EP 125: Designing Home-Based Care | Gregory Snyder
This week we talk about designing human-centered care, at home.
Gregory Snyder is a clinical innovator and physician executive leading technology-enabled care delivery models to improve healthcare quality and safety. He is a graduate of Princeton University, Sidney Kimmel Medical College at Thomas Jefferson University, Brigham & Women’s Hospital Internal Medicine residency, and Harvard Business School. He practices hospital medicine at Mass General Brigham Newton-Wellesley and is Entrepreneur-in-Residence at the Mass General Healthcare Transformation Lab. Greg is Clinical Assistant Professor at Tufts University School of Medicine, Associate Faculty at Ariadne Labs, and adjunct faculty for the Institute for Healthcare Improvement. He is focused on scaling virtual hospital at home programs and improving the quality and safety of home-based care as Vice President of Clinical Strategy & Quality Improvement for Medically Home. Greg has partnered with diverse healthcare technology ventures to improve healthcare quality, safety, value, and experience.
Episode mentions and links:
Greg’s restaurant rec: Parc Philadelphia
Follow Greg: LinkedIn
Episode Reflection:
From my perspective, the idea of hospital at home is as exciting as going to the moon! There are few things in healthcare cooler than the idea of providing high-quality and safe care utilizing cutting-edge tech, to heal you in the place you find most comforting, surrounded by those you love. If you’re a regular listener of the show, you may remember that on Episode 107 we had Helen Ouyang on to talk about her NYT Magazine article and the stories she shared of people receiving hospital-grade care at home. In that episode, we heard some awesome human stories of why hospital at home is important and is a fantastic partner to this week's episode where Greg laid out some of the systematic reasons why moving some acute care into the home just makes sense. The reason hospital at home is so compelling is because there are so many positives to utilizing it, especially in cases where people need a higher level of monitoring and attention, but don’t really need to be in a hospital. The benefits of providing this care in the home extend far beyond the patient as it can provide a better experience for everyone in a person's circle of care. Technology, while essential to enabling high-quality monitoring and communication at home, is not the most important component whereas coordination of a distributed network of care is a really exciting opportunity where I can see a lot of exciting innovation occurring. Hospital at home blends the worlds of technology and human-centeredness together in a synergistic way that you really don’t see in other applications of health tech. As Greg said, it’s a win win win win, and we don’t get many of those in healthcare.
Written by Rob Pugliese
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Bon Ku: Welcome back to another episode of Design Lab. I'm your host Bon Ku on this podcast, we explore the intersection of design and health. You can reach out to me on Twitter at B O N K U on Instagram at D R B O N K U. Our guest today is a good friend of mine. He is Dr. Gregory Snyder. Who is a clinical innovator and physician executive leading technology enabled care delivery models in order to improve healthcare quality and safety. Greg graduated from Princeton University, Sidney Kimmel Medical College at Thomas Jefferson University and the Brigham and Women's Hospital, Internal Medicine Residency, and Harvard Business School.
Greg practices, hospital medicine at Mass General, Brigham Newton-Wellesley and is an Entrepreneur in Residence at the Mass General Health Care Transformation Lab. He is a clinical assistant professor at Tufts University School of Medicine. Associate faculty at Ariadne Labs and adjunct faculty for the Institute for Healthcare Improvement.
Greg focuses on scaling virtual hospital at home programs and improving the quality and safety of home-based care. And he's the Vice President of Clinical Strategy and Quality Improvement for Medically Home.
We really want you to visit our website at designlabpod.com. There you can do two things. You can subscribe to our newsletter if you haven't done so already. Our producer, Rob Pugliese will send you his thoughts, his reflections on each episode every week. And you can learn more about the guests.
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Interview
Bon Ku: Dr. Greg Snyder, welcome to Design Lab
Gregory Snyder: Dr. Bon
Ku,
thank you for having me. It's such an honor to be here. I appreciate it.
Bon Ku: For the listening audience. Greg is a good friend of mine. I knew him when he was a medical student in Philadelphia. So I'm gonna call you Greg, if that's okay.
Gregory Snyder: You should call me Greg, and for your listening audience. Friend, I would say mentee as well.
Bon Ku: no, you're my mentor.
