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REGISTER TODAY! HAH USERS GROUP ANNUAL MEETING | THU. OCT. 27

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 2019

Unique feature|

  • 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

Web site| http://integracare.org/patients/integra-at-home.cfm

Media coverage| ConvergenceRI – “Change in demographics, a change in care”

Public resources|

  • 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

Contact information|

  • Ruth E. Scott, RN, MHA, CCM, Senior Director, Population Health Management: rscott@carene.org
  • Ana Tuya Fulton, MD, FACP, AGSF, Executive Chief of Geriatrics & Palliative Care, Care New England Health System, Medical Director, Integra Community Care Network: afulton@carene.org
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