The essential role of population health during and beyond COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Engaging Hospices in Quality Measurement and Improvement: Early Experiences of a Large Integrated Health Care System.

The quality of hospice care remains highly variable in the U.S. Patients, providers, and health care systems lack a comprehensive method of measuring the quality of care provided by an individual hospice. Partners HealthCare sought to assess hospice quality based on objective and quantitative criteria obtained directly from hospices and through public reporting. Here, we describe the process of creating and administering this assessment and the initial creation of a collaborative network with high-quality hospices. A multidisciplinary advisory council developed criteria and a scoring system, focusing on organizational information (e.g., nursing turnover), clinical care quality indicators (e.g., visit hours before death), and training (e.g., medical director certification) and satisfaction (e.g., patient and family surveys). All Medicare-certified hospices in good standing in Massachusetts were eligible to participate in a request for information (RFI) process. We blinded data before scoring and invited hospices scoring above the 15th percentile to join the initial collaborative. Of 72 eligible hospices, most (53%) responded to the RFI, and 32% (n = 23) submitted completed surveys. Hospices could receive up to 23.75 points, and scores ranged from 2.25 to 19.5. The median score was 13.62 (interquartile range 10.5-16.75). For hospices scoring above the 15th percentile (n = 19), scores ranged from 10.0 to 19.5 (median 14). The hospice RFI process is one health care system's attempt to evaluate hospice quality. Further research will determine whether the scoring system proves to be a sensitive, specific, and reproducible measure of hospice quality, and whether the collaborative can foster quality improvement over time.

Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial.

Background: Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking. Objective: To compare outcomes of home hospital versus usual hospital care for patients requiring admission. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03203759). Setting: Academic medical center and community hospital. Patients: 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions. Intervention: Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing. Measurements: The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days. Results: The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%). Limitation: The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability. Conclusion: Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care. Primary Funding Source: Partners HealthCare Center for Population Health and internal departmental funds.

Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial.

BACKGROUND: Hospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient's home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking. OBJECTIVE: Determine if home hospital care reduces cost while maintaining quality, safety, and patient experience. DESIGN: Randomized controlled trial. PARTICIPANTS: Adults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma. INTERVENTION: Home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing. MAIN MEASURES: Primary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience. KEY RESULTS: Nine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups. CONCLUSIONS: The use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial. Trial Registration NCT02864420.