Gregory Snyder: Yeah. Well, yeah. Right back at you. So I love it. I love it. Both are true.
Bon Ku: Greg, what are you up to these days? What, you have a few different roles. Tell us about what your like day-to-day looks like.
Gregory Snyder: Yeah, I am a practicing internist. I practice hospital medicine in a community academic hospital that is a part of the Mass General Brigham health system called Newton Wellesley Hospital.
Bon Ku: That's in Massachusetts,
Gregory Snyder: It is in Massachusetts. It's in the sort of outskirts of Boston, in Newton, Massachusetts.
As a part of that, Newton Wellesley Hospital is a teaching site for a number of different academic institutions, including Tufts University School of Medicine, where I'm a clinical assistant professor and help teach medical students. it's also a teaching site from Mass General Hospital, and I am an entrepreneur in residence of the Mass General Healthcare Transformation Lab.
, I, advise a company called Marial Health, but my main role is as Vice President of clinical strategy and quality improvement for Medically Home Group. And, your listeners are probably wondering what is Medically Home group? What do they do?
Bon Ku: Well, first you have a lot of freaking jobs. You have more jobs than I do, so I'm like blown
Gregory Snyder: number one job bond is I have three kids and, and a very, very busy partner. And so being a dad and a and a good partner is job number one.
Bon Ku: Yeah. So what does company, medically home, what do you do for it?
Gregory Snyder: Yeah. Medically Home is a company that. Is enabling and building the future of decentralized healthcare. And, we focus on that and have focused on that in many different ways over the years. I think we're known, primarily for hospital at home, today. But, we do a number of different, , things in the space of decentralizing healthcare.
We do hospital at home. Where we partner with, predominantly hospital provider systems to help them build and then to build the services of their hospital at home programs. we also do emergency department in home increasingly. Now, this is a sort of new and evolving model of home-based acute care, and that's something that we've been focused on a lot over the last few years.
It will be in the future,
Bon Ku: what does that mean? Emergency care at home.
Gregory Snyder: Oh, I think that, Bon, I, I just, I was fortunate to give a talk the other day called No More Buildings. And I think that, you know, that's, that's perhaps the theme of decentralizing healthcare is, is that we see a future where Hospital care can be based in the home emergency.
Most emergency department care, not all can be based in the home. Not all hospital care can be based in the home, but for those risk stratified conditions, that are appropriate for home-based care. We should be moving them into the home and letting emergency departments treat truly emergent patients.
letting hospitals treat truly step down or ICU level of care patients, where we feel we can really decentralize so much of the care that's currently being delivered in hospitals and emergency departments.
Bon Ku: Now you used a couple of terms that I think not all the audience will be familiar with,centralized care versus decentralized care. So for those who, are not familiar with these two different care delivery models, can you explain the difference between the two?
Gregory Snyder: Yeah, well, I'll explain it in two ways. I think I'll explain it historically and I'll explain it by analogy and, I'll say historically that. in the remote past, let's rewind a hundred years, it would've been the status quo, the standard of care to receive care in your own home.
Bon Ku: Hmm.
Gregory Snyder: And hospitals were really built for two reasons. The first was to bring together clinical services and resources, predominantly doctors and nurses. there was a, sort of thought that centralization of clinical intellectual horsepower and services would be a good thing for patients.
And it certainly was for certain types of patients, certain populations of patients. In fact, most hospitals were really built to serve patients who were highly socioeconomically vulnerable, so the original hospitals were essentially for poor people, like underserved people, and while the rich got their care at home, right, they didn't go to hospitals.
yeah the idea of a general hospital, a city hospital, you know, a, quote unquote safety net hospital hospitals were really built as places where people who perhaps didn't have homes could receive care. People who lived in, in major, you know, metropolitan areas, for example.
But, Folks who are socioeconomically advantaged would still receive care in their homes. And again, I'm rewinding quite a bit. and the visiting doctor was obviously a phenomenon that many of our probably grandparents at this point we're very well familiar with, and that's gone away over time. And, we'll say what we know now, which is what hospitals and, and facility-based healthcare has really become.
it's a place where yes, socioeconomically vulnerable populations get care, but it's a place with lots and lots of technology and lots and lots of specialty services and lots and lots of care that is provided to people who can pay for that care. So it's changed a lot over time.
