your role as medical director. What made you so interested in this work? And what do you do kind of on a day-to-day basis as a medical director?

Dr. Constantinos (Taki) Michaelidis:

Yes, thank you for that question, Susan. And you know, there's a personal story there and then certainly a professional journey. On the personal side of things, my mom was a nurse up in rural New Hampshire and spent decades going home to home as a home care nurse and just loved everything about being in the home, caring for her patients, getting to know them in a deeper way, understanding their social determinant challenges. And so I think I maybe had some home in my blood.

And when I came out of my own internal medicine training, trained at a really lovely program, and still I would notice that very, very often our patients would call in 5:01 p.m., 5:02 p.m., and oftentimes not feeling great, and we would often tell them to go to the emergency department. And I always ask myself, wouldn't it be lovely if we had a different set of tools to care for our most complex patients? 

And I think all of us can think of maybe our own frail family members or complex and vulnerable patients where you know, they're doing well at home. Maybe they just need a little bit of acute care. And if you keep them out of the ED or the hospital, they might avoid some of those things that happen in the hospitals that all of us want to avoid. 

So for me, that was where my personal excitement about home, acute care at home got started back a number of years ago. And then from a professional perspective as the medical director on this journey. So I am the medical director of our UMass program and have an amazing dyad nursing partner, Casey Phillips, and she and I work very, very closely together.

And so I oversee certainly our physician team, work with my boss, who's the chief of hospital medicine, Dr. Greg Leslie, who's a lovely and thoughtful progressive human being. And the question is always simply, what else do we need to build? What else do we need to add on to our already awesome program to make it even better and care for a broader range of patients? We take a very needs-based evaluation approach to our patients in the ED and on the floor is what do they need and how can we meet that need?

And so I do a little bit of certainly care for patients in the model, do a lot of growth work, a lot of change management, a lot of incentive alignment, a lot of working with our executive team who are very, very supportive, but my gosh, so busy as well and trying to be respectful of their time and sort of linking the frontline care with the executive leadership kind of primary principles around how do we build capacity? And I would love to hear your perspective on this.

In my own perspective in terms of capacity is that you know, lots of rural, urban, suburban health systems across the country are facing the same challenge. And whether it's a critical access hospital in a rural part of the country or an urban medical center in New York City where they're spending four or $5 million to build a bed, I am very, very convinced that we are not going to build our way out of this crisis of capacity in these United States. We ourselves also built a 72-bed lovely unit that opened just about a six months ago, and we saw a little bit of a decrease in boarding and that's been a real nice win, but the boarding is still there and I think we're going to have to all get way more creative across our country as we think about capacity, especially with the silver tsunami coming down the road for sure.

Susan Jarvis:

No, I agree 100%. And I think I do think the Hospital at Home program is going to be instrumental in helping us get through the silver tsunami and provide care in a different way. Just think, you know, going forward the next 10, 20, 30, 40 years, we've got to adapt. We, health care has done that in the past where we've changed how we deliver care, you know. I think about outpatient surgery in the '90s and you know, when it was all inpatient and then it became outpatient surgery and then just all of the things, and I think this is just the next logical step in how we deliver care and how we deal with the capacity issues because I think we do all have them for sure.

Well, we talked a minute ago about bumps in the road and new programs and challenges and that type of thing as I was saying.

Dr. Constantinos (Taki) Michaelidis:

Sure.

Susan Jarvis:

We are very early in our journey here, and so we're experiencing some challenges. You talked about change management, and change management is huge with this program as you get buy-in and that type of thing. When you stood up your program, what were the biggest challenges or hurdles that you had to figure out going forward to get it successful?

Dr. Constantinos (Taki) Michaelidis:

Yes, I love that question and would love to hear your perspective on this as well. There are so many different things that arise from being in the home that are unique about being in the home. And you know, I think about, you know, our, you know, New England terrible winter storms where we've got two, three feet of snow. And I'm sure you say, we say two, three feet of snow. Yeah. And you folks are like two, three feet. That's it. That's it. All of our ambulances have plows on the front, which I love. When you shared that story earlier, I was like, these folks know winter.

