UNLEASHED: Episode 13

0:00Welcome to Unleashed, a podcast in which we challenge every clinician listening to us themselves. What would I do if I were Unleashed? What would I do if I could reinvent care from scratch? I'm Glyn Ellwyn. And I'm Chris Trimble. And listen, we have some very good news. We're going to be with you at least once per month until the end of this year. A great big thank you to our two sponsors, the Dartmouth Institute for Health Policy and Clinical Practice, and EBSCO, Makers of Dynomed and Dyna AI. And with that, let's get on with today's episode. Our guest is Joe McDonough. Joe runs Innavive, a home health company based in Massachusetts. So we focus on the behavior health population. People with severe mental illnesses, we focus on patients that are diagnosed with schizophrenia,

1:00schizophrenia, effective disorder, major depressive disorder, bipolar disorder, and this sort of a bunch of varieties within those disorders. In really the five disorders, personality disorders, you know, anything that can impact a patient's ability to remain healthy in the community. Already a challenging population, but there's more. Most people who have significant levels of mental illness also have challenges with their physical health and not just a few. About the 10 to 12 different medical comorbidities, along with their primary psychiatric diagnosis, they're prescribed an average of 15 to 18 different medications. That is a lot of complexity. And there's also this. Our population, they're often alone. They've burnt out their families. They really don't have any support. Chris, this is very tough. This group of people is among

2:03those with the highest medical needs. And they're socially isolated, lonely, in other words. They have a very hard time taking care of themselves or getting the primary and preventative care they need. And the result is predictable. A lot of hospital and ER visits. And often things don't go well leading to even more complexity and expense. Okay, I think we've set the table. This looks like a difficult situation to address. Before we go on, let's give our listeners three questions to think about as they listen. Absolutely. Question one, could we do better if we deliver more services to this population in the home instead of in hospital or clinic? Question two, if yes, who will pay for home health services for this population? And question three, other than payment, what would be

3:05the most challenging day to day aspect of running a home health operation for this population? When we come back, we'll start Joe's story at the beginning. Joe McDonough's career choices trace back to a tragic experience in high school. He was on the wrestling team, a really good wrestling team. And we had a great team, great group of guys where I were very good friends. And my senior year after we won the championship, my friends got in a car accident and two of my close friends passed away and a couple of my other close friends were seriously injured. And it really impacted all of us. Today, lots of young people are quite comfortable talking about mental health. That wasn't the case back then. You know, we need nothing at that time of PTSD or trauma. But we we all felt it one outcome for Joe. He became intensely interested in

4:08psychology. And when I was in college, I ended up working at an impatient psychiatric facility. I saw some very tragic things. And I would see the same people coming in and out all the time. And oftentimes they would leave and they would be stabilized. And then a week later, they would be, you know, really psychotic or they would be actively using drugs or they'd be suicidal again. And there were some really, really terrible things I witnessed. Joe remembers one patient in particular. There was this young guy who was literally my age. I was 22 years old at the time. His name was Charlie. He was from Charlestown, Irish Catholic kid from Charlestown and great guy. Charlestown's the neighborhood just over a bridge from downtown Boston. There was something that Charlie's family had a difficult time with. Charlie was gay. He had like four or five brothers and four sisters, very large Irish Catholic family and they disowned him. They disowned him. Fortunately, Charlie's treatments seemed to be helping.

5:14His mood elevated. He was in a much better place. He was smiling. And I remember the day he was discharged. He shook my hand, gave me a hug and thanked me for everything that I had done for him there. But Charlie was not doing as well as it seemed. You got discharged and a day or so later, he ended up dropping in front of a train. To Joe, Charlie's death was senseless. And he wondered if it could have been different. I always wondered if if there was home health at that time or program like ours at that time, we could have sent a nurse could have been waiting for him when he got home and potentially could have prevented that. Several years later, after Joe finished nursing school at Yale, he was working at a mental health facility in Connecticut. He saw the same issue. Patients didn't do too well at home. I would see patients going in and out and I would see patients being discharged and I would look at the medications they were being prescribed. And I just knew at the time, and even talking to some of the psychiatrists, we just knew they were going to be back. And

6:18and unfortunately, sometimes when they didn't come back, something bad happened to them. Well, they would be, you know, justice involved. And, you know, they would end up in jail. As time passed, Joe sharpened his diagnosis of what was wrong with the system. It wasn't just that there was no care in the home. It was also for whatever reason, Connecticut at that time, they really separated the behavioral health from the medical. I saw that they had, you know, much more medical needs and I realized that it had to be much more integrated. So mental health and physical health could not be treated in two separate worlds. For Joe, that principal was hammered home by an experience with another patient that he'll never forget. Her name was Gail. She was somebody that suffered from schizophrenia. She had a significant case of COPD that would have trouble breathing. Sometimes she smoked. She was very stable psychiatrically. She really was a truly lovely person.