Bon Ku: So even though what you're doing is relatively new, this like decentralized care model, you're not really designing anything new, right? You're, it's like, it's pretty like old school what you're doing, but like, how can you be sure that giving care at home, you're going to get the same like results,
right?
Because. You go in a hospital that's pretty fancy, man. It's pretty state of the art. There's like cat scanners, MRIs, like, like proton pump therapy, all this stuff. They're like, they're these $2 billion facilities. Like they're, They look pretty fancy.
Gregory Snyder: Right, right. And you know, it's so interesting that you mentioned this sort of fancy. Procedures and, and technologies that, as you know, as we know, really lead to a lot of cost in our system. Yet, , separate from hospital at homes, quality, safety, clinical outcomes, we're not getting very good outcomes in this country.
Right? if we're to compare ourselves to other countries, for example, and we could have an argument or discussion around that, but there is a big piece of what is, in my view, value-based care in this equation. You know, the value equation being quality over cost, numerator, quality, denominator cost, and and so for every time we build a building and spend that money on a building, I think we need to ask ourselves, are we getting the value out of that building that we want for our patients?
and so that was sort of where I was going with the historical explanation of centralization. the analogy of centralization, decentralization, to your earlier question is, maybe the cab stand, right? Like today we don't, oftentimes we don't go to a place in order to hail a taxi. We instead stay where we are and ask a driver to come to us through an application, for example.
that's another sort of analogy for what might be viewed as the difference between centralization of a resource and decentralization of a resource. I hope we get to talk more about the clinical outcomes of hospital at home though, because that's, that's part of the most fun part of hospital at
Bon Ku: Yeah, well let's talk about that. What does that actually look like? A,
like a medical team coming to your house as a patient? If you have like
a pneumonia for example, like walk us through
Gregory Snyder: Yeah.
Bon Ku: of, some use cases
that you have at medically home for,
Gregory Snyder: Yeah, great. Great
question. Yeah, and, and actually, you know, thank you for raising that, point because there are a couple of different flavors of hospital at home care, and I'm gonna focus on hospital at home, just so your listeners are aware, because there's lots and lots of forms of home-based care, home-based primary care, home-based, palliative care, home, hospice, urgent care, et cetera.
For hospital at home. The two main flavors are what you described as sort of physician house call program where doctors or advanced practice providers licensed independent practitioners are the, predominant sort of, if you will, provider type that's going to the home. They're obviously able to do a lot of different things.
They're able to do advanced physical exams and, perhaps place IVs and give medicines. Perhaps do some of the things that, you know, even an RN might do in a hospital or an LP n might do in a hospital or, a social worker might do in some cases, because they're able to really understand a patient's social determinants of health in the home and put that together with advanced clinical assessment.
That is not our model. at Medically home, our model is, is to really dissect the actor from the activities. Where there are lots and lots of activities that need to be performed and occur in a home-based care setting is particularly for acute care.
Look at it this way. Imagine yourself sort of sitting or standing in front of the door of a patient's room in a hospital.
You would see lots of people come through that door. You might see phlebotomists come through to draw blood. You might see RNs come through to do physical exams, draw blood place Foleys, measure urine output, and advocate for the patient. You might see physical therapists come through that door, mobile imaging, pushing an x-ray machine, and then you'd see the doctor as well.
And so our view is that you really need to replicate all of those services in a very multidisciplinary way. In the home. we also take the view that in order to scale hospital at home, doctors should be providing remote telemedical, virtual care,
Bon Ku: Mm.
because it would, it would be not feasible to send a doctor to every patient's home. Like there's like not enough doctors to be able to do that.
Gregory Snyder: There's not, I mean, we have, we have physician nursing staffing shortages generally. we have staffing shortages of all types of healthcare professionals today. An example is, paramedics as well and e m s professionals. And, our view is that in the setting of those shortages, we really need to match the appropriate activities to the appropriate level of licensure.
To perform that activity as part of a, a holistic care plan in the home. Now, that care plan should be devised by a doctor and a nurse and an advanced practice provider at times, as it would be in the hospital. however, that care plan sh should be executed by a whole multidisciplinary array of provider types that might include. A nurse, an in-home infusion rn, for example, a wound care rn, an in-home physical therapist, an in-home advanced practice provider at times, but oftentimes an in-home community paramedic or phlebotomist or courier or mobile x-ray technician.