Susan Jarvis:

Do you have snow in New England?

Dr. Constantinos (Taki) Michaelidis:

And so I think there's so many different nuanced areas. One, stepping back for the moment, one piece that I would share is, when we stood up our brand new brick and mortar 72 bed hospital about six months ago over several years of planning, I think about all the folks who are at the table, nursing and pharmacy and the physician medical group and facilities. And there was so much effort and took two or three years of planning. 

And if I had to step back and say one area that I think all of us in home hospital probably could do a little bit better is maybe all of us could be a little bit less scrappy and a little bit more saying, you know, hey, we are building a 20, 40, 60, 80 bed virtual unit.

 I would never build an 80-bed unit with a friendly doc and a friendly nurse holding hands saying we can do this. You don't get resources, you know, that's, that's, you know, 60, 70, 80 million dollars. That's a full hiring strategy. It's, you know, it's a multi-year approach. And so I think we've got to be careful where even though I think there's a lot of ways in which building a program is less expensive than building $5 million beds, $3 million beds, it is still a real endeavor. And so I think we don't want to underestimate the resources required to build and stand up a virtual hospital. So stepping back to your original question around, what were some of those bumps?

I think part of it is just all the good old fashioned things. We need great nurses and medics and physicians. We got to hire them and train them. We need logistics management. We got to build resiliency for weather, for electrical storm or electrical downtimes with storms. We've got to make sure we're adhering to all of our policies. We've got to think carefully about patient acquisition. How do we align incentives? It's definitely a multifactorial approach, but would love to hear from your perspective. What would you identify as some of the key things that were bumps in the early days?

Susan Jarvis:

Well, you know I love those comments about you have to plan and resource it appropriately. And I think we maybe started with a scrappy nurse and a few scrappy doctors. And I think we've learned, you know, we've got to put a little more infrastructure around that as we go. And it is kind of like, you know, you're, you're not sure or your patient or you're going to get buy in from your patients. Are you going to, is it going to be a successful program? So how much do you invest versus trying to be scrappy and build it as you're kind of building the program?

We had the COVID pandemic and then we had our capacity issues and we had our physicians who came and said, look, let's look at this. The other things that we had in place already, we had been working on a virtual nurse pilot. So we had virtual nursing and then we had community paramedics already. So we've had community paramedics here in Fargo for over a decade.

We actually train community paramedics. We own and run the 911 ambulance service in the Fargo-Moorhead area and some others throughout our footprint. But years ago, they came forward and said, hey, there's this new program of community paramedicine. It's going to be great. It's going to help us fill gaps. And so we had community paramedics and they're used to going out into the home.

And they're used to noticing things that you might not always notice when you're in a home and that type of thing to make sure that we were taking care of the patients appropriately. So we had a lot of the infrastructure in place, but it's still, even after we got the waiver, I we took a good bit of time to make sure we had all our i's dotted and t's crossed when we went for the waiver, but it still took us about a year after we got the waiver to get enough staff of the rest of the staff to be able to implement the program. 

And all along then we were working on our infrastructure and what was the technology going to look like and how are we going to get drugs to the patients, all of those types of things. And so that took a while, a little bit longer than I expected it to take to get staffing to get started. And again, we started small. 

The other thing I would say, and we are still encountering this, although I think as we get the word out about the program, it's just patients buy in when they come in and we say, you would be a great candidate to be in your home, but also in the hospital. And we get a lot of skepticism still. And I wonder how you countered that in your program.

Dr. Constantinos (Taki) Michaelidis:

Yes, and holy cow, that is a deep and nuanced question, and we probably could spend two hours just talking about that alone. You know, a couple of thoughts. The first is that what we find is that when we reach out to a patient or a caregiving team on our own and say, think this patient is great, do you mind if we reach out to the patient and family? In the aggregate, about 20 to 30% of those patients ultimately end up with us.