7:23But if Hollywood was going to cast somebody, you know, in a very stereotypical way and as somebody diagnosed with schizophrenia, you would cast Gail. Joe, now a working nurse in Boston was caring for Gail in her home. And he was with Gail one day when she was having difficulty breathing. And so I ended up calling the EMT. They instructed them to say, look, she needs to have a complete, you know, pulmonary evaluation. You know, she's really struggling. And so they brought her to the ER at a major hospital in in Boston. But the ER staff zeroed in on her psychiatric history. And they just assessed her psychiatric symptoms. But they said that she was not psychotic. They didn't really need to admit her. So Gail was discharged. She got sent home and then she ended up in essence suffocating on a floor, which to this day still still outrages me. The error in the ER, the focus on Gail's psychiatric symptoms remains a painful memory for Joe.

8:26I was not sending her there for that. But the truth is Joe still sees the same kind of decision-making. Patients like Gail are so complex that it's too much to solve all at once. So clinician simplify. And there's a lot of wonderful people in the system. But I think the way the system is right now tend to look at people from a psychiatric perspective or a medical perspective. People tend to want to put them in a box and you have to look at them as a whole person. Treating the whole person, that is Joe's true North. But today's health care system is falling far short of that goal for people with severe mental illness. They're traditionally underserved, traditionally have difficulty accessing care, have difficulty accessing primary care in particular. And they tend to be much more sicker than the general population.

9:27It's not that this population gets no care. They get enough to have a whole lot of prescriptions. So many that it's hard to stay on top of them all. So for you or I, who are relatively high functioning, or at least most days, but for you or I, it would be very challenging. Because remember, these are medications that prescribe different amounts. They, you know, their prescriptions are due different times. Let's consider a patient who's relatively healthy compared to many that innovate treats. A patient that merely has one mental health problem and one physical health problem. He could take a 50-year-old man that's diagnosed with schizophrenia but also is diagnosed with insulin-dependent diabetes. Now, that person is going to have a difficult time, you know, cognitively. They're not going to be able to operate their glaucomative of mind trying to correlate their glucose score to their sliding scale of what they're supposed to inject. And so they're just simply not able to manage that. And that's why many of them fail in the community in their

10:27hospitalized so many times. And they presented the ED numerous times throughout the year. Yeah, blood sugars could be out of control. It could be really high or really low, which is very dangerous. They could be psychotic. Diabetes is common in Joe's population. So are cardiac and pulmonary issues. And yet, they may see a primary care physician every six months and have a 15-minute visit. And there's really not much that can happen, that can help them in the current system. And so for them, it's a constant revolving door ED visits, hospitalizations, and really struggling at home. And as that door revolves, the patients often feel mistreated. They're not treated with respect. They're not given the attention they deserve. So I think a lot of them don't really like interacting with the medical system to be honest. Don't really like interacting with the medical system. That might be understating it a bit. People don't realize how traumatic it is to have a psychiatric and patient hospital stay.

11:31It's very traumatic. They're getting increased psychosis or they're becoming manic or they're becoming severely depressed or the glucose levels are up and down or they're hypertensive. The hospital stays are traumatic and these patients are in there a lot. It's not uncommon for some of these patients to be in the hospital 12 to 18 times a year. 12 to 18 times per year. In Joe's view, that is system failure, plain and simple. The way the system is constructed now, the hospital tends to be the hub of care and in really it's backwards. Backwards, because the hospital should be the backstop, not the hub. So Glenn, what are your thoughts so far? Well, what a devastating system failure. We'll stop. Right, and it's not just system failure in some abstract sense. This is personal for Joe,

12:33tracing back to the tragedy he endured in high school and the patients he's seen die prematurely, like Charlie and Gale. Charlie, Gale, I know that more like them. All right, so how do we start to get our minds around this? Well, for starters, Joe is correct that we need to treat the whole person because the physical health and mental health conditions are often related to each other. Diabetes, for example, can be a direct consequence of the psychiatric medications. Smoking, for example, can be a consequence of loneliness. Everything is tied to everything else. Added all up and there's a whole love for anyone to try to grapple with. Never mind someone with a serious mental illness and psychiatric medications. Well, they just make it harder to focus and concentrate. So, these patients need support. Someone to check on them, remind them, motivate them,