Bon Ku: so these are patients that, as a hospitalist you take care of patients who get admitted to a hospital. So that's a centralized form of care. But some of these patients that do get admitted, like, they can actually not be admitted to the hospital diverted
and get their, get the same level of care at home.
Gregory Snyder: Yeah. Again, there's two ways in which hospital at home is delivered today. And I wanna really, you know, credit our, , our innovators in the federal government at the c m s for this because, There was a lot of work done by many different leaders in the hospital at home space to create,, an acute hospital care at home waiver program during the Covid pandemic, to allow for hospital at home to be scaled and to meet more patients in the home, the same level of acute care with the same level of reimbursement for Medicare fee for service and Medicaid fee for service, patients in the home.
Bon Ku: so let me translate. So the government basically started paying for this
Gregory Snyder: they did. Yeah,
Bon Ku: because before the government
didn't pay for it. why, like why wouldn't the government pay for something that is more cost effective that you're just saying?
Gregory Snyder: Well actually, let's talk about the outcomes, to your point, because I'm gonna gently skirt the question about why the government would or would not pay for this for a moment, because I think the question is, why would anyone not want to support this? And, and the anyone could include providers, patients, caregivers, payers, commercial payers.
That is government payers. yeah. Thank you. You know, I think that there's the view for hospital at home, and I agree with this view that this is one of the very rare. Win win win wins in healthcare where it's very clearly a win for patients. That's the most important thing, and is a win for their caregivers.
That's also a very, very important thing. I wanna return to that in relation to design, by the way, because there's a very important discussion around patients and caregiver experience in this model.
Bon Ku: Yeah.
Gregory Snyder: but they win and. We have very good evidence to suggest that they win. there's developing evidence to suggest that they win.
they win from the perspective of clinical outcomes. And so for that reason, doctors win. We got into this to provide high impact care to our patients. And we're able to provide care that has a better safety profile, a better quality profile in the hospital at home than in the brick and mortar hospital.
There is now more research on that fact than for any other service delivery innovation. I would submit, and this has been well put out there, I'm, I'm citing others when I say this, but hospital at home is the most well evidence, service, delivery, innovation ever.
Bon Ku: What,
Gregory Snyder: Yeah.
Bon Ku: so can you give us an example of a disease process that you get the same outcomes like. Versus being admitted to a fancy hospital like you being taken care of by you and your team of like dozens of people versus like, Hey, we're going to, instead treat you at home by, by different tools that we have.
we'll talk about those tools later.
Gregory Snyder: Yeah. Well, and let me, let me say, just to return to my earlier comment for one second, while it's so well evidenced, that doesn't mean that we should stop doing research and quality improvement in it. In fact, it's more important now than ever. So that was a quick aside. Now let's take a patient with, C O P D as an example.
You've seen these patients, you see them all the time. They come into your emergency department, they're exacerbated. And their primary care doctor probably knew that they were becoming exacerbated, may have trialed some oral antibiotics and steroids as an outpatient. You know, the primary care doctor was incredibly busy, was over committed to patients that were coming into the office and wasn't able to address this patient's calls, into the office from outside, couldn't schedule the patient for a two or three day, you know, urgent follow-up visit.
And so a patient continued to get worse despite appropriate therapy and goes into the emergency department. We've all seen this movie before for C O P D and heart failure and asthma, and acute exacerbations of chronic
Bon Ku: Sure, and, and that's where I step in. I'll put them on breathing treatments and put IV in them, give them steroids, admit them to an inpatient hospital floor to be taken care of. Someone like you.
Gregory Snyder: Yeah. And you know, for that patient, a hospitalist like me would admit them and probably wouldn't be concerned about diagnostic uncertainty.
You know, we know that they're short of breath. We, it might be a combination of heart failure or C O P D, but it's one or the other, and maybe something else is going on that we need to rule out. But you know, we can confidently bring a patient home and treat them for the thing that we're going to otherwise treat them for in the hospital.
We would bring that patient home the majority of the time out of, directly out of the emergency department.
