Focusing on Aging Populations to Improve Transitions of Care with Kurt N. Martin, Senior Director of Operations for MedStar Health – Geriatrics and Senior Services

[00:00:00] Welcome to the Mimora Health Care Delivery Podcast.

[00:00:08] Through conversations with industry leaders and innovators,

[00:00:11] we uncover ways to simplify how patients and care teams navigate complex care delivery.

[00:00:20] Hi everyone, this is Dr. Jamie Holbert, Chief Medical Officer at Mimora Health

[00:00:26] and host of the Care Delivery Podcast.

[00:00:28] I'm joined today by Kurt Martin, the Senior Director of Operations for Jerry Aschrex

[00:00:33] and Senior Services at MedStar Health.

[00:00:36] Kurt, would you mind introducing yourself to our listeners

[00:00:39] and sharing with us a brief overview of your role?

[00:00:44] Good afternoon everybody.

[00:00:45] It's Kurt Martin.

[00:00:46] I have been in healthcare for about 26 years.

[00:00:50] The first 21 of those were all spent in the military health system,

[00:00:55] with the US Army.

[00:00:57] I retired in 2019 after 21 years and found MedStar Health as I went through that

[00:01:04] transition journey and I found myself trying to answer one question.

[00:01:09] How can we do this better for older adults?

[00:01:11] It felt every time I was coming home on vacation

[00:01:14] as I was supporting soldiers around the world,

[00:01:17] every time I came home it was to help an older adult navigate a health care system

[00:01:21] built by 40 year olds or 40 year olds.

[00:01:24] And it really didn't seem to be meeting the needs of the older adults in my own family.

[00:01:29] And I wanted to be a part of the solution.

[00:01:32] I wanted to help figure out how we can do it better.

[00:01:35] And that's how I found MedStar Health and it was during that transition period

[00:01:40] I had an opportunity to meet with leaders at MedStar Health

[00:01:43] from Dr. George Hanali, my partner,

[00:01:46] to our senior leaders in the hospitals, T.J. Sanker and others.

[00:01:50] And really they have a vision and they needed some help

[00:01:54] bringing that vision to reality.

[00:01:55] So it's been an interesting five years that I've been with MedStar now

[00:01:59] and it's all been focused on how to build systems that work better for older adults.

[00:02:05] That is great.

[00:02:06] Really excited to hear more and maybe to start.

[00:02:10] Why the focus on older adults?

[00:02:13] What is the major problem in this space

[00:02:17] that your team is working to solve?

[00:02:20] I'll go back to my high man, the army.

[00:02:23] And we had General Patti Horroho, who always used to talk about that

[00:02:28] blip of time, that 700 minutes or so a year.

[00:02:33] And that we as health care professionals get with our patients.

[00:02:38] And it's something like 525,000 minutes in a year.

[00:02:41] And if we see our patients for one hour a month in that either,

[00:02:45] which I think in primary care, we're lucky to do that.

[00:02:49] And I think we do that more in older adult care than anywhere else.

[00:02:52] But you really only have a piece of time with those older adults

[00:02:57] and with our patients in general.

[00:02:58] So how do we make the most of the time we have with our patients?

[00:03:02] I get in the right people in the room.

[00:03:04] And then what are we doing to impact change for all those other minutes

[00:03:08] that patient isn't with us, knowing that's where the majority

[00:03:12] of health care is happening for that person.

[00:03:15] And as we look at what MedStar Health is doing,

[00:03:18] we're really taking a look at that system of care in the older adult,

[00:03:22] not just the individual themselves, but the caregivers

[00:03:26] and the support structures, the meals, the home safety,

[00:03:31] all those social determinants of health that we talked about.

[00:03:35] And where do we start?

[00:03:36] I think we in health care tend to be overwhelmed

[00:03:40] by where to start with some of these problems.

[00:03:42] And I think this is a great population to start with

[00:03:45] because they're experiencing all of it.