Whereas when the patient is referred to us on day one or day two or day zero of their hospitalization by a confident physician or nurse or case manager who knows that patient and has already raised the idea with a patient, our accepting rate is typically closer to 70 to 80%. And so part of what we're trying to get to is, you thinking about our emergency departments, they're so busy down there, a really sick patient comes in with a pneumonia on three or four liters of oxygen.

And probably between the time we talked to them and the time they got into the ED, they've probably been down there somewhere between 10 and 20 hours. They've probably had four nurses and doctors all say, you know, you're really sick, you're going upstairs, you're really sick, you're going upstairs. And then we come along and we say, you're really sick, you're going home. And you know, that's just a little bit, a little bit sort of chaotic in their mind. Like, what the heck? Do these folks know they're talking about? Get all these different messages.

And so what we have done with our emergency medicine doc and nurse colleagues and our ED is we've done some very basic like seed planting efforts for them where we just say to them, all you got to do is understand rough idea of what we provide and just tell the patient, I think you're a great candidate for the program. Let me have those friendly hospital home docs and nurses come and talk to you so that we're setting things up early. And then I will say too, the advantage that we've had now that we've been operating for about four years, and I think you folks will have that advantage probably about a year or so from now.

It did take us about one to two to even three years to build the flywheel of patient expectations. And so now what ends up happening is that we've cared for about 4,000 patients is that many of those patients who come back three years later already know about us or their friend or their son or their mother or their daughter or their husband was cared for by us. And so they no longer think it's kind of nutty.

They just say, yeah, like you took great care of my son, my mother, my grandmother. That's just normal. Like why would I ever come back to the hospital if you can do that at home? And so I think the number one thing that we feel very strongly about, and I'm sure you folks have seen the same incredible outcomes, is that when we provide high quality, safe, patient-centered care and we delight patients or families and they're sleeping well at home and they're respected and given autonomy of being in the home.

They just say amazing things about us and they say, they rave about us to their friends and families. And so I think we probably hit that flywheel about two or three years in. Thankfully, is the first year was hard though, for sure. It is very hard because you're like everyone, every single person you're talking to has never heard of you ever before. So that's new.

Susan Jarvis:

We are starting to see some patients who have been in the program and then they come back in and they say, can I go back into my home and be in the hospital? So we're starting to see, you know, get a little traction there. And I do think our doctors and nurses are doing a great job of, you know, talking about the program and that type of thing. But the more they hear patients' stories about how great it was and our patients have been very satisfied.

Dr. Constantinos (Taki) Michaelidis:

Yes.

Susan Jarvis:

I think, you know, like you said, just that flywheel will just really start humming. So that's great. Just to change the subject just a little bit, we talked a little bit about snow and snowdrifts and you get to your – but I think yours might melt after you get yours. And I think ours stays here for a long, long time. But so we are very rural.

Dr. Constantinos (Taki) Michaelidis:

For sure. Yes.

Susan Jarvis:

But you have some rural areas too and I think that that has probably we probably have some similar unique challenges maybe barriers around transportation or language or weather or any type of thing like that. So how did you counteract, what, what were those types of barriers and then and how did you counteract those and how what do you do every single day to make sure you if you don't have a snowplow you can get out there to take care of your patients?

Dr. Constantinos (Taki) Michaelidis:

For sure, for sure. And we'd love to hear your approach on this as well. You know, I think we are very lucky that our snow does melt after a couple of months at least. You know, when we thought about building and scaling our program over time, we thought about a combination of geographic reach and payer contracts and building capabilities to meet our patients. 

And that's how we thought about the opportunity and expanding the opportunity. You're 100% right. We are in an urban environment in Worcester by about 20 minutes outside of our main medical center. You're in suburbia and another 30, 40 minutes you're at the New Hampshire, Rhode Island, Connecticut border, surrounded by farmland and cows in a beautiful part of our state. And so we kind of have to build capabilities to go everywhere. And that includes things like four-wheel-drive vehicles. We got to build redundancies for power loss. 