Bon Ku: What,
like, that's an option. I could go as, as the ER doc, I go like, I could admit you to the hospital, or I could give you the same care and discharge you to home with the team that's gonna take care of you.
Gregory Snyder: That's right. and I think this is really important for emergency department doctors because, I empathize with you. It must be difficult to have patients come into the hospital and, you know, historically you've had basically one decision to make as far as where the patient goes after your treatment.
Do they go home or do they go upstairs? And obviously that's changed a lot over the last several years and decades. It may be. Do they go home? Do they go to a skilled nursing facility? Do they go upstairs? Do they go to another hospital? But what about this other option of, yes, they need to go be hospitalized, but they can do that in their home.
That's an option that's on the table now, for the first time.
Bon Ku: I personally don't have that option at my hospital. I would love that option because, some patients like don't want to get admitted to the hospital. Okay. so there's two types of patients that I see to just categories. You know, one, the patient who, who wants to get admitted cuz they think that they're gonna get better care, better outcomes, cuz they're in the fancy state of our building.
But then other patients were like, I don't want to do it. Like I hate hospitals and I want to be at home because that's, the most comfortable place. I can't sleep when I get admitted to the hospital. So let's address those two subtypes of, of patients.
Gregory Snyder: I also want to include the caregiver in those subtypes because for the patient first, there are many patients who need to come to hospitals and be hospitalized for continuous monitoring and continuous infusions and positive pressure ventilation. The things that we do in step-down units in ICUs.
We are currently not providing that level of care in hospital at home today, and then there are many patients who get hospitalized and we are hospitalizing them because we're going to give q 12 hour, q eight hour, or Q six hour medications. And that's every 12, eight, or six hours, or we're gonna give, , every day or every, four hours labs.
Those types of patients can be brought home, for the services. Now, from the perspective of safety as well, I think there's there's a perception that by being in the hospital you are very, very closely monitored. Right?
Bon Ku: Yeah, there's People bother me all the time, right? There's like dozens of people coming in into my room and like there's all this activity going around.
Gregory Snyder: Right, right. And so that's true.
And so what we need to do our work in hospital at home is to replicate that experience through telepresence, through virtual care. With the right virtual care technology, we can make it such that you are monitored either continuously or intermittently. And we are also able to put that monitoring together with humans, with virtual providers, like virtual nurses and virtual doctors who are also monitoring you as part of their care plan.
And so let me just describe, the medically home model, that I was referencing before, cuz our model is to have a virtual nurse and a virtual physician and what is predominantly a virtual advanced practice provider. In what is sort of a telemedical command center, and we called a command center because of references to the aerospace and engineering.
And you can imagine a command center really operating a decentralized network outside of that command center. So there's centralization of the clinical brain, so to speak, the brain that is creating the care plan and the doctor, the nurse, the advanced practice provider, and others. Of course, the pharmacists, the social workers, the case managers, those are all folks that are part of that centralized resource, even if they're not sitting in a physical location.
That team then works with decentralized clinicians and nonclinical service who are executing their care plans in the home. And, and fulfilling goods and services to the home. And what we do at Medically Home is put those two things together. We help to manage that service provider network so that doctors and nurses and advanced practice providers at health systems predominantly can create care plans that get executed in the home.
And can be confident that the quality and safety and experience and timeliness and, and all of the things that are important to high quality care that are happening in that service provider network.
Bon Ku: How do you design that experience to be human-centered in this like semi virtual environment?
Gregory Snyder: mm-hmm.
Bon Ku: There's some things that I do where I see the patient before me at the bedside and you know, I'm pretty touchy feely with my patients. You know, I hold their hand a lot when I talk to them.
I put my stethoscope on their chest. I listen to their heart and breath sounds. I think that human touch,
like, I think that's like a lot of what patients expect, you know, when they go see a doctor. So don't you lose that human to human interaction a hospital by at home model?
Gregory Snyder: No, I think , you do not, you lose the human interaction. In fact, I would submit Bon that right now, as you and I look at each other on Zoom, that we're having a pretty deep connection on this podcast, and we don't need to be sitting across from one another at the table that I'm sitting at right now in order to have that connection.
In fact, when I'm practice, I practice in a brick and mortar hospital for your listener's awareness. When I practice in that model, I'm able to talk to my patients at the bedside. I'm actually able to have longer conversations with them, virtually having video visits or having telemedical communication with them.
