Q&A with Michael Dandorph of Tufts Medicine: 'Home care was an enormous advantage for us'

Tufts Medicine comprises hospitals, a home health division and a clinically integrated network of physicians. How did that diversified business model help you weather the COVID-19 pandemic?

I arrived at Tufts Medicine, then called Wellforce, in late January 2020. About six weeks in, we had to prepare to handle the COVID-19 patients who were about to hit our doors. We decided to curtail some of our elective services to be ready for that.

We quickly mobilized an organization that was historically very much a holding company; everybody did their own thing. There were collaborations when it made sense. Anybody within the system had veto authority. When COVID hit, we were starting a process to transition from this holding-company mindset to an operating company—it was something the board really wanted us to focus on. I thought it was going to take us a couple of years to get everybody aligned around a common mission and vision. But COVID hit, and we immediately needed to figure out how to work together in a different way.

We were short on ventilators, we were short on personal protective equipment. We had to make decisions that really affected the entire system from a cash management point of view and from an employee policy point of view—(implementing) work from home, standing up telemedicine. We quickly formed teams from across the system to start to think about how to mobilize the resources that we had to make sure we were focused on two things: saving as many lives as possible and keeping our people as safe as we can. And that level of focus compelled people to come together.

From there, we started to build an integration plan around this mindset that we were stronger together. We had different assets across the system that we could be leveraging. Home care was an enormous advantage for us because we were able to keep people who didn’t need to come into the hospital out of the hospital. That taught us a lot about how to integrate home care and our clinically integrated network into our hospital network.

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On the home health side, how does that shape operations going forward? We’ve seen more acute services moving into the home. Remote monitoring is such a big component of chronic care management. Has the scope changed how you’ll deliver care in the future?

We learned a lot about what it would take to do more acute care in the home, and it’s certainly an area we’re investing in now and want to scale in a meaningful way. We quickly piloted a program called mobile integrated health, where instead of somebody coming into our emergency department, we would deploy a team of paramedics that would do that emergency care visit in their home, and frequently avoided the need for that individual to come into the hospital. We know once they’re in the hospital and the ED, providers are trying to get them either discharged or into a bed. Now we have a process that discharges them to the home, and that’s connected in our electronic health record, which we just stood up in April.

Does that alleviate some issues around capacity for your most acute patients in the inpatient setting? And from a staffing perspective, I imagine you’re able to mobilize and leverage different caregivers in the home and through that virtual component.

I’d say it did. And then in the fall of 2021 this Great Resignation hit us, and we started to deal with some staffing shortages. We’ve been thinking about how to make sure that we have the right staff in the right places. But we’ve also been challenged with having to increase the number of contract labor staff that we have. So I wouldn’t say we’ve realized the promise yet, but we are working diligently in terms of making sure that we don’t lose sight of the fact that the future of care for certain acute episodes will be in the home. That will open capacity for us to be more efficient for the patients who actually need to be in the hospital.

Does that hinge on reimbursement? I know there’s a Medicare waiver, but is this scale impeded on the commercial insurance reimbursement front?

A little bit. The state mandated parity early on to make sure that we could use technology and telehealth within the home. What we’re doing now is also working with the private payers. We don’t expect to get paid the same amount for the care that’s done in the home. (Inpatient care) is much more intensive than a home care visit. So the payers, the employers and the consumers should really benefit from this, as well as us. That’s an opportunity for us to expand our reach.

Tufts has about 400,000 lives under value-based contracts. Did that diversity in terms of your payer mix and those reimbursement models help sustain Tufts through the intermittent elective procedure shutdowns over the past two years?

We have value-based care agreements; I wouldn’t say that we’re as far as being capitated for those lives. So, from a cash flow point of view, we actually saw a dip in our volume and the resulting dip in our financials. The CARES Act and other state support has helped us muddle through, but in the fall of 2021, we went close to five months without providing elective services. That, coupled with the increase in staffing, has been a challenge, and we’re working our way through how we recover from those financial times.

Your organization, like so many others in the state, is anchored by an academic institution. A big focus of the Massachusetts Health Policy Commission is ensuring that lower-acuity care gets to the most appropriate setting, often community hospitals. You have all this fixed infrastructure when it comes to your academic institution; how do you ensure that patients are going to the right setting at the right time?

When I got here, one of the early things that we developed as part of our vision was how we think about the academic medical center as a distributed model that we can use to help elevate the programs that are in the community hospitals and keep people out of the academic medical center. Tufts Medical Center is a relatively small academic medical center of about 450 beds. We’re trying to make sure it’s a resource in the system for care that can’t be provided closer to home. And what we’re really committed to—and this is where the HPC and Tufts Medicine are very aligned—is wanting to provide care at the lowest cost. We want to double down on being more value-based, risk-driven and moving into more capitated care models. We think we’re well prepared to mobilize (our clinically integrated physician network) to lower the costs of care for the people and employers of the Commonwealth.