Whatever It Takes:
Building a Healthcare System like "Cheers" (Where Everyone Knows Your Name)



Dr. Steven Stein, April 5, 2017

Fragmented care by fragmented providers during fragmented hours in fragmented settings through fragmented funding has not provided person-centered care.  Whatever It Takes (WIT) is an attempt to change that narrative in an incremental way for that person who has an event in their home that the person or their family considers an emergency.

WIT brings together St. Joseph Mercy Home Care and Hospice (SJMHCH), St. Joseph Mercy Hospital – Ann Arbor, Integrated Health Associates (IHA) and Huron Valley Physician Association (HVPA) physician groups, Emergency Physicians Medical Group (EPMG), Huron Valley Ambulance (HVA), and, some key community agencies such as Area Agency on Aging 1B (AAA1B) and Washtenaw County Community Mental Health (WCCMH) to consistently assess situations considered by a home care patient or family to be urgent, and, deliver an immediate response in the manner that is most appropriate and cost-effective for each event. WIT accepts the fact that patients and families often reach out in different ways when they have concerns.  They may call their physician's office.  They may call their home care agency.  Those with a personal care response system may press their pendant button.  They may call 911.  The home care agency might identify an urgent situation through remote monitoring (e.g., major gain in weight in someone with a history of heart failure who documents that they are more short of breath).

The program rests on a few major pillars: 

The first pillar is establishing a minimum common data set (MCDS) that gives providers immediate access to some key information about the patient believes they are experiencing a medical emergency. The provider will know certain elements of that person's history (e.g., physician's and case manager's contact information, chronic conditions, allergies, history of recent hospitalizations, some key social determinants of health (e.g., transportation issues, living alone, history of abuse, etc.), and any risk stratification scoring (i.e., high, medium, low risk) that has been previously done on the patient.  We call the MCDS the "Cheers" Form – one step toward building a healthcare system like Cheers – where everyone knows your name.

The second pillar, after  an initial phone triage that either reassures the patient and arranges follow up with their physician or, in a true emergent or urgent situation, arranges for immediate response that has a community paramedic or home care nurse entering the home, assessing the patient, video-conferencing with a physician, obtain orders for stat diagnostics (e.g., labs, oximetry, EKG, etc.) that are done right there in the home, treating the patient under the telehealth supervision of the physician.  If the treatment is effective (e.g., IV dose of Lasix for heart failure, nebulizer treatment for asthma, first dose of IV antibiotics for a pneumonia, etc.) and thus not require an immediate transfer to the ER, a follow up appointment with the relevant physician will be arranged for the same day or next day as well as a plan to meet any other identified needs (e.g., meals on wheels, a more thorough home safety evaluation, a follow up mental health visit, etc.).  Other times, the treatment may be unsuccessful and the physician will make the decision to have the community paramedic bring the patient to the physician's office, an urgent care center or an ER. 

The third pillar will ensure that the incident is well documented and the information related to both the assessment and treatment is sent to the primary care physician immediately so that the documentation an event that happened at 2 AM will be in the hands of the physician when the patient comes to their office for a same day appointment at 11 AM.

Initially, the program will serve only Medicare FFS home care patients that are enrolled in St. Joseph Mercy Home Care and Hospice in Washtenaw County.  The two year goal is to serve all patients in the Medicare Shared Savings Program affiliated with SJMH- AA.  That will take us from serving hundreds of patients to serving many thousands of patients – continuing us on our path to build a healthcare system like Cheers – where everyone knows your name.