[00:03:48] And they're at our heaviest users of the health system right now.

[00:03:51] Yeah, very well said.

[00:03:52] Tell me about some of the ways that your team is supporting

[00:03:57] the needs these older adults and some of the challenges

[00:04:02] that you're trying to support in that population.

[00:04:05] So I think we have to look at the journey of the older adult

[00:04:08] in our health care system to then talk about our vision

[00:04:12] for how to help that journey.

[00:04:14] And if we really think about what older adult goes through,

[00:04:18] first off, oftentimes we're healthy.

[00:04:21] We've turned 65.

[00:04:22] We're now on Medicare Medicaid.

[00:04:24] We're starting to learn what those benefits are.

[00:04:26] And then we have our first attack, our first stroke,

[00:04:29] our first take your pick of incident.

[00:04:32] And now we've started needing to utilize a health care system

[00:04:36] that we aren't trained to use.

[00:04:38] We haven't typically used for the majority.

[00:04:40] You think about the majority of your life from 18 to 44,

[00:04:44] you're only really using the health care system in emergencies

[00:04:47] and your annual primary care visit.

[00:04:49] Now you're having to navigate specialists.

[00:04:51] You're having to navigate skilled nursing and public care

[00:04:55] and all of these other aspects of health care

[00:04:58] that you've never needed before.

[00:05:00] So as an older adult on that journey,

[00:05:02] you've now had your presentation at the ER.

[00:05:05] Maybe you've spent time in the inpatient side.

[00:05:08] Now we're sending you to the subacute rehab for the first time.

[00:05:11] You don't know what physical therapy is going to be like.

[00:05:14] You don't know what your resources you're going to have at home.

[00:05:17] Maybe your children have moved out.

[00:05:19] Maybe you're trying to age in place on your own

[00:05:22] or maybe you're in an extended family household.

[00:05:25] Everybody's situation is different.

[00:05:27] And we as a health care system,

[00:05:29] we tend to see this as boxes, right?

[00:05:34] I worry about you in the time that you're with me in the hospital.

[00:05:37] I worry about you.

[00:05:38] If I'm the skilled nursing facility,

[00:05:40] I'm worried about you until I let you out of my skilled nursing facility.

[00:05:44] So forth and so on.

[00:05:46] We are really trying at MedStar to look at it as a system

[00:05:50] and trying to intercede

[00:05:52] in all the different transitions of care locations

[00:05:55] where we tend to see the bounce backs to the hospitals.

[00:05:58] We tend to see changes in the quality of care

[00:06:01] as we transition from skilled nursing to home

[00:06:05] or hospital to skilled nursing.

[00:06:07] All these places where we have the opportunity to drop the ball

[00:06:11] and really trying to put a team together that is connected

[00:06:16] and creates that connective tissue

[00:06:18] between these different elements of our health care system.

[00:06:22] And that's what we're doing.

[00:06:23] Yeah, really excited to dig in a little bit more.

[00:06:25] Tell me about some of the ways that team is

[00:06:29] outreaching and interacting with these populations.

[00:06:34] I understand that many of these touch points are not happening

[00:06:39] when the patient is in the clinic,

[00:06:41] but they're happening in ways that are meeting the patient where they are.

[00:06:45] So it starts with the narrative interdisciplinary team.

[00:06:49] And I know we all talk about these things,

[00:06:50] but for us that includes social work, clinical pharmacy,

[00:06:54] because I haven't met a patient yet that goes into the hospital

[00:06:57] with one set of prescriptions and runs out the exact same.

[00:07:01] We also include physical therapy

[00:07:03] because a lot of our challenges in older adults are with mobility.

[00:07:06] And we focus on that Institute for Healthcare Improvement

[00:07:09] and the 4M model for the age-friendly health system.

[00:07:13] And what does that mean?

[00:07:15] It means we're looking at how these older adults are managing themselves.

[00:07:19] And then we're putting our providers.

