One of the most promising opportunities to improve care and lower costs is the move of care delivery to the home. An increasing number of new and established organizations are launching and scaling models to move primary, acute, and palliative care to the home. For frail and vulnerable patients, home-based care can forestall the need for more expensive care in hospitals and other institutional settings. As an example, early results from Independence at Home, a five-year Medicare demonstration to test the effectiveness of home-based primary care, showed that all participating programs reduced emergency department visits, hospitalizations, and 30-day readmissions for homebound patients, saving an average of $2,700 per beneficiary per year and increasing patient and caregiver satisfaction.
There are tremendous opportunities to improve care through these home-based care models, but there are significant risks and challenges to their broader adoption. Let’s look at five key barriers to moving care to the home and explore potential solutions to overcoming these challenges.
1. Patient preference. As home-based care grows in use and acceptance, it is crucial to consider patient preferences for home-based care vs. care in traditional brick-and-mortar settings. A study of older persons’ preference for a treatment site revealed that 54% of surveyed participants preferred treatment for acute illness in the hospital rather than at home.
There are several factors driving patients’ preference for settings others than the home. For some, receiving care at home can be a constant reminder of illness and an unwelcome invasion of privacy. Prior negative experiences with caregivers or stories of elder abuse and neglect can also influence patients’ attitudes towards home-based care. Some patients may enjoy the social aspect of seeking care outside the home and interacting with people, and others may be embarrassed about their living situation.
These preferences should be respected and not disregarded. Physicians must elicit information about patients’ needs (which can differ from those of family caregivers) and engage patients in shared decision making about whether home-based care is the right choice for them. In addition, home-based care programs should establish strong relationships with outpatient facilities, hospitals, and other long-term facilities to accommodate patients’ changing preferences and facilitate handoffs.
2. Clinicians’ concerns. There are several challenges that can deter clinicians from participating in home-based care. Compared to the hospital or office environment, caring for patients at home requires longer visits and therefore a smaller panel size (the number of patients for whom a care team is responsible). Home-based care clinicians see, on average, just five to seven patients a day. Physicians spend more time understanding and addressing the social and economic conditions that impact health — such as remedying medication discrepancies, identifying home safety issues, and connecting patients with social services — but are disadvantaged under traditional fee-for-service models that tie payment to number of patients seen and procedures performed.
For home-based care to scale, payment models must reward, not penalize, clinicians for spending extra time coordinating and managing care. Clinicians should be able to share in the savings accrued from preventing unnecessary hospital and skilled-nursing-facility stays and not purely be rewarded on a fee-for-service basis. Not surprisingly, the recent growth in home-based care has come from health systems that operate under fully-capitated or other risk-based contracts. In addition, payers must eliminate outdated restrictions on the technologies (e.g., remote patient monitoring, telehealth) and equipment eligible for reimbursement.
Another challenge is clinician safety. Clinicians are understandably disinclined to visit homes in areas with high rates of crime, making it difficult to embed home-based care programs in some medically underserved areas. Attracting clinicians to home-based care requires measures that prioritize clinicians’ safety. For example, at the CareMore Health System, a care delivery organization that serves high-cost, high-need patients, clinicians are provided with training on defined protocols and de-escalation techniques relevant to home-based care and security escorts when necessary. In addition, CareMore clinicians have immediate access to emergency response through a “panic button” located in the Amaze mobile app used by home-based care teams.
A final problem is medical training. Medical schools and residency programs must prepare the next generation of physicians for the inevitable shift from hospital to home by integrating home-based care into required curricula and training. Some programs are taking this step. For example, the house-call curriculum for internal medicine residents at the Johns Hopkins University School of Medicine significantly increased residents’ knowledge, skills, and attitudes relevant to home-based care. Such programs can address the shortage of physicians trained in home-based care and fill the gaps in medical education about caring for frail and vulnerable patients.
