Agreed, it's been a fantastic conversation and excited about the future of Home Care! I agree that days at home is a great metric, and just to add to that....

I think the overall emotional journey of going to the doctor's office or hospital is unfortunately negative. No one ever wants to see a doctor. Despite numerous attempts to reimagine the hospital experience, you sometimes just can't get rid of the stigma of the hospital.

With Home Care and the hospital coming to you, we can actually completely sidestep that jarring experience. So I see that as a major metric and a corollary to the "days at home."

And of course, the admissions avoided is always a nice win for providers. And then there's the grey space between someone that needs an admission and outside the scope of primary care where Hospital at Home programs can fill in and really improve someone's quality of life (think of your mild heart failure exacerbations). In fact, we're seeing someone right now that fits that build and the poor guy can't sleep because of his volume overload while inpatient team doesn't want to admit him because it's not serious enough.

Greg, I think success metrics should be an area of research for home based interventions. Using one metric may not be ideal.For example, there is emerging research that the All-Cause Readmission measures used in the Medicare program may be contributing to increased mortality.
 
The metrics should be balanced and incorporate elements of clinical quality, safety, experience, equity, financial and operational outcomes to show a compete picture of impact and effectiveness. Along the lines of return on health (ROH). More to come on Return on Heath in May ?

The AARP Innovation Labs has been a superb partner to advance technological improvements in healthcare. As a digital health start-up, we are honored to partner with them as our “Champion” via the MassChallenge accelerator program. Specifically, they are assisting with voice of customer surveys and our connections to industry experts. This research enhances our understanding of how users engage with our product and gain detailed insights to inform the product. Such partnerships also help us to validate our value proposition (for each market segment) and our go to market strategy. Such a partnership explores opportunities for design thinking insight, research possibilities, and product showcasing.
Senior care living organizations are also thinking about how to expand their reach. By partnering with technology, they can create relationships earlier with prospective clients by partnering on medication assists via technology into the home. This creates a new revenue generator for them while building trust with those in the community.

Hi Kathleen, I love this question and would just say that the answer is a strong yes and that the first sherpas/doulas/spirit guides (I use words with an intentionally spiritual context) in the health journey for our patients are almost always the family members who helps with ADLs, neighbors who pick up the mail, nurse across the street who helps fill the pillbox. To the degree possible that any home-based solution (chronic care, acute care, etc.) really partners with this network of caregivers the probability of clinical success rises dramatically. In addition to family, caregivers, neighbors (community!) I will just say there are an army of historically highly underpaid caregivers (PCAs, HHAs) that are frankly often the real heros in home care both on a chronic and acute basis. In our home hospital program, if we have a patient with a pneumonia who is delirius, we know that this patient will do far better in the home hospital than brick/mortar hospital but if we can't wrap family support or 24/7 HHA support (which we will do when needed), we may not be able to care for that patient safely in the home while they are acutely delirius. This obviously represents <0.01% of the ways HHA/PCAs provide care today in the U.S. but just highlights the incredible value they provide to patients and families as often the final defense against institutionalization.

Social interactions are extremely important to people, the quarantine demonstrated that. The question to keep in mind is will technology allow us to augment the human connections? Sometimes, senior citizens may have viewed their doctor’s visit as a social outing – their adult child caregiver son or daughter picks them up, they make connections with the front desk person, the nurse, the doctor. We need to ensure these types of bonding connections still exist even when we move to RPM and telecare. We know that keeping patients at home is the most empowering way we can optimize their health and wellbeing and technology is a great tool for that.

The new world of digital health we live in is very exciting although we should be cautious about differentiating smoke from fire. Shifting from clinic-based care to home-based care simply brings up some basic questions how do you (a) get vitals (b) get relevant exam findings (c) get labs, (d) get EKGs, (e) get imaging, (f) get spirometry, etc, etc etc. Much of how this gets solved gets to the underlying value proposition (whose problem are you solving and what do they care about and how much would they be willing to pay. A 90 year old with shortness of breath is very different from a 25 year old with palpitations but they both probably need an EKG but the 90 year old is much more likely to end up in the ED with a $10,000 admission and so that creates some structural differences in how those two patients are likely to be served (unfortunately, I would love cheap home EKGs for everybody!)

I see two big challenges that are front of mind in this area:

1. Not everyone has broadband connectivity in their homes, and many people don't have strong cellular signals either. Consequently, RPM and tele care may not work for everyone unless we upgrade their connectivity (which I believe the administration is seeking to do as part of their infrastructure proposal).
2. RPM in particular creates a data generation, ingestion and response issue. Traditional clinical workflows are not generally built around continuous data flows. So how do we separate the signal from the noise, and once we have the signal, what is the right intervention? We're only just beginning to design for this new model of care.

I think the other piece that we should just remember is that all of the above (technology, telehealth, supply chain services) should all be designed to serve the human connection between caregiver and patient. If any of the above disrupts that connection, shame on us! If it serves that connection this is fantastic! (and notice that I did not say physician and patient but rather caregiver and patient)!