[00:07:20] We've got the ambulatory systems that are traditional primary care,

[00:07:25] but with the interdisciplinary team support.

[00:07:28] That way we can show you when you go home,

[00:07:30] we can check on your caregiver.

[00:07:32] We can coordinate with the Alzheimer's Association

[00:07:35] for additional resources in our base primary care practice.

[00:07:40] We're getting into the home.

[00:07:42] I remember one story of this older adult couple that was aging in place

[00:07:47] and they were doing a wonderful job and they were very vulnerable

[00:07:50] and they couldn't necessarily navigate many of the systems.

[00:07:53] And our social worker went in and one day found them

[00:07:57] sitting comfortably in their home but heating it

[00:08:00] and keeping the other in the arm because they couldn't figure out

[00:08:03] how to pay the electric bill.

[00:08:05] It wasn't that they couldn't pay the electric bill,

[00:08:07] they couldn't navigate the system to pay the electric bill.

[00:08:11] And that was what was preventing them from having heat.

[00:08:13] Once you get heat into the house, suddenly they're much more comfortable

[00:08:16] and it was really just a matter of somebody being able to help them

[00:08:20] pay their bill on time and set up automatic paint.

[00:08:23] It's not something I need a doctor doing.

[00:08:25] It was something that for the house of that patient needed to be done.

[00:08:29] And that's where the social work and the other team members can come in.

[00:08:32] Clinical pharmacy is critical.

[00:08:34] We talk about deep prescribing, we talk about opioids in older adults.

[00:08:38] We talk about all the different beers list,

[00:08:41] which is that list of medications that impacts older adults differently

[00:08:46] because we know that those interactions exist.

[00:08:48] Now you're visiting multiple oligists

[00:08:51] and you need that individual that can help you navigate

[00:08:53] between what your neurologist, your cardiologist,

[00:08:57] your endocrinologist, all are prescribing different things.

[00:09:00] And sometimes those things interact and not all of them

[00:09:04] trying to help records interact with each other.

[00:09:07] And especially in an area like Maryland where MedStar Health

[00:09:11] has a lot of offices, they're all of the health care choices

[00:09:14] for those older adults.

[00:09:15] They plenty of other opportunities.

[00:09:18] And we want to make sure that when they're choosing us,

[00:09:20] we know what's happening with their care.

[00:09:23] And the electronic health records don't always talk to each other.

[00:09:25] So how do we navigate that?

[00:09:27] And it takes a human being interceding

[00:09:30] and making sure that we're having the right conversations.

[00:09:33] And we're filing a home, hospital, skilled nursing.

[00:09:36] And we've got physicians and nurse practitioners in the home,

[00:09:41] in the hospital, in the ambulatory setting,

[00:09:44] in the skilled nursing setting,

[00:09:45] and with following and communicating with each other

[00:09:48] as a team, taking care of those older adults

[00:09:51] that are enrolled in our complex care clinic.

[00:09:54] So I know you mentioned a lot of different roles,

[00:09:57] including social workers and nurses and physicians and others.

[00:10:03] Can you maybe just walk through what is the composition of this team?

[00:10:07] Who are the different roles who are involved?

[00:10:09] One look at four different domains of care.

[00:10:12] We have our standard ambulatory clinic,

[00:10:14] which is the interdisciplinary team.

[00:10:16] We have an autographed registered nurse doing the tree on us

[00:10:20] and it'll be cute to blow up.

[00:10:22] So we make sure if a patient has gone to the hospital,

[00:10:25] we know what's happening.

[00:10:26] We also have social worker clinical pharmacy,

[00:10:29] physical therapy, all as part of our interdisciplinary clinic

[00:10:33] in the ambulatory setting.

[00:10:34] And then if the patient goes to the hospital setting,

[00:10:38] we are working with our hospital leaders again

[00:10:41] in that age-friendly health system mindset

[00:10:44] to look at and make sure that we have a geniatrician

[00:10:48] and or a geriatric nurse practitioner

[00:10:51] that has eyes on our patients when they're in the hospital setting.