So for instance, we have a strategy for if there's a storm that knocks out electricity or power or heat in one of our patients' homes. We bring backup O2 cylinders for every one of our patients on oxygen. We build communication resiliency, so they've got phone or internet, so if one goes down, they have a backup strategy to get in touch with us. And then most importantly, and I would love to hear, you folks might have had a real nice advantage with your local community paramedicine capabilities that we were.

We had to build those kind of ground up when we launched. And so we didn't quite have that same foundation you folks did. That said, as we've gone further and further out into the community, those local EMS and 911 partnerships are critically important. So anytime we go into a new area, we partner with local EMS and 911 systems, we build communication pathways and awareness. So when they, you know, arrived to one of our patients’ homes, when we need their help, there's like a sign in the door, they see the patient with the bracelet on, they say, my goodness, this is a home hospital patient.

And we remember all the pathways that we worked on together for escalation. So I think the other part is that as we move further away from our main medical center, we typically, it's more and more important to bring the capabilities with our paramedics, with our nurses. And so we have urgent med packs, we have point of care testing, we use the i-STAT device quite a bit for phlebotomy and lab tests in the home.

And so I think that's been a real capability. And I've seen some of our peer programs who even, again, we're operating about 40 miles or so radius. And we have some peer programs in North Carolina that are operating almost about 150 by 50-mile radius. And for them, they have incredible on SUV capabilities in terms of medications and diagnostic. So we'd love to hear more certainly around how you thought about the opportunity in the community as you went further away and how you thought about your community paramedicines as an asset, paramedics as an asset and outfitting them for all scenarios.

Susan Jarvis:

Well, yeah, and I think that you helped us a lot with anticipating a lot of those things as we got our program ready. We are still going just about 25 to 30 miles as we're getting up and going. But we get pretty rural after about 10 or 15 miles. So we haven't expanded out as far. The 150 miles is very, very interesting.

I love the idea of exploring like what else could you have for that group that is providing the care that they need? So we're still learning, I think. The biggest thing, you know, besides having them well trained and everything that they need is we do have the ability to have snowplows on our vehicles. So to get out there and make sure we get out and see patients.

Dr. Constantinos (Taki) Michaelidis:

Yes.

Susan Jarvis:

Funny story, we started the program last year and the day we said, we're open and we're ready for business, we had a blizzard. So it was back last winter. We did not admit anybody that day because brand new program, which we tried, but people did. They're like, what? You want me to go home in this? And so we didn't. It took a couple of days for us to get our first admission.

But all of those things you have to take into account and you have to make sure that you're able to provide that care. I think we are very fortunate in the EMS world. We have a lot of resources with our EMS services. And one of the things we've talked about is how are we going to scale this? Because we do have also critical access hospitals throughout the rural footprint. How could we perhaps use local resources for the in-home visits?

But our virtual nursing at, you know, back at the hub here in Fargo. Do you do any of that type of kind of set up right now?

Dr. Constantinos (Taki) Michaelidis:

We do a little bit for sure, although we know that as we go, probably the next step to move further away from our medical center will by mandate for us to meet the patients' needs, have to involve more deeply involved care with the local 911 systems. And there'll be some interesting questions about credentialing and partnerships and communication for sure. I have worked in prior home hospital care models that used a more decentralized supply chain. 

And there's some real strengths to that model as well, where if you've built a partnership where there's a critical access facility that's like, let's say 300 miles away from you, but they have some real capabilities and they've got a local 911 system that works for that critical access hospital, but maybe they just need a little bit of physician support, a hospitalist, a virtual acute care nurse to backstop them and provide the backbone of the continuous hospitalization experience, that there may be some interesting ways to do that work. So I do think the decentralized supply chain is really, really interesting.

Susan Jarvis:

That's really interesting to explore. Well, your program has been up and going for several years now, and you talked a little bit about the word of mouth and people are saying, this is a great program. What do you, how do you measure success from a quality standpoint, from a patient experience standpoint? And can you tell me a little bit about maybe a patient's story of someone who was in the program and how it impacted them in a positive way?