I also have to rely on their perspective, and this gets to your question, I have to rely on their perspective. I also am heavily reliant and dependent upon the perspectives of the multidisciplinary care team that is also evaluating them virtually or in the home. And so in that way, hospital at home is a real forcing function when the clinician and clinicians in the command center are virtual, it's a forcing function for multidisciplinary care.
The doctor and the nurse and the advanced practice provider must work together to understand their varied clinical virtual exams and assessments. Not only of a patient's medical condition, but also of their social determinants of health, of their capacity to make decisions of their caregiver burden, of their perceptions, of the care model, all these things.
And then we also have to work with the folks who go into the home to execute those care plans. We have to be very closely tethered to them.
Bon Ku: Hmm.
Gregory Snyder: But we have to start with the patient's perspective in all of this. And, you asked about sort of, I think in healthcare we talk about patient-centered decision making, and, patient-centered medical homes and in the, the words patient-centered come up a lot and I think that's great, but I actually really do love human-centered.
I prefer it. And I prefer because while this model puts the patient at, the top of the pyramid and the patient is number one, there's also the caregiver in the
Bon Ku: Yeah.
Yeah.
Gregory Snyder: We admit the whole family. When we admit a patient to hospital at home and we admit non-family caregivers to the model. We in many ways become a part of their family in a way that does not occur in the hospital because we are in their homes with them.
We're, we are in their place of authority and autonomy, and they get to tell us what, their home is like, but also what they do day over day. those are variables that are controlled for when we emit patients to a hospital room.
Bon Ku: I love that. I like human-centered better because patient-centered, you get this mental model of like being in a brick and mortar hospital as opposed to being at home and, and that patient experience often sucks. I've had family members, you know, when they get in the hospital, I'm like, they're at the bedside waiting all day long cuz like, I don't wanna miss the medical team rounding.
You know, they're gonna round, they come in for like five minutes and then they're gone for the rest of the day. I'm like, Ugh, I don't wanna miss that time when, when they're actually there. It, it's a terrible experience for a caregiver
and especially during covid when so many of us were, could not even visit, family members in, in the hospital.
So how do you do things like listen to a patient's heart or lung sound as a. Doctor,
but not not actually meeting the patient in real life.
Gregory Snyder: Yeah. No, that's such a wonderful question. I mean, first just to, you know, be very clear the, predominant form of delivering hospital at home today. Is by taking patients out of emergency departments and off of medical surgical floors, to put them back into the home for their hospital at home length of stay, if you will.
And I, I say that because it's important to recognize that in those models, there, there are doctors placing stethoscopes on patients and doing advanced physical assessment in person. In order to make a diagnosis or determine a level of acuity or determine whether or not the patient needs the hospital at all in the case, of you in the emergency department, but then when the patient is in the hospital at home, in our model, I am tethered.
I am tethered to another type of care provider in the home who I work with, I have to collaborate with to do a physical exam. For example, I might, depend upon a licensed independent practitioner, like an advanced practice provider who I, I've asked to go into the home to perform a heart failure exam.
Look at a patient's jugular venous distension, you know, check on their pitting edema, weigh them, do a pulmonary exam. I may actually do the same thing with a very well, well-trained mobile integrated health community paramedic. And the well-trained piece is of course, very important. We're taking home-based care providers, and we may be upskilling them to have them do advanced physical assessments for various different clinical conditions. The similar concept applies to an in-home registered nurse with whom I'm working, and like I said earlier, I think this makes me dependent upon the level of quality.
In that in-home service provider, in a way that is not true all the time in the hospital. If I don't have confidence in a resident or nurse or an a P P exam in the hospital, I may go do one myself. Right? And this model, we need to make sure that we are upskilling our service providers so that I as doctor feel comfortable being tethered to them.
Bon Ku: So let's, put on your future predicting hat here in maybe like 10, 15, 20 years. like what percentage of patients do you see
Gregory Snyder: Mm-hmm.
Bon Ku: being treated at home? Versus in the hospital, is that gonna increase by like 5%, like 10%, a hundred percent? Like what do you think?