[00:10:55] Transition to the skilled nursing,

[00:10:57] we've got medical directorships

[00:10:59] and we're overseeing the quality of care

[00:11:01] in some of the skilled nursing facilities,

[00:11:03] the larger ones around our hospitals,

[00:11:05] as well as partnering with groups like Future Care,

[00:11:08] Communicare and others that run these buildings

[00:11:11] to make sure that our patients when they're there

[00:11:13] are getting the right care.

[00:11:14] And in some cases,

[00:11:15] it's in our physicians and nurse practitioners

[00:11:18] that are providing that care directly.

[00:11:19] So that's the third domain.

[00:11:21] That fourth domain is home-based primary care.

[00:11:23] When that group of adults is no longer capable

[00:11:25] of coming to us or they are a caregiver

[00:11:29] for an individual with a mobility challenge

[00:11:31] and they meet all of the Medicare criteria

[00:11:34] for home-based care,

[00:11:36] we will bring the physician and nurse practitioner

[00:11:38] out to them.

[00:11:39] We have social work and a registered nurse

[00:11:42] on that team to help manage their care 24-7

[00:11:45] to take the phone calls

[00:11:47] when we need to take the phone calls to triage patients

[00:11:50] and to really just make sure they're getting

[00:11:52] the services they need at home

[00:11:54] for those that can't come to us.

[00:11:56] Because again,

[00:11:57] this is about meeting the older adult

[00:11:59] where they are in the system,

[00:12:01] but he's older adults

[00:12:03] or what else is the system?

[00:12:05] And we got to be where they are.

[00:12:06] Kurt, I know there's a lot going on

[00:12:10] across the country in trying to bring care

[00:12:14] to patients where they are.

[00:12:16] And part of that involves caring for patients at home.

[00:12:20] Tell us about some of the ways

[00:12:22] in which your team is providing care in the home.

[00:12:25] Our care is pretty straightforward

[00:12:28] in that it's home-based primary care.

[00:12:30] I think what makes it unique is

[00:12:32] we are actively seeking out

[00:12:35] these alternative payment models

[00:12:37] that are offered by the Centers of Medicare

[00:12:39] and Medicaid Innovation and CMS in general

[00:12:43] just to again make sure that we're able

[00:12:46] to provide the level of care

[00:12:47] that these older adults deserve

[00:12:49] in the setting where they need it.

[00:12:51] And I think that's been one of the challenges

[00:12:53] historically in home-based primary care

[00:12:56] is the payment models just don't keep up with the need.

[00:13:00] We've been,

[00:13:01] we were some of the initial members

[00:13:03] of the Independence at Home trial

[00:13:05] that was a CMMI project from,

[00:13:09] or demonstration that lasted over 10 years

[00:13:12] from 2008 to 2018.

[00:13:15] And it's wrapping up now.

[00:13:18] We transitioned into primary care first

[00:13:21] which was another alternative payment model

[00:13:23] where we saw that Independence at Home

[00:13:26] was starting to sunset and we said,

[00:13:28] okay, we still need another payment model

[00:13:32] that is better than fee for service

[00:13:34] even though maybe not as good as independent at home.

[00:13:38] And now from PCF, we have primary care first

[00:13:41] we have now transitioned into

[00:13:44] one of these new accountable care organization models

[00:13:47] because they provide these additional

[00:13:49] per member per month payments and shared savings

[00:13:53] so that if we can prove that

[00:13:55] and through the data

[00:13:57] that our patients are staying out of the hospital

[00:13:59] and their total cost of care is less

[00:14:02] we get a part of that shared savings

[00:14:04] for Medicare and Medicaid at the end of the day.

[00:14:07] And honestly, I've got the data

[00:14:10] and we've looked at the data

[00:14:11] and we can truly say that we are definitely making

[00:14:15] a difference in making an impact

[00:14:17] in the older adult lives that we can touch

[00:14:20] and we are saving Medicare and Medicaid.