3. Supporting infrastructure. The lack of supporting infrastructure, including life-sustaining and assistive durable medical equipment (DME), makes it challenging to manage patients’ acute care needs at home. The poor availability of DME largely resulted from competitive bidding policy of the Centers for Medicare & Medicaid Services (CMS), which prompted a 40% decline in DME companies between 2013 and 2017, including those that supply home oxygen to 1.5 million Americans. Competitive bidding forced companies to compete for contracts and agree to ever-lower reimbursement rates, biasing bids towards lower-cost, lower-quality equipment. For patients to remain independent at home, payment models must incentivize DME companies to improve service and produce high-quality equipment. Because DME such as oxygen or nebulizers needs to be delivered to patients within hours with a high degree of confidence, the DME supply chain must be nimble and redundant. Payment models should reward companies for speed and reliability.
For patients receiving less acute home-based care, help with caring for themselves (dressing, bathing, toileting, cooking, and moving about safely) is critical to their ability to remain independent and safe at home. However, insurance programs typically do not cover support services to help people with such activities. Health systems and payers should work together to bring patients more in-home support services. In 2018, CMS announced expanded supplemental benefit coverage for Medicare Advantage plans to include non-skilled in-home care services. Offering these benefits, such as the 16 hours of help with daily activities and 28 days of prepared meal delivery offered by the SCAN health plan each year, can drive adoption of home-based care models.
To fully support patients at home, an entire ecosystem of care needs to be available. For example, CareMore has a network of vendors for the various elements of the home-based care delivery system such as mobile labs, mobile radiology, and at-home medication delivery. These supports are necessary for home-based care to meet patients’ needs and offer a wider spectrum of services. Health systems must invest in strengthening this infrastructure in coordination with clinical care.
4. Patient safety. There are specific risks to patient safety in the home setting. These include: environmental hazards such as infection control, sanitation, and physical layout; challenges with caregiver communications and handoffs; lack of education and training for patients and family caregivers; the difficulty of balancing patient autonomy and risk; the different needs of patients receiving home-based care; and lack of continuous health monitoring.
It is important to rigorously assess and mitigate these risks when moving care to the home. There should be clear inclusion and exclusion criteria to assess the suitability of a home-based solution. Safety must be considered in each patient interaction — in the design of medical equipment and supplies used at home, the development of communication tools for home-based care teams, and the education of patients, family caregivers, and home-based care professionals. These considerations should be integrated into clinical care. (In the CareMore home nursing program, for example, clinicians conduct regular home safety checks and make appropriate recommendations.) On a systems level, we need consistent standards for measuring safety at home and mechanisms for sharing data and best practices across health care organizations.
5. Regulatory environment. Home-based care is governed by a patchwork of regulations that are not uniformly applied or monitored. There are no national or state requirements for the quality of home-based care, with the exception of care provided under the Medicare home-health benefit, and limited regulation of the education, training, and licensure of home-based care professionals further endangers patient safety.
To reduce the safety concerns and liability risks around providing “unregulated” care, health care administrators must commit to consistent regulation and more stringent enforcement of home-based care. While not comprehensive, we recommend instituting (1) standardized methods and requirements for measuring and reporting the quality of home-based care services, and (2) certification programs for home health aides, personal care aides, and other professional caregivers.
The resurgence of home-based primary, acute, and palliative care has gained traction for its demonstrated potential to improve outcomes and reduce costs for our country’s most frail and vulnerable patients. Alongside addressing the barriers to delivering safe, effective, and patient-centered medical care at home, administrators and policymakers must prepare for the broader impact on the U.S. health care system — for example, the growth of home-based care may reduce the need for hospitals — and change how we define success in health care.
For home-based care to flourish, we must deconstruct the fee-for-service chassis and shift towards value-based arrangements that reward health systems for moving care back to the home. This requires aligning the incentives for all stakeholders, including physicians and payers, and implementing risk-based contracts to address the lost revenue from hospitalizations. Adjusting the payment and regulatory environment in which health care delivery organizations operate will be crucial to the success and growth of home-based care — at a time where we need disruptive new models of care delivery more than ever.