This is another area where the VA has quietly excelled. They've been doing telehealth & remote monitoring since 2002! They had a small monitoring unit (connected to a phone line) that patients could upload their information through. Btw, this device was designed by the legendary design firm, IDEO.

I think there's many lessons to be drawn from the VA's experience and is also a great plug for Design Thinking as we create new services and products in Home Care in general. From a process standpoint, I've noticed that many healthcare organizations have aspirations for outstanding patient-centric care but often lack the processes to get there. This is where Design Thinking's processes/approaches can be very helpful (Omada is example of a great startup that did this).

I think designers need to be much more ubiquitous in healthcare organizations and can help discover the deep empathy to create the right solutions. It's only with deep empathy can we make sure we don't overlook the importance of the points made by Lisa and Dr. M. We really need to push ourselves to develop true empathy that leads to better product design.

Hi Kathleen, this is a critical question. Depending on the population - and my experience is more with a Medicare age population - there can be a massive digital divide with economic overlay (in Medicaid population), racial and rural overlay that can complicate this work. For instance, in our acute home hospital program we have to be very intentional about ensuring multiple layers of redundancy for connectivity for patients in the home given their illness and if they are in areas with very poor known connectivity of cellular back-up and no hard-line internet (quite common), it becomes challenging and then we are at risk of perpetuating the above inequalities. There are regulatory solutions and plan-specific solutions here that can be thoughtful. I look at the work of SCAN (homehealthcarenews.com/2020/12...) and think this is one of many thoughtful approaches to understand and directly go after some of the underlying DEI challenges.

Good question, Kathleen. Technology can be a double-edged sword. On one hand, telehealth expands a provider’s reach by leaps and bounds yet health equity drives us to commit that we are not just serving people who have internet and smartphones or live in an area with broadband. Innovation must bridge that gap.
There is a rising risk population who could benefit from services in the home but there is no way to get it. The family might not know what to do or how to finance. By working with partner organization to advance health equity, we can help get technology into the home to better care for patients. Other important questions will be how we get this technology to the patients – do they rent or buy it and how will payers coordinate with them.

This is such a good question and would love to hear from all of our panelists on this one! I think much of this question about home-based logistics has to align with the acuity of the patient. Much of the supply chain ecosystem in place right now for home-based care is around long-term support services (PCA, HHA, SN, SLP, PT, OT, DME) for chronic needs and outside of this, there is quite limited infrastructure for home-based diagnostics (remote vitals, in-home labs, in-home spirometry, in-home EKG in-home imaging, etc.) routinely used in both chronic/low acuity settings (primary care) or in acute/high-acuity settings (acute care). The economics for driving those services into the home for acute care work easily but are much more challenging for primary care and so this leaves a big gap for primary care based virtual organizations (Ro, Firefly, etc.) looking to access home-based services.

Great insight by Taki, and I agree. Another way to think about it is to remark on how the current brick and mortal health care system (usually based around primary care relationships, but also longitudinal specialty relationships) deal with breakdowns in on-demand need delivery. This usually manifests in ED visits and inpatient admissions, or incomplete care delivery. One thing that can set home care medicine/home based care services apart is access to patients, but as Taki noted there can be deficiencies in the back end services. I am not sure how different the rates of service breakdown are in home based care rather than brick and mortar and it would sure be interesting to see those numbers if anyone has them. Necessity is the mother of invention, and hopefully these breaks in the system will motivate implementers to develop a full suite of interconnected home care services which run the continua of acute to maintenance, and episodic to longitudinal.

I think this is one of the places where you are going to see the true platforms start to differentiate themselves. Whether it is Amazon and their ability to get seemingly anything to anyone within a day or two, or CVS/Aetna, Walgreens and Walmart with their stores (or mini-warehouses, if you will), or even B2B incumbents like Cardinal and AmerisourceBergen, there are a number of players in and around healthcare that understand the last mile - and have made the enormous capital resources necessary to deliver (literally). Once you can get the stuff where you need it, adding the humans to the mix is very solvable.

A shift away from the need to aggregate human capital and physical resources in a single location is going to be truly disruptive for healthcare. Again, I'll raise the point that we need to be mindful of equity in these contexts, as not all communities are well-penetrated by these players.

I am such a proponent of acute care at home. There's evidence that families are starting to be interested in care in the home. There are 103 hospitals in the CMS program to test the model. Humana and Dispatch Health are testing their model. Early results indicate positive clinical outcomes for patients and good financial savings for hospitals/healthcare systems. I believe the backend services' shoring up will come down to the payors--do they see the value? If they determine it valuable, companies will step up and provide the services quickly. Then it becomes a care coordination effect.

There is tremendous opportunity around the logistics for enhanced technology and software platforms to drive these capabilities in a given geographic area!

The essential change is that each home begins to resemble a hospital but highly customized to the needs of an individual patient. Thus, a large static location that provides service is now decentralized into separate pods that appear dynamically. This granularization of service location with dynamic characteristics is beginning to appear everywhere. In another thread, I had talked about home healthcare and the Amazon fulfillment model. But we are seeing the same with Uber and even Cloud computing with Server space allocated across different locations dynamically (what is called serverless computing). The key is to understand the supply-demand dynamics of the service offered and use that to create an on-demand service. Obviously, this is never easy, particularly in healthcare with all its complexity. The important thing is to start with the simple things with few dependencies and gradually scale up to something bigger.

