Kristofer Smith, MD, MPP is the Chief Medical Officer of Landmark Heath, where he oversees efforts to establish a high-quality and clinically effective home-based medical care model for patients with serious illness.
We sat down with Dr. Smith to discuss his experience caring for patients with serious illness and developing programs to provide health care at home, among other topics. The following interview has been edited and condensed.
You have spent your career serving patients with serious illnesses. Can you share why you’re involved in this area of health care?
I’m involved in the care of patients with serious illness for a number of different reasons. it starts with my family. As a kid who grew up on Long Island, surrounded by extended family, I saw firsthand the struggles of folks as they got older, navigating the health system.
For example, when I was in middle school, my great grandmother moved in to live with us because she could no longer manage on her own. My mother was busy raising four children, and I watched her try to navigate and manage the health needs of my great grandmother and saw firsthand how difficult it was to get services in the home, how difficult it was to get her out to see the doctor. Ultimately, the demands of my great grandmother, as her illnesses progressed, became so much that we couldn’t keep her at home. This wonderful and fiercely independent person who never wanted to live in a facility, spent the last year of life in a nursing home.
It’s experiences like that, which made me understand the challenges of aging in our communities. And then as I became a physician and was blessed to be connected with really great, innovative leaders at places like Mount Sinai. I saw that you can bring care to the home through interdisciplinary teams. It was an obvious place to make a difference.
The concept of serious illness may mean different things to different people — share with us your thinking on what is encompassed by this term.
When I use a “patient with serious illness,” and I use it synonymously with a “patient with advanced illness,” what I mean, and I think by and large, the field means, is that you’re looking at a patient who’s got a substantial chronic condition, and that chronic condition is in its late stage, or advanced state, where that condition is impacting the ability of the patient to function independently.
So, it’s a serious illness in an advanced state that’s leading to functional impact.
And the reason I think of it that way is because of a lot of the work that I’ve done over the last 15 years is to try and build programs that are high intensity, which means high cost. In order to be sustainable, you have to be able to target the right complex patients. If you can identify patients who have a serious illness in an advanced state that is demonstrated by frailty, you have a high-needs cohort with high medical expenses, and you can help them, but you can also sustain your care model because the help you’re providing them is decreasing low-value, unwanted, unnecessary care.
What role have new payment mechanisms that incentivize providers to give patients with serious illnesses alternatives to the emergency room played in accelerating the development and expansion of home-based or community-based care models?
There have been a number of very helpful centers of innovation around care for frail seniors. The three largest are probably CMMI and the work that really thoughtful leaders have done to put forward care models like Independence at Home or high needs ACOs. These demonstrations create the financial environment where if providers do good work helping patients to remain at home, you can realize a financial return that allows you to reinvest in your program to continue to grow.
The VA has been a center of real innovation and experimentation in care of patients with serious illness through home and community models. And then I also think that Medicare Advantage has been very focused on figuring out how to provide better care for patients using the latitude that they have to partner with other organizations, whether it’s traditional delivery providers or new market entrants.
What metrics, if any, should a home- or community-based provider use to gauge their success, especially when delivering care to patients with severe or chronic illnesses, or when the treatment is palliative? How can providers work to reduce bias that might be perpetuated by over-reliance on metrics?
It starts with: what do you think this group of patients and family members need? if you think about my great grandmother, she had several chronic conditions, cardiovascular disease, dementia, frailty.
But she also lived a number of years with those conditions, and had intermittent exacerbations of her conditions. And what she needed was a comprehensive program that was able to provide in-home longitudinal care, in-home urgent care, in-home palliative care when she got to that latter stage. My mother needed in-home social support to help with my great grandmother’s social isolation, and to help access community-based resources.
If you think then of the needs of those of patients in a comprehensive home-based medical care program, then you can start to unpack: how you would monitor and measure whether you’re providing what patients and families need?
Part of it is, do they have the right constituent members of the team? Then in terms of what you should be measuring, I think global measures — things like days at home — is a good global measure. But that’s your summative measure. And so underneath that, what are the activities that you need to do or need to monitor to make sure that you’re having an impact on days at home?
I think you need to be measuring whether patients are calling you, how responsive you are, and how much patients trust you. And those are some ways I think of, of getting at whether patients see you as the center of their care team, or so peripheral that they don’t even think about you.
And then the last thing I’ll say is that measurement of success is also fraught with health equity challenges. I live in New York City. And if I were to take care of a cohort of patients who lives in the Bronx with many social determinants challenges, substantial chronic illness, historic challenges with systemic racism, and then think about taking care of a cohort of patients on the Upper East Side, the utilization patterns of those two communities may be very different. If the Upper East Side communities have 500 admits per 1,000 and the Bronx community has 800 per 1,000, I could have performance that looks really terrible in the Bronx. If you don’t understand the baseline characteristics of that community, you may think that I’m doing really terribly compared to the Upper East Side, but actually we’re doing tremendously well compared to the utilization patterns of those communities.
Can you share one key hope and one key concern about the future of caring for people with serious illness?
I’m very optimistic that we have enough evidence to know what works and how we can help to take care of patients. And we’re really at a moment in history where it’s more about operationalizing the evidence, as opposed to needing to continue to experiment.
Where I get nervous is that it is hard to operationalize at scale. My concern is always that everybody’s going to look to say, despite the fact that we know what works costs $350 per patient per month, we’re going to try and do it for $250, and then wonder why they didn’t have the same results as the evidence-based models have shown. I think that we have to do what has been shown to work, and not try and substitute lower cost ingredients into that recipe.