[00:14:23] And yeah, this is the opportunity to benefit from that

[00:14:27] while we provide all of these wraparound services

[00:14:31] that otherwise they may not have access to.

[00:14:33] That's great.

[00:14:34] I was going to get to that question around ROI

[00:14:37] because I've seen a number of studies

[00:14:40] that in many cases,

[00:14:42] providing additional services for primary care

[00:14:46] particularly for patients who have complex needs

[00:14:50] it makes sense and it feels like the right thing to do

[00:14:53] but he doesn't always result in cost savings.

[00:14:57] So I'm curious in your case

[00:14:59] how have you set the success measure

[00:15:02] such that you're able to track towards

[00:15:06] the proving out of an ROI here?

[00:15:09] And I think that's the challenge

[00:15:10] of all the value-based models, right?

[00:15:12] Because so much of the value

[00:15:14] the financial ROI is on the back end.

[00:15:17] It's proven negative,

[00:15:19] prove that patient wouldn't have used the system as much

[00:15:22] or that your intervention kept them from the hospital event.

[00:15:27] And I think that's what will always be a challenge

[00:15:30] in these value-based systems.

[00:15:31] And I think as we live in Maryland

[00:15:34] and we function in Maryland

[00:15:36] where the total cost of care is a measure of success

[00:15:39] that we use,

[00:15:40] as it had been for independence and home

[00:15:43] and some of these other models

[00:15:44] we have to be able to show

[00:15:46] that we are reducing the total cost of care.

[00:15:49] And I can point to 50% fewer inpatient visits

[00:15:54] for our patients when we look at the level

[00:15:56] of complexity based on all the different diagnosis codes

[00:15:59] and compare that against a similar Medicare population.

[00:16:03] We know our patients use the hospital 50% less.

[00:16:06] They use the ER 45% less

[00:16:09] that they get readmitted 50% less

[00:16:12] because we have the time

[00:16:13] and the ability to follow up with them.

[00:16:15] So we know our patients use the hospital less

[00:16:18] and that reducing,

[00:16:19] we know that's where the majority

[00:16:21] of healthcare spending is.

[00:16:22] It's in the hospital,

[00:16:24] it's in the subacute rehabilitation.

[00:16:26] So if we can keep the patient happy,

[00:16:28] healthy and at home where they wanna be,

[00:16:31] we want them to be everybody benefit.

[00:16:34] And then it's just a matter of proving

[00:16:36] that cost savings on the backend.

[00:16:37] Yeah.

[00:16:38] In terms of the spending that you need to do

[00:16:42] to hire the personnel

[00:16:45] and deliver these services,

[00:16:47] are there other expenditures that go beyond

[00:16:51] just hiring FTEs to do this work?

[00:16:55] Is there technology?

[00:16:57] Are there other things that you need to account for

[00:17:00] to set up a model like this?

[00:17:02] There aren't necessarily other technologies.

[00:17:05] We do have laptop computers

[00:17:07] where our providers have the wireless capability

[00:17:09] so they can be in the home

[00:17:11] and documenting all their care at the same time.

[00:17:13] We would love to get to the point

[00:17:15] of remote patient monitoring.

[00:17:17] I think that would be an ideal state.

[00:17:19] We are not there yet,

[00:17:21] but the idea of just being able

[00:17:23] to monitor glucose levels and monitor heart rates

[00:17:26] for those that are dealing with CHF

[00:17:28] or any other chronic ailment that we try to manage,

[00:17:32] I think that would be an ideal state.

[00:17:34] We have not gotten there yet,

[00:17:35] but I think there are potentially additional resources

[00:17:38] for that somewhere down the road,

[00:17:40] especially as the rewards for these models

[00:17:43] start catching up with the timeliness of payment.

[00:17:46] Yeah, that makes a lot of sense.

