Clinical Operations & Care Protocols
Medically Home has spent over 15 years exploring the complexity of the home environment and the services needed to provide safe, high acuity care in the home that is equivalent to or better quality to that in a traditional hospital. While the specific treatment for a medical condition doesn’t change in the virtual hospital, how it is delivered changes dramatically.
- Central to the model is a Medical Command Center staffed by physicians and nurses who virtually oversee the patient’s care 24/7. The command center team can provide care to patients who may be miles – even states – away from where the command center is located which is key to efficient operations.
- Care protocols are tailored to emphasize a view of the whole person for a more robust and effective plan of care. Adding insights from the home environment to the clinical picture of a person enables a plan of care that not only treats the patient’s acute illness, but also provides needed support for chronic illnesses and social determinants of health.
- Specialists and other key hospital services such as case management, clinical pharmacy, and the patient’s PCP remain a key part of the care team via e-consults and virtual visits. Specialty care visits can seamlessly include the entire care team including the primary virtual hospitalist team, the in home clinical provider, and the patient’s caregiving team.
- Integrated acute and restorative phases of care linked together with an episode-based reimbursement model enable a seamless acute and post-acute experience for patients to recover on their schedule, not the hospital’s.
The result of applying our Chassis is a powerful capability to provide an overall continuum of care for patients with serious and complex illnesses. Beyond typical general medical cases, the Chassis can also be used to provide care for other high risk hospitalized patients: oncology (chemotherapy or stem cell transplant), post-bone marrow transplant, post-surgical, and post-solid organ transplant recipient patients.
The World’s First Advanced Rapid Response Logistics System
Medically Home developed the world’s first advanced Rapid Response Logistics System delivering services and supplies into patient homes, on-demand, around-the-clock.
- Enabling the delivery of safe, high-quality care for serious and complex illnesses at scale in over 30 urban and rural markets across the country.
- A curated network of care givers, treatments, tests, medications, and supplies function as an integrated ecosystem with the clinical and service standards, provider credentialing, training, and tools to deliver high-quality, safe, on-time, reliable and efficient care.
- Orchestrated by Cesia™, our proprietary software, which simplifies and automates the complex logistics of decentralized high acuity care with scheduling, dispatch, visit tracking, and more.
- Patients receive exceptional care exactly when they need it with visibility to their schedule and care team profiles.
- Physicians safely treat patients with complex illnesses with confidence that when they place an order in their EMR, the service will reliably occur on-time in the home, every time.
- In-home providers focus on delivering great care as an extension of the command center team with the tools to confirm orders, document services, and route the most efficient schedule.
Our unique and proprietary platform, Cesia™, is the engine of the new, scalable, decentralized healthcare system delivering safe, world class clinical care for the highest risk illnesses. Key functions of Cesia™ include:
- In-home care orchestration – tools that turn the physician’s order from the EMR into rapid and reliable actions delivered to patient homes. This gives patients visibility into their daily care plans and enable in-home service providers to efficiently deliver excellent, on-time care.
- Voice, video and smart routing – reliable, redundant connections with special patient safety features and an elder-friendly interface so that patients have rapid and consistent access to their care team 24/7.
- Vitals data and alerts – simplifies biometric data collection, including connected devices, patient reported outcomes, and photos of wounds/infections.
- Revenue cycle management – data to support charge capture and clean claim submission for acute FFS arrangements as well as integrated acute and post-acute 30-day episodes.
- Automated insights – reporting and management context for command center and in-home care quality, utilization, cost and more that enables the program to scale.
Cesia™ and Cesia Continuum® integrated software services were named after one of Medically Home’s cofounder’s mother, Cesia Rakowski, as a reminder to provide the same amazing care for patients they would want their family members to receive.
Medically Home’s technology kit is specially designed to turn the home into a safe site of care for serious and complex illness with a focus on:
- Rapid deployment – equipment is deployed in less than thirty minutes by a clinician or technician in the home on the day of admission without requiring the patient or their family to have wi-fi connectivity, specialized technology, or equipment.
- Safety features and redundancy – advanced cellular routers with access to multiple mobile carriers, personal emergency response wearable, technology alerts, and battery back-up give patients and their clinicians complete confidence that they will have access to each other when they need it, 24/7.
- Advanced clinical monitoring – zero-effort interfaces to key medical devices and high-frequency monitoring equipment, as well as advanced tools to support point of care laboratory testing provide the care team rapid insights into the patient’s evolving condition.
- Personalized and easy to use – elder-friendly tablet for video visits plus a “pick up the handset” hot-line phone for ease of use for every patient. Cesia’s integrated smart routing ensures patients quickly reach a member of the care team with context on their care – on average in less than 30 seconds.
- Turnkey – Medically Home manages the kit hardware, installation and all connectivity/networking services, and provides 24/7 technical support to clinicians in the home and in the Medical Command Center.
Medically Home has shifted the paradigm of traditional reimbursement which incentivizes short lengths of stay and care fragmentation to create a model that delivers more care with superior outcomes at a lower cost. Our decentralized care model arbitrages the heavy fixed costs of the hospital footprint and shifts investment into more direct patient care over a longer period of time.
Better care delivers better economics, and everyone wins:
- Patients win by getting more care that is tailored to their needs and achieve better outcomes including lower mortality, fewer hospital acquired infections, lower rates of delirium, and a more pleasant, person-centered experience than being in a traditional facility.
- Payers win through better outcomes for their members and lower costs including reduced hospitalizations as well as reduced readmissions and downstream 90-day utilization by 50-75%.
- Providers and health systems win by delivering better outcomes, creating more capacity to serve patients with minimal capital spend, and capturing a greater share of post-acute revenue with 30-day episodes.
Medically Home’s payer team works closely with payers and hospital systems’ managed care teams to establish contract and revenue cycle structures to support the model. In addition, our experts help hospitals navigate and apply for the CMS hospital-at-home waiver to enable reimbursement for fee-for-service Medicare and Medicaid patients.
Clinician, Caregiver, & Patient Experience
Healing in the comfort of their homes surrounded by family and pets, with a direct line to their care team, more control and visibility into their schedule, and achieving better outcomes, it is no surprise that patients consistently rate the virtual hospital experience with high marks. Each health system partnered with Medically Home sees that their virtual hospital is the top performing “hospital” within their network regarding patient experience.
One remarkable result of providing care for patients with serious, complex, or high-risk illnesses in their home is how much health care providers love practicing this way. Care practitioners are spending more of their time talking to, teaching, and, most importantly, caring for patients. Getting to know their patients with insights into the home environment enables them to provide robust, tailored care plans which lead to better outcomes for patients. By seeing the impact they are making in patients’ and their families’ lives and using their skills in new ways, the entire care team – physicians, nurses, and in-home providers – are finding joy in their practice again.
“I think I’m practicing the best medicine I have in 18 years here, with this new system.”
Michael J. Maniaci, M.D., Chair, Hospital Internal Medicine Physician Lead, Advanced Care at Home, Mayo Clinic in Florida