Where: Beth Israel Deaconess Medical Center, a 650-bed teaching hospital affiliated with Harvard Medical School in Boston.
The issue: Improving quality of clinical care, including post-discharge transitions, for older patients in long-term care facilities.
In 2003, a hepatologist in New Mexico, Sanjeev Arora, MBBS, MACP, launched Extension for Community Healthcare Outcomes, or Project ECHO. Its goal was to have specialists use telecommunication technology to train primary care clinicians in effective hepatitis C treatment, allowing them to manage the condition in communities where access to specialists was limited. Project ECHO has since expanded to 39 hubs for nearly 30 diseases and conditions.
With the thought that nursing home residents with dementia could also benefit from something like Project ECHO, Melissa L.P. Mattison, MD, FACP, worked to bring the model to Beth Israel Deaconess when she was associate chief of the section of hospital medicine.
How it works
A pilot program, ECHO-AGE, launched in 2012 and linked clinicians in nursing homes with an expert team at Beth Israel Deaconess, said Dr. Mattison, an assistant professor of medicine at Harvard Medical School. The hospital now has 2 such programs for geriatric populations, which are overseen by Lewis Lipsitz, MD.
Using secure, HIPAA-compliant video conferencing, staff members at long-term care sites present challenging cases to Beth Israel Deaconess' team, which includes a behavioral neurologist, a geriatrics psychiatrist, and Dr. Mattison, a geriatrician. “Normally, a nursing home doesn't have access to a behavioral neurologist or a geriatrics psychiatrist, let alone 2 who are sitting in a room and will talk with you about the care of that patient at the same time,” she said.
Another program, ECHO-CT (the CT stands for “care transitions”), launched in July 2013 with the aim of improving transitions for older patients as they move from inpatient care to skilled nursing facilities for rehabilitation, Dr. Mattison said. Under this program, a weekly learning lab uses the ECHO model to bring together staff at participating skilled-nursing facilities with Beth Israel Deaconess hospitalists and others on the acute care side to run through real cases and review any concerns.
“We are really are striving to educate residents, students, hospitalists, and specialists in the hospital about how to smooth that transition as best as possible … using lots of different mechanisms that others have shown to improve transitions in care,” Dr. Mattison said.
Medication reconciliation is a particularly big issue that often comes up in ECHO-CT, according to Grace Farris, MD, a hospitalist in Beth Israel Deaconess' division of general internal medicine. She recalled an elderly woman who had been discharged to rehab on trazodone, zolpidem, and quetiapine at bedtime.
“We wondered how she could even tolerate all of these meds; then the [ECHO-CT] pharmacist discovered that her home Ritalin had been dosed at 8 p.m. while she was hospitalized, which obviously resulted in insomnia,” Dr. Farris said.
A trial of ECHO-AGE published in the December 2014 Journal of the American Medical Directors Association suggested that it could improve care. When ECHO-AGE recommendations for patients were followed, long-term care sites were much more likely to report that patients improved clinically—74% compared to 20% otherwise. Hospitalization was also less common among residents when sites adhered to recommendations.
Dr. Mattison gave the example of 1 case involving a woman living in a nursing home who had previously had a stroke. She had behavioral health problems involving paranoid thoughts, such as being fearful that someone would take her to Texas. The woman was also easily agitated during group activities, prompting staff to consider sedative or antipsychotic medications. But the case, presented to the ECHO team, proved solvable: The team's neurologist diagnosed left-sided neglect—a result of her stroke some time earlier—which meant the woman couldn't properly perceive what was happening on the left side of her body. The clinicians then worked together to come up with strategies, such as rearranging her bed and positioning her left-side away from stimuli, correcting the “paranoia.”
So who's paying for the nursing facility staff or the specialty team to spend an hour a week discussing patient care? “The answer is nobody,” Dr. Mattison said. “There's no reimbursement for that.” ECHO-AGE and ECHO-CT are currently funded through private foundation grants.
Theoretically, a nursing home with a disruptive patient with severe, progressive cognitive impairment has no incentive to keep that patient out of the hospital, Dr. Mattison said. The nursing home wouldn't incur the cost of sending a patient to the emergency department in an ambulance and at the same time would be getting reprieve from the patient's disruptions, she noted. “I think the biggest challenge is that the financial incentives often don't line up,” Dr. Mattison said.
However, finances aren't the only incentive to improve care. “What we've seen much more commonly, in fact almost universally, is the nurses and the doctors who are providing care to these vulnerable folks with cognitive impairment very much want to do what's right for the patient,” said Dr. Mattison, who in July began her new job as chief of the hospital medicine unit at Massachusetts General Hospital. “This is the right thing for the patient—and that's who we're answering to,” she said.
Creating a financially viable model is the next step, as grant money won't be a sustainable funding source. “And so that's what we're working on now,” Dr. Mattison said. “We're trying to continue the clinical process, as well as show value, so that it would be a sustainable business model.”
With each hospitalization or readmission costing roughly $19,000—plus up to $2,000 for an ambulance ride—the ECHO programs for geriatrics have potential for serious cost reductions, according to Dr. Mattison. “It doesn't take that many admissions to be avoided, and you've paid for the program for the year,” she said.
Words of wisdom
Talking over a tough case with someone else, especially an expert, can be helpful to any clinician, and new technology offers more ways to do that, whether it's a smartphone app, FaceTime, or another tool. “We live in a pretty exciting time with technology and with health care—and we have been practicing health care in pretty much the same way for quite some time. And this is a novel way to share knowledge and support patients throughout the community and across distances that is relatively new,” Dr. Mattison said.