Name of the program| Integra @ Home
Health system| Care New England Health System (CNE)
When established| 2018
Core services| Home visits by paramedics and by clinical providers; Lab work and tests at home; On-call service; Sending reports to primary care provider; 30 days of follow-up monitoring after discharge from an acute episode
Population served| Older adults, >70, those with multiple chronic conditions and frequent exacerbations
Area served| Rhode Island, state-wide
Outcomes or successes|
- 52 current patients (5/20)
- 108 since program inception (as of 5/20)
- 63 ED aversions this year (FY 2020 10/1/2019-present); 140 FY 2019
- 42 Hospital aversions this year (FY 2020 10/1/2019-present); 75 FY 2019
- Referral to Hospice to date = 15 (13.8%)
- Completed goals of care conversation and documentation: 92% FY 2020; 95% FY 201
- Meds at the Bedside: Pharmacy collaboration program
- Integra @ Home (acute care at home/hospital at home program) – Collaboration with community paramedicine program, home based nurse practitioners and physician assistants. Pre-enrollment program to allow proactive as well as reactive visits and care.
- Strong focus on:
- Ongoing goals-of-care conversations with patients and loved ones to ensure the care provided aligns with those goals.
- Close integration with geriatrics and palliative care faculty at CNE to provide ongoing education and case conferencing support.
- 24/7 activation and on call team
Leadership| Ana Tuya Fulton, MD, FACP, AGSF, Medical Director of Integra; Ruth Scott, RN, MHA, CCM Senior Director Population Health
Media coverage| ConvergenceRI – “Change in demographics, a change in care”
- CMS Case Study
- Using Nurse Care Managers Trained in the Serious Illness Conversation Guide to Increase Goals-of-Care Conversations in an Accountable Care Organization – Journal of Palliative Care
- Case Study Brief – Palliative Care Education for Care Managers in an ACO