[00:17:48] Are there any specific burst

[00:17:52] that you can share with me

[00:17:53] in terms of some of the results that you've seen?

[00:17:56] Have you published or otherwise shared more broadly

[00:18:00] some of the early successes of this program?

[00:18:03] We have not published.

[00:18:04] That would have been great,

[00:18:05] but actually early as we got to the eight year mark

[00:18:09] in the Independence at Home program,

[00:18:11] we did do a look back on our work

[00:18:14] and we could definitely demonstrate

[00:18:16] a 20% total cost of care savings

[00:18:19] for our home-based primary care team

[00:18:21] specifically in the work that they were doing,

[00:18:23] keeping the patient happy and healthy and at home.

[00:18:26] We have not been able to do that same kind of deep dive.

[00:18:29] We're just starting to see the impact studies

[00:18:33] where we're looking at how much fewer utilizations,

[00:18:37] how many fewer utilizations we've had

[00:18:39] of the inpatient in the emergency department

[00:18:42] for patients that are utilizing our services

[00:18:45] for their complex care versus similar patients that don't.

[00:18:49] But again, that's where I can say 50% less ER utilization,

[00:18:54] 50% less inpatient utilization.

[00:18:57] And that adds up to cost savings.

[00:18:59] I haven't quantified all that cost savings yet

[00:19:01] that I'm looking forward to being able to publish

[00:19:03] that one of these days.

[00:19:04] Yeah, those are impressive results

[00:19:06] to see 50% reductions in utilization.

[00:19:09] So Kudos to you and the team.

[00:19:11] What is the magnitude of the e-term action

[00:19:15] in terms of the number of patients reached?

[00:19:18] Can you describe to us the scale at which you're delivering

[00:19:22] these services or how many patients have been through this program?

[00:19:25] I think that's also one of the wonderful things

[00:19:27] about this program is you're managing these older adults

[00:19:31] based on their need.

[00:19:32] I think if we look at primary care as a continuum

[00:19:36] from well elder to then needing so

[00:19:39] that well elder that's playing pickle ball three days a week

[00:19:42] and walking three miles a day,

[00:19:44] they can stay with their internal medicine.

[00:19:46] They're doing great.

[00:19:47] Keep doing great.

[00:19:48] The services that we're offering in our ambulatory centers

[00:19:52] and then in our home based primary care, it keeps escalating.

[00:19:55] So as you start to maybe have that first o-loatman

[00:19:59] or first diagnosis of Alzheimer's

[00:20:02] or some sort of dementia,

[00:20:04] maybe you had your first fall, your first heart attack,

[00:20:07] your first take your pick.

[00:20:08] Now you're eligible for

[00:20:10] our more comprehensive care management.

[00:20:13] And we've taken care of,

[00:20:15] last year we took care of over 3,000 lives

[00:20:18] amongst the different programs.

[00:20:21] Not the, on average,

[00:20:23] she'll stay with our home based primary care team

[00:20:25] about eight months.

[00:20:26] But again, that's before they make a transition

[00:20:29] to palliative and hospice type care.

[00:20:31] You don't get to be homebound for a reason.

[00:20:34] Yeah, we manage a lot of these complex older adults

[00:20:36] across making meeting their needs where they're at.

[00:20:40] Excellent.

[00:20:41] And with that, we're gonna close things out.

[00:20:44] Thank you, Kurt, for sharing your insights

[00:20:47] with me and our listeners today

[00:20:49] and the magnitude of the impact you're having

[00:20:53] on the lives of these older adults

[00:20:56] with complex medical conditions.

[00:20:58] Really is remarkable.

[00:21:00] So thanks again for joining us, Kurt.

[00:21:03] And until next time, everyone.

[00:21:05] Thank you.

[00:21:06] Thanks for listening to the

[00:21:10] Memora Healthcare Delivery Podcast.

[00:21:12] For more ideas on simplifying complex care

[00:21:15] for care teams and patients, visit memorahelft.com.