By Barb Gorman
I had the opportunity last month to interview Linda Colantino, senior research analyst with the Center for Medicare and Medicaid Services (CMS) during her site visit to Housecall Providers (HCP). Linda’s current role is team lead for the national demonstration project, Independence at Home (IAH). Joining Linda on the site visit was Judy Abbate and Ashley Malpass, two colleagues from RTI International, the demonstration’s implementation contractor. The following is an edited excerpt of that taped interview.
Barb: Can you tell me why you decided to visit HCP?
Linda: You can read all that you want on paper and talk to people on the phone, and that information is very helpful, but when you have the opportunity to sit down and meet the people who are on the ground doing the work and be able to visit a patient involved in the project – when you put that all together, the picture becomes much clearer.
One of the reasons I specifically wanted to come to Oregon, and we have very limited travel funds at CMS, is that Housecall Providers is the only primary care practice in the demonstration that interacts with patients living in adult foster homes.
Barb: Yes, the adult foster homes are pretty unique to Oregon.
Linda: I’ve been trying to put this all together for some time now, how your primary care providers interface with the caregivers who are paid in these settings. Trying to discover how it all connects. The adult foster homes take in the frailest and sickest individuals, as does everyone in this demonstration, and to offer this type of service, coupled with in-home primary care– I think would be the best type of intervention for this population. It is exciting and conceptually I think it adds a dimension to this demonstration that had Housecall Providers not submitted an application and been accepted, would not have had the depth that it has now. All of that being said, I really felt it was important that whatever funding we had, I try to come out.
B: How is RTI involved in the demonstration?
L: They are involved in multiple ways and do a lot of work for CMS. RTI has the technical and research expertise that CMS depends on and I have worked with them on other projects in different roles at CMS. With regard to IAH, RTI is working with us to implement and manage the operations of this demonstration, and analyze other variables than the ones we’re looking at in the implementation stage.
B: What can you tell me about how the demonstration is going thus far?
L: I’m finding it to be extremely interesting. This is an intervention that is not the norm. We’ve been looking at care coordination, value based purchasing, and all kinds of things at CMS, but this demonstration is interesting because you’ve got provider based, not organization or company based, but provider based organizations that are responsible for carrying out the tenets of the demonstration. I would say it’s going well, with a lot of challenges and barriers not just for CMS and RTI, but for the providers themselves.
B: Challenges to meet the bench marks?
L: Just to understand what it’s like to be a part of a demonstration. To be accountable and responsible and meeting the criteria that we have to, per the legislation. That is my job, to make sure that whoever is participating in this demonstration is meeting the criteria required of them.
B: Hasn’t that criteria changed since the demonstration started?
L: No, it’s been tweaked, but it hasn’t changed. You can’t change legislation without going back to Congress and having them change it. What is legislated, what is required, we have to follow through on that. That’s how we will measure if the demonstration, as a whole was successful.
I think that it is going as well as any demonstration; it has ups and downs, but we’ve learned a great deal from it already. I think the general opinion is that this is a no brainer- how could this not be the best possible thing to do? But when you run a demonstration you must be able to show with data, hard data, that it meets all the requirements as to whether or not it can be a public part of the Medicare program. We’re all working as a team to make that happen, along with all the providers.
B: Yes, we wouldn’t want to have a demonstration that’s achieving the triple aim, and then not make the shared savings model one where providers couldn’t afford to deliver this type of intervention.
L: Now, that’s not exactly so- that is the end result, but it is much more. We’re hoping that the demonstration looks successful financially, but quality is extremely important. In all of the programs at CMS the focus is really on quality because if you’re saving money, but you’re not improving quality for the patient, then there’s a problem. In regards to the quality and the savings, I don’t think there’s much of a problem. The issue is how to integrate IAH within the Medicare framework. Who should be providing this type of care and what would the criteria be for patient enrollment.
B: So provider participation wouldn’t open to just anyone?
L: Yes, Medicare’s not going to do that. There’s a lot to consider. We have to now look at the results and then try to figure out the bigger picture now of, if we want to make this part of the Medicare program, who should be able to participate? The demonstration says you have to already have been taking care of at least 200 patients that look like this, do we want to keep that the same? They have to all have had a hospitalization in the last year, so we know the beneficiaries in the program have incurred costs with Medicare that is already pretty high. There are so many variables that we are looking at to make sure that we are getting this right. It’s not a matter of an acceptance of whether this is the right intervention for this type of patient, because I think everyone agrees that it is.
B: I imagine it is an enormous task to ensure that qualified providers are offering care to the appropriate population?
L: How can we control it to the extent that the right people are delivering the right care, at the right, time to the right beneficiary? If we do that I think we will definitely impact the cost and improve quality, given the patients we see when we do these site visits – it is amazing that they’re home. And it’s wonderful, surrounded by all the people who care about them, as opposed to being in an institution where it’s not quite the same.
B: Tell me about your visit to the adult foster home? What stuck out for you?
L: I thought I was going to go a home with various rooms. Well this one is set up totally differently. I thought it looked like a little motel, with little units attached. It’s fascinating. You walk in and it’s shaped like a U, it’s – like a little apartment with a kitchen, some bedrooms and a living room. And in the bedroom was the owner’s husband in the bed, and she had another room, it was immaculate, it was lovely. There are other units like that, and there’s a caregiver that goes from place to place, just as if these rooms were in a house.
B: Approximately 60% of our patient population live in adult foster care.
L: And we’ve never seen anything like that. A great intervention.
B: What I love about the adult foster home model is that you have frail, many times bedbound residents, who in the past would be living in a nursing home, yet right outside their door, kids are running around, the dog is barking, chicken’s frying – life is happening. The residents are part of it all – not separate.
L: Isn’t that better than being somewhere in an institution? I tell you, each patient wouldn’t want to be anywhere else, at that time, and at that point in their life…they seem happy where they are.
B: Finally, what are you going to take away about Housecall Providers from this visit?
L: The professional environment here is palpable, and the respect for the people that are here too. There’s a sameness with all of the sites in the demonstration because there has to be, because they have to provide the same information, the same kinds of intervention, but I think Housecall Providers has a uniqueness. The fact that it’s a nonprofit organization providing care in an environment that we haven’t see from any other provider involved in the demonstration. I think the challenges for Housecall Providers are probably a little bit more than what some of the other providers in the demonstration are experiencing.