Gregory Snyder: Yeah, good question. I mean, so I won't give you only my perspective here. I think it's important to be slightly data and expert opinion driven and, and so, you know, most, of the expert opinion in this space to date, and the data were, it exists, which suggests that about 20 to 30% of current hospital volumes could be put into the home.
Bon Ku: Wow. A
third.
Gregory Snyder: yeah, a third. And, and look, I'll say openly that when I treat patients in the hospital, I go through my list of patients and I develop their care plans. But I also ask myself, what am I actually doing for this patient today?
Bon Ku: Yeah.
Gregory Snyder: And could I have done that thing for them in a home environment with a very high quality and high functioning provider network of services that is decentralized and a lot of the time.
In fact, I would submit that, you know, sometimes 60 and 70% of the time the answer is yes on a medical surgical floor. Right? and so 20 to 30%, that's of all comers. So that would include patients that go to the I C U and step down unit. We can't take those today, and I don't know whether in five or 10 years we'll be able to, I think we'll be pushing on a step down unit, But
Bon Ku: that number kind of rings true with me. Cuz I think, you know, like 20 or 30% of patients I'd see in the emergency room then admitting, I would feel comfortable. Like, like I don't think they like, need such a high level of care, but like, I don't think they could go home and just like be safe.
And I would love that.
Extra option. And, and for those listening who don't work in hospitals, sometimes it's a little bit of a battle to go like, Hey, I think this patient needs to get admitted. And sometimes on the other end it's like, well, can't that patient go home?
I'm like, well, maybe they might have a bad outcome.
And so having this other option of like, Hey, I could send this patient home and they're going to get cared for is pretty remarkable. I, I think that's pretty revolutionary.
Gregory Snyder: It's a great option. I think, you know, to your earlier question too, we have some work to do in hospital, at home in order to meet those numbers. Those are not the numbers we're meeting today. And we know that every practitioner in this model knows that. we, our challenge right now is to scale this model.
Everyone wants to see this model scaled, and that's what we're hyper focused on. at the moment. That requires a lot of things. It requires. A permanent regulatory and reimbursement framework for this model. it requires really clear standards and indicators against those standards for quality and safety.
In this model, it obviously requires a decentralized and distributed workforce that is highly capable of executing against those standards. are things that we are developing, and constantly focused on. We'll get there.
Bon Ku: Are other countries doing it better than us in the US of this hospital and home model?
Gregory Snyder: Is this an international podcast
Bon Ku: Yeah, there are people, yeah. People from all over the
world tune in.
Gregory Snyder: Well, then I'll say, I'll be politically correct then and say that, we collaborate a lot. In fact, earlier this year, our teams were at , the, uh, World Hospital at Home Congress in Barcelona, Spain. And, as an aside, we presented out on our quality framework for hospital at home, and it was very well received.
We, we won an award for it. And, you know, that's the type of collaboration we, we see in the, in the world, space. There's a lot of leading systems that are not based in the us, are based in places like Spain or the uk or France or Israel or, Taiwan and Singapore. And it's really important that we have in
Bon Ku: they're, they're all beating us again.
Gregory Snyder: No, no, I think, well, you know, I think I actually think back to, and I, I should add to that list just for completeness, you know, Australia and Canada and you, so there, there are lots of them out there. I think that, is an international delivery model that was imported to the us.
Other countries have been doing this for a much longer time than we have in the US and they've been doing it very well. I would say that a lot of countries, however, are still working to scale their hospital at home programs. You know, for example, Australia, they were quoted recently at our World Hospital, at home Congress as saying that they treat probably between five to 7% of hospitalizations nationally.
Now I would submit that that is a very clear version of scale, five to 7% of hospitalizations. That is a lot of hospitalizations in the home. That's a lot. then there are countries who are, , pushing the fold in different ways by expanding high acuity care and, and blending it with lower acuity care to improve transitional care into the home.
And so we have a lot to learn from other countries in this space.
Bon Ku: What technologies are you getting most excited about that's gonna help scale hospital at home? You know, there's like,
Gregory Snyder: yeah.
Bon Ku: AI chat, g p t, drones, all this stuff.
Like what, what do you see as some like groundbreaking technology that's gonna help help you all to scale?