Dr. Constantinos (Taki) Michaelidis:

Sure, and thank you for that question. It's probably the most fun thing to talk about in the program because it really brings to light the power of the home. And in some ways, think the home is, we're re-recognizing the home as the right site of care for many populations, in particular, our most complex, our most disadvantaged, our most medically frail population.

Recently about a number of years ago, we had cared for a gentleman, 67 or so, who came into our emergency department and he had a history of high blood pressure and diabetes and end-stage kidney disease and actually had a kidney transplant a couple years earlier. Was living in the community, his girlfriend lived next door, his daughter was a nurse practitioner who had a good relationship with but lived about two, three hours away. 

And he'd come into the ED just feeling off or so and had his initial set of labs there in the waiting room. And he was in the waiting room for about eight or nine hours and just got very frustrated and he left without being seen. And I think all of us know that that is obviously something that we want to, that's partially why we build home hospitals. We want to reduce those left without being seen to zero.

Our emergency medicine team called him back and he came back to the hospital with a very severe infection of his transplanted kidney. He was screened by our nursing team after seeing the transplant infectious disease doctors and kidney doctors. We asked him the home safety questions. He was brought home. We met him outside the home and we provided all the good old fashioned acute care that you and I both know is so standard. Your team does an amazing job every day. Our team does an amazing job every day. 

And over the course of the next four or five days, he did great, and he was discharged after about five or six days with us. And I love that story for two reasons. One is that a good old fashioned acute care, which is so critical, it's also just standard. We both do it all the time. Our hospitals do this work all the time, which is amazing. But what was particularly unique is the other things we found in the home. So for instance, he was showing signs of mild cognitive impairment that hadn't previously been well recognized. He had medication bottles that his primary team thought had been stopped months ago, but he was actually still taking some of them.

He was having trouble affording some of his medications. And so suddenly we've got the cognitive impairment, the medication errors, him skipping some of his transplant medications, and we can bring a medical and social SWAT team into the home. And we are involving social work and his daughter in our care team and doing multidisciplinary huddles and de-prescribing and getting rid of old medications and doing all of these things to reduce his risk. And in subsequent several years, he's not had a single readmission. 

And so I think that's the real positive, a real, real power, I would say, of the home. It's good old fashioned acute care, which both of our teams do all the time, with the power of the home all together. And I think to your point earlier around quality and safety, and would love to hear how you folks are thinking about this too, we've said to ourselves, you know, we have a reasonable and thoughtful quality and safety infrastructure in place at our medical center, and we want to continue and simply build on top of that. 

So when we look at all of our usual metrics, we track those in our hospital home specific dashboard with a couple of nuances in the Press Ganey, these scores around HCAHPS to make sure we're identifying the experience in the home and not maybe the experience in the emergency department before they got to the home. They're both very important, But we also want to separate them so we can understand the opportunity. And so what we've seen is, 60 to 70% reductions in mortality, five to 15% reductions in 30 day readmissions. 

We've seen essentially no harm, great events like DVTs, CLABSIs, CAUTIs, falls with injury. We've never had one of our paramedics or nurses in the home ever injured by a patient or caregiver in part because patients don't get delirious and agitated in home. They're just so much happier to be home. Our patient satisfaction in terms of top box recommend and overall rating of care, they're in the 89 to 92% range over the last several years, which for us in our health system is probably the highest patient satisfaction unit in the entire health system. And so it's been super rewarding for the whole team. And we'd love to hear too how you folks are thinking about quality and safety and patient satisfaction in your program.

Susan Jarvis:

Well, first, I just want to say that patient story is amazing. I mean, that just really encompasses what we can do with this program for our patients in their home. We have the staff that are the people that are used to looking for those things and intervening in our community, paramedics, and that's part of their training, right? And to be able to wrap that all together and really provide that wonderful care for that patient. Just amazing story. 