13:34and help them tackle the burdens of mental illness and the medications. And they need support from someone who can see the full picture, not just the most immediate problem. Right, but the system just doesn't provide that. Now, wonder then that these patients experience healthcare as a revolving door. Going from provider to provider with little likelihood that the providers are even talking to each other. Nobody is coordinating the effort. Right, so no surprise. Things go wrong. Problems escalate quickly and these individuals end up in the emergency rooms and in hospitals. And once they're there, the problem is obvious. Hospitals are designed for episodic care. They really have no ability to check in on people after they've discharged to make sure things are going according to plan. So, system failure, full stop. I'm afraid so. Somebody has to be the glue that holds things together.

14:38Somebody has to manage and coordinate care day to day. It's a lot of work. Certainly too much for someone struggling with mental illness, physical health and medications. Right, quite possibly a home health company, just like in a vibe. But what about the economics of that idea? Home health visits are expensive, especially if they need to go on and on indefinitely. Yeah, sure. Home health visits are expensive, but let's face it, so are hospitalizations. So, can we get right to the most obvious question, the one that even an astute high school student might ask right away? What's the break even? Yeah, I think you mean how many hospitalizations have to be avoided to justify the cost of providing regular home care to this population? Exactly. And we'll get into that when we come back. Okay, so let's get to some numbers. The annual cost of

15:44in a vibes home visits for a typical patient is about $27,000. Sounds like a lot of money. But that same typical patient without home care will have over $200,000 worth of annual hospital expenses. So, here's what Joe said about the break even. So, even if we stop one hospitalization, we've more than justified our services for the year, but we stop on an average of about six hospitalizations. Saving one hospitalization is enough, but on average, in a vibe stops six. And there's more. We had one patient last year that we admitted that presented to the ED every day because he was lonely in a Massachusetts that's $3,800 an ED visit. So, that's a tremendous cost to the system. And since we've been working with this gentleman that he has not been to the ED at all. So, hundreds of thousands more for what amounts to loneliness care. I asked Joe what

16:49in a vibe views as a success. So, some patients that's keeping the amount of the hospital all together. Other patients before we were working with them may have been hospitalized, you know, 12 times the year before. Maybe we can get them so they're only hospitalized four times. Fewer hospitalizations and fewer procedures too. But, you know, for in a vibe, it's not just about the economics. They're more independent at home. They live in a much better quality of life. So, that's success for us. Keeping them safe in their homes. Keeping them stable. And really, in some cases, given them, you know, years added to their life. Joe's company recently expanded to Colorado. For several patients, we admitted we're all patients that were diabetic that had some sort of amputation, whether it's toes, feet, in some cases, legs, amputations. That's what happens when these people aren't cared for. When we come back, we'll look more closely at how

17:53in a vibe operates. Let's now zoom in on what happens at in a vibe every day. When the company accepts a referral, they start with an assessment in the home. These patients spend most of their time at home, and that's really where the care should be provided. It's a wheat. We assess a lot of the different social determinants within their home and within their environment and their neighborhood that can contribute to negative outcomes. For instance, a patient on insulin may not have a working refrigerator while the insulin is not going to be effective or safe for the patient to administer. If they do have a working refrigerator, do they have coca-cola and ice cream and other things that are going to, you know, drive up their glucose levels? So, do they have a roommate that's actively using drugs or abusing them or stealing their medications, right? They also review the patient's treatment plan. And our nurses will go in and they'll admit a patient, and the patient has a psychiatrist,

18:56they have a primary care physician, and let's say they have a diabetic specialist or a cardiac specialist or both. Almost 100% of the time we find that the different providers have not spoken, have never spoken. We work with everybody to put together a treatment plan. For some patients, the treatment plan includes directly administering medications every day. We've had some patients that have had multiple overdoses, whether it's intentional, or whether that they just cognitively did remember that they took their medications half hour earlier. So, in those cases, we want to make sure that we're the ones administering. In and around densely populated Boston, nurses don't have to spend much time in the car. If a nurse is seeing patients in Chelsea and Massachusetts, it was a very small community, and they may be doing 10 to 12 visits that day, but it's a very condensed area. You know, sometimes you might have four or five patients that live in one building. I was curious about how In-A-V compares to more traditional VNAs, visiting nursing associations.