Gregory Snyder: Yeah. Well, well first, you know, you might, you might think there, there's not as much discussion of drones in hospital at home today, as you might think. Um, though that's been discussed, it's not something that is of, primary focus. I am really glad you asked the question in the way that you asked it, you know, what are the technologies that will help hospital at home scale?
Because technology will help hospital at home scale. Technology is not going to drive scale and hospital at home. I think that's a really important distinction that's oftentimes confused, generally, but also in our space. I think to your question, we could certainly benefit from higher fidelity clinical monitoring technology.
A lot of remote patient monitoring in my view is, is commoditized at this point. But we do need different types of technologies and hospital at home. For example, we need high fidelity remote monitoring that a patient can wear for seven to 10 to 30 days that is, easy for. For a patient to put on their body that is very clean user experience, but also very, clearly and consistently transmits data because this patient is acutely ill.
They're not a post-acute remote patient monitoring patient. A lot of the technologies that have been developed for remote monitoring we're not developed for acutely ill patients. And so we're moving up the acuity spectrum right now.
Bon Ku: what do you mean by like, telemetry recording?
Like, and like respiratory rate and pulse oximetry, all
Gregory Snyder: yeah. yeah. There's wonderful technology that exists for single lead, telemetry in hospital at home.
There are technologies for seven lead telemetry. We're obviously able to do, 12 lead ECGs, intermittently in hospital at home. I would say that no one that I know of is, is bringing home the 12 lead telemetry box with all of the leads going off the patient's body. Cuz we'd like to reduce wires in the hospital at home as much as we possibly can.
That's one example. You mentioned respiratory rate and there's some really interesting vital signs monitoring that's not necessarily heart rate or rhythm monitoring happening in hospital at home. That might include respiratory rates and SpO2, intermittent or continuous, but also things like falls detection.
And mobility. Patients are more mobile in hospital at home. They're getting outta their beds, they're moving around. That's a good thing. And so, you know, really detecting that, but understanding when that's safe and not is important. You also mentioned artificial intelligence. This is early days, for that in hospital at home, but we're developing more and more data and there are certainly platforms that are really innovating in this space.
I think, where we've put our focus at medically home is actually on the enablement and management of that very complicated network of decentralized service providers. This is an area that undoubtedly needs technology enablement to scale because it's so different from what we do in the hospital today where we may use an electronic health record to drive order to fulfillment a centralized supply chain in a building.
But when you imagine 18 different categories of clinical and nonclinical goods and services with multiple levels of redundancy in those 18 different categories. That's driving around to different patients homes in a 10 or 20, or 30 or 50 or a hundred mile radius outside of a hospital in both urban, metro, adjacent rural, and truly rural areas, that problem becomes very, very complicated from a logistics and supply chain management perspective. And so that, that's what our technology focuses on in Medically Home. there's other ways in which technology I think can really support the model that are a little less, less software, and hardware dependent.
I think we need just really good patient communication, technology and hospital at home. From a human-centered design perspective, we need great ways for our patients to consistently give us feedback on how we can improve
on our care while we're caring for them.
Bon Ku: I could talk to you all day about this, Greg, but you're busy. I gotta let you go here. my final question, if a listener to come visit you, Greg, where would you take them out to eat?
Gregory Snyder: I love where I'm sitting right now. It's a rainy day in Boston, but what I would probably do is drive them to the Boston Logan International Airport and fly them down to Philadelphia to have dinner with you Bon. Probably a Parc because that's where, that's where my wife, first met my parents in Rittenhouse Square.
And and I always enjoy a good, a good meal from a Steven Star, Jose Garces restaurant. So
Bon Ku: yeah, we could, we could eat on one of those sidewalk tables and, and people watch.
Gregory Snyder: Yeah,
Bon Ku: love it. Love it. Well, thanks Greg for coming on the show. So good to connect with you again.
Gregory Snyder: Amen. Oh, such a pleasure Bon and, it's been an honor. I look forward to decentralizing care with all your listeners in the future.
Bon Ku: Let's do it. It's always so good to have friends on the show. I hope you enjoyed my conversation with Greg. You can follow him on LinkedIn.
Design Lab is produced by Rob Pugliese, editing by Fernando Queiroz our theme music was created by Emmanuel Houston and the cover design by Eden Lew. See you next week.