So thanks for sharing that. We're, as again, as I said earlier, we are really, really new in this. Our, you know, we're, quality, our quality measures are looking great for the patients that we've had in the program. The biggest thing is the patients are so satisfied and so happy and it's been a great experience for them. And so we're still in the process of building out how we make sure.

I love your point about separate out from the emergency department visit and the Hospital at Home stay. I think we have not done that and I think that's very important to do. Across the board, patients have been extremely happy, extremely satisfied. And we even have one patient who actually called back up and said, hey, I want to do a story, a promotional video. I want to tell the world about what the great experience was that I had in your Hospital at Home program. 

And so we're in the process of doing that. We're going to use that to promote the program as well as get some local media involved in that type of thing. So I think both of us and not just us, but people that are doing Hospital at Home across the country really believe in the program and really feel like it is kind of, I don't know, the next step or the next big thing in how we take care of patients. And it's going to be with us for a long, long time if we're able to get our CMS waivers extended. Both of our programs rely on the CMS waiver.

We are having this conversation late in third week of September of 2025 and our waiver is set to expire in about a week on September 30th. So what message do you want to share with our policymakers about the program? I think you've done a great job of sharing how great the program is. What else would you like to share?

Dr. Constantinos (Taki) Michaelidis:

Yes, Susan, thank you so much for that question. It is so critically important to where we are today in a home hospital in the United States. That CMS acute care at home waiver that was passed in 2020, and we've now seen three extensions across multiple administrations, blue and red, that will expire, to your point, in about a week or so, on September 30th. 

And so I would just ask our folks in Congress, the House and the Senate side to please, please pass at least a five-year extension of the acute hospital care at home waiver, as well as the telehealth waiver. They are so critically important to everything that we do. And what we've shared with our local representatives is that there's so much bipartisan support, red states, blue states, we all face the same issues around capacity and meeting our community needs. 

And most importantly, from a cost perspective, the Congressional Budget Office, when they looked at prior versions of this bill, they scored the bill as budget neutral. So Susan and myself, we're not coming to Congress saying, please give us $500 billion or trillion dollars. Instead, we're coming to Congress and saying, hey, this doesn't cost you anything extra.

And by the way, it's the lowest mortality, safest, highest patient satisfaction care model that exists in the hospital environment today. And so let's get this done and work together. That would be what I would say. Susan, would love to hear your perspective.

Susan Jarvis:

Exactly. I think we've got, we need a little bit more stability in the waiver. We need the five years. We, as we're starting, we're working with our payers to say, Hey, will you cover this? We've had payers say, you know, we want to wait and see what happens with the waiver. If this program is, you know, if the waiver is not going to happen, then we don't want to invest the time in figuring out how we're going to pay for, you know, get the patients paid for. And so the stability there is very, very important.

You know, we had a little bit of pause when we launched the program, we'd gotten the waiver and then we launched the program and I think the first waiver, we launched in December and the first deadline for the waiver was the end of March. So we took a leap of faith and we said we're going to do it. 

But then, you know, it is just the uncertainty is kind of hard. And so if we could get that for at least five years extended, I think we can just really run with it and just make the program even better and continue doing what we're doing for patients and grow the program and really expand. So I agree 100%.

Dr. Constantinos (Taki) Michaelidis:

For sure.

Susan Jarvis:

Well, thank you so much for sharing your insights. We serve different populations. We're, again, a lot more rural. But the common thread, I think, is really, really clear that this program relieves pressure on hospitals while giving patients care where they want it most and where they're most comfortable. And that is in their homes. Sustaining this model is going to continue, we're going to need continued policy support and collaboration. And I'm really, really hopeful that we can shape a future where it becomes a permanent part of care delivery. So final words from you.

Dr. Constantinos (Taki) Michaelidis:

Yes, Susan, just so grateful for this conversation. I love the word you use, regulatory stability, collaboration across this important enterprise of home hospital across the country, and continuing to push this model forward for our most complex patients. Kudos to you and your team. It was such a privilege.

Susan Jarvis:

Thank you so much. Great conversation.

Alan Helgeson (announcer):

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