20:00These are organizations that serve seniors, typically for a few weeks after a hospitalization. So, I asked Joe what would surprise a nurse from a traditional VNA if they shadowed an In-A-V nurse for one day? I just think the environments that we go into, they could be challenging environments. A lot of our patients smoke. They don't always live in the, you know, the cleanest environments. And so, our nurses go into, you know, we've been in crack houses. I mean, we've been in really challenging situations. So, I think that's probably the first thing they would notice. I asked about safety considerations. Patients are screened for safety before home health services can begin. And we do let our nurses know that there's any time they do not feel safe, they just need to leave immediately. Sometimes patients can be symptomatic and they can be argumentative, but we have nurses that are used to working with this population. It does sound to me like stressful and difficult work, but we have unbelievably dedicated

21:06nurses that are very passionate about the behavioral health population. And so, they're really focused on the population and they love this model. My conversation with Joe came just one day after a blizzard hit Boston. Our nurses were out yesterday in the snow and I think this year we did over 2,500 patients visits on Christmas Day. And actually, for the right kind of nurse, one that is dedicated to this population, it's not too hard to see why caring for patients in their homes might be preferable to working in an institutional setting. And they realize when they come into our program that they're truly able to really make a difference in the quality of life of these patients and keep them out of the hospital and give them a better chance of just living a much more improved lifestyle. It does, however, take some training. We have a very elaborate educational program within our company, so we have very intensive orientations, often nurses that go through our orientations say that's the most

22:11comprehensive orientation they've ever gone through. What are your thoughts, Glen? Well, not the last break, I said, devastating system failure full stop. Yeah, that's what you said. And it seems all the more devastating now that we've heard that the intervention, home care, delivers economic impact far beyond multiples beyond break even. Yeah, you really don't need a spreadsheet to analyze this one. Right. And there's something more profound going on here, beyond economics. How do we put a price on adding meaning to someone's life? Having someone visit their home, someone who knows their name, someone who understands them as a whole person and understands their medical situation in full. And then maybe even has a laugh

23:14with them. I hear you. And it just begs the question, why isn't this already happening everywhere? Right. Well, and especially since it's hardly any idea, only a few decades ago, many family doctors made home visits routinely, especially to people who were elderly or found it tough to get around, or who was seriously ill at the end of life. So here it's not doctors, but well-trained nurses. They assess needs in the home, develop a coordinated plan that includes both physical and mental health and then visit the home on a regular schedule. That's it. Plus, reading between Jo's lines, they also offer a hefty dose of kindness. That's the entire concept. It's not rocket science. The nurse's job does not sound easy, though. No, not at all. And a lot of nurses wouldn't be too comfortable with these home visits. People with serious mental illness are not the easiest

24:16to care for. And as we've heard, many patients live in tough conditions and in poor neighborhoods. And yet, I think I hear Jo saying that this is actually a great job for the right kind of nurse. Yes, especially for those who are accustomed to and really care about people who have these combinations of problems. These nurses have impact. And they see first hand the improvements that they are achieving, less chaos, fewer hospital visits, less mental distress. That's a huge intrinsic reward, knowing that you are making a difference and seeing the evidence of a person doing better, much better, because you are doing a great job of supporting them. And I think it's probably hard to have an impact as large or as visible in an institutional setting. Absolutely. Well, I think we've left ourselves with one big issue, Glenn.

25:17How do we get these home visits reimbursed? We'll be right back. Anyone who's been around healthcare for a while knows that just because an idea makes obvious sense does not mean that there's an easy way to get it paid for. Medicare, the federal program in the United States that covers seniors, does have a well-established payment model for home visits. At least for episodic needs. But the people that in-a-vive treats are too young for Medicare. They're unmedicated, the program run by the states. Every state in the country has issues with the behavioral health population and high costs and patients that are not doing well in the community, but there's only certain states that have systems that are willing to pay for it. And support home health. Right. Every state has its own rules. Some states do pay for home health,

26:18but they often cap the number of visits per year, which doesn't work well for this population. I asked Joe if he'd considered expanding his model to other health conditions that could benefit from more intensive home healthcare. But his focus is firmly on geographic expansion. This population has needs in all 50 states and we're in three of them. We have expansion plans beyond this year that there's multiple states that we're looking at and speaking with. That said, getting state-medicated administrators behind home health, it's typically a long process. We deal with some really great well-meaning people that are doing their best, but again, I think anybody that's dealt with government, it's just hard. You know, it's very diffuse and it's very fragmented. For instance, they may have a hospital department that looks at hospital costs and they may have a home health department that looks at home health costs. Right. You have to get several people with distinct areas of responsibility

27:20moving in the same direction ready to write new rules and regulations. Joe and his team have analyzed all 50 states to identify the most promising opportunities. Among the factors they've looked at, the magnitude of the need, and the strength of the political support, thus the recent expansion to Colorado. They've really struggled in access to care, I know Governor Paulus, he has put in a lot of money in the last few years to increase access to care for behavioral health. Another factor, the extent to which Medicaid programs are using managed care companies and value-based contracts. Thus, Indivive is operating in Iowa. Iowa has managed care programs that are managing their Medicaid and we have some unique partnerships with the managed care programs there. Part of the promise of managed care and value-based contracting is additional flexibility. As a company, that's where we want to go. We think that

28:21this population would really do well with a value-based program and I also think within the confines of the of the current home health regulations it's restricting. For example, Indivive might be able to send more kinds of providers into the home. If we were able to have nurse practitioners, go to the home once a month and do primary care assessments when I'm currently able to do that or have nurse practitioners do psychiatric evaluations. Joe is also interested in working more closely with managed care companies to share data. I mean, one of the things that we're excited to do in Iowa is partner up with these managed care programs to do data sharing because often when we get referred to patient, you know, we don't know what has happened with the patient prior, meaning we don't know how many times this patient's been hospitalized. That said, Indivive has long been working on assembling more complete patient records. So we have an extensive database that we utilize, you know, with sales force and sales force.

29:22I think we're one of the only behavioral health home health company that's utilizing it in that way. We have other diagnosis. We have other physicians. We have the visit frequencies that they're currently being seen each time they're hospitalized that also goes in there if we're aware of any ED utilization that is in there. So we're constantly collecting data as it comes through when then we're able to run reports. We're able to really organize our patients in a way that we can start tracking outcomes and start looking at sort of emerging trends with our population. For instance, we've found at the 15th month mark that we pretty much stop hospitalizations altogether. So a lot of interesting data that Joe and his team are working on converting into insights that will help them deliver even better care. There's just so much interesting information to gather about this population. I'm just always curious on what drives negative outcomes in and

30:25frankly drives positive outcomes. We'll be right back to wrap up. What are your thoughts, Glenn? Well, one thing I've noticed, Boatcher, is that he never blames individual people. He blames the system. He's not saying that Medicaid administrators are bad apples. He's saying that they're hands are tied. Yeah, that's right. It sounds like the typical administrator has too narrow a span of control to move forward with an offering like inner vibes. So he looks for states where there are high level politicians like the governor and Colorado to support him. Or he looks for contracts with managed care companies who may be more nimble or may have value-based contracts that allow for more flexibility. But still, all of this does sound kind of crazy. The cost effectiveness of inner-life service is just bound or obvious.

31:27There's no need to hire a health economist to run the numbers. So given that, what could state governments do differently? You know, I think in the corporate world, there at least be consideration of a reorganization. Instead of having someone in charge of hospitals, someone in charge of clinics, someone in charge of home health, and so forth, you'd name lead administrators for specific populations. So let me, let me try and follow you. So you mean a lead administrator for people who have severe mental illness? That's the idea. And ideally, such a leader would have a wide span of control. They'd be able to influence spending across all types of healthcare operations. And maybe even influence the Department of Corrections and the Department of Education as well. So one person or maybe one team who could influence all the services that this population needs

32:28and all of the costs? Yeah, that's right. Do we wait around for that to happen? Well, I suspect that value-based managed care contracts are a more realistic possibility, at least in the near term. One other note I'd like to make. I like the way Joe is working incredibly hard to aggregate all of the available data about these patients, and then analyze it to find even better ways to careful them. Yeah, I was impressed with that too. And managed care companies are natural allies here. But you know, this is another area where AI could have a big impact. Yeah, maybe so. I'd like to dig into that some more. But let's not forget that this is not just about money. And it's not just about using the latest amazing technology. What I hear in Innovive is that it's about humanity. Today, we've heard about patients with a challenge that

33:32nobody would ever choose a serious mental health condition. Innovive's most profound work is helping giving them back a life. Thanks so much, Glenn. And listeners, thanks so much for joining us. Before you go, one quick request. If you like the work we're doing, would you please subscribe to Unleashed in your podcast player. And maybe consider telling five of your best friends, or even 500 of your best friends, all about Unleashed. Thanks for considering it. Coming up in future episodes, more about home health, more about AI, and much more about innovation on the front lines of care. We'll be back again soon. This podcast has been brought to you by the Dartmouth Institute for Health Policy and Clinical Practice by EBSCO, producer of Dina Med and Dina AI, and by your hosts, Glenn L. Wynne and Chris

34:39Trimble, script development, audio production, and music composition by Chris Trimble and Treehouse Audio Productions.