There probably is a really significant change in not just the location but the way we staff the human beings to deliver the care. As it currently stands the hospital is the main driver of efficiency--humans sitting in the ER, or floor where they can maximize efficiency and thus revenue growth in a centralized location. Given the new disruptive technology around complex allocation algorithms, real time matching of need, and significant cost savings that occur with sending care givers to the home, the staffing will likely change to a much more fee for service of all providers and not just physicians who are allowed to bill. Without this change there will still be misaligned incentives around care delivery at the home. With on demand servicing of care at home we'll also hopefully be able to change a lot of the necessary requirements for what is needed for billing for care, for example, the definitions of complexity of care and visit types that are now still almost entirely defined by in person visits. This then changes the incentive structures for in office visits to in home and telemedicine visits in the future.

Hi Kelly, couldn't agree more and the world of home acute care is expanding rapidly. As somebody on the Medically Home team who supports our local home hospital partners (Mayo Clinic, Adventist, etc), the payer discussions are frankly amont the easiest parts of home hospital program launch. The program creates such fantatic safety, quality, satisfaction and utilization outcomes that there are plenty of savings to be shared with the payers - in the form of major reductions in readmissions, SNF transfers, etc. - particularly over extended (30-day) bundles of care for the most vulnerable patient populations. In other words, getting paid is not the hard part! It's decentralizing all the care (logistics, 24/7 clinical care, safety back-ups, remote monitoring, etc.) in a way that is 100% invisible to the patient.

Laura, I love this question! I would argue that the short answer is "yes, absolutely!" That said, there is more capital flowing into digital health than ever before, valuations are quite high and there continues to be a risk of "too much smoke, not enough fire" which we all need to be cautious off. One of the main tensions right now is "delivery system up" or "digital delivery down" competition with each set of players trying to solve the opposites competitive strengths in a better way. For instance, Ro acquisiton of Workpath for home phlebotomy services to better solve blood draw (in the home!) relative to the way that a clinic may solve blood draw (come to our clinic!).

Great question! The jury is still out to some degree re: which solutions, and novel technology in particular, will actually bring value. As it turns out, care in the home setting is quite similar to care in any other setting: More technology is not necessarily better care. And in fact shiny tech may at times distract from the core goal of human-centered care. The ultimate winners in tech startup space in my mind will be those that can facilitate the right-sizing of the in-home care approach given a particular patient's medical and social context.

Couldn't agree more with Patrick. More technology - particularly in our most vulnerable elderly patients - is often not helpful and frankly creates more patient frustration, risk, complexity, cost for really little additional value add (classic geriatric teacing -> just because you can do something doesn't mean you should do it!). Most of the tools used in home hospital are the exact same tools used in brick/mortar hospital (P, BP, sp02, temperature, secure tools for video visits etc.) and what is hard about home hospital is the acuity management, the supply chain bringing services to the home, the integration with existing care infrastructure and focusing on eliminating all caustic elements of hosptialization (sleep disruption, activity loss, falls, DVTs, infectious processes, etc.) while maintaing all the important elements. Technology alone is really just a small part of the discussion here!

also in line with the above, there is just a lot of uncertainty in how compensation and payment models work. Whenever I hear about a new startup in the DH space its always unclear if they will see to be a primary payment recipient or bill insurance for savings, which is always a bit of a black box. The innovations arent just around the delivery of the care but also the compensation which allows for new and more agile models to thrive.

I agree with Patrick and his comments around caution for shiny objects. While there was early optimism about the potential benefits of electronic health records (EHRs), reported outcomes with ubiquitous use are mixed, and EHRs is believed to be the only technology implementation which led decreased productivity after spending billions in incentive payment . We need a robust mechanism such as clinical and pragmatic trials to test digital health intervention efficacy and in setting they work.

Hi Kathleen, I certainly hope that all the negatives of COVID disappear and all the positives of COVID remain well into the future (expansion of telehealth, expansion of acute care in the home, hospital without walls regulatory unlocking, CMS FFS home hospital waivers). Much of the regulatory relief has been tied to the duration of the public health emergency (PHE) and so when the PHE disappears the concern is that we lose some of these positive steps forward. On the home hospital side, there is a lot of advocacy work ongoing with CMS/CMMI to create regulatory structures that continue to support Medicare FFS payment for home hospital programs once the PHE is no longer extended.

I guess the answer depends on how we measure its success. If we believe that in person care will almost completely go away, I don't think that is likely. At the same time, we are not going back to pre-pandemic world where telehealth seemed to be an option only when absolutely necessary. This change is driven by greater acceptance of telehealth by patients. However, the impact on the system will be dramatic. I predict that telehealth will become an effective triage system where 80% of patient calls will be closed right during the telehealth call with a prescription or request for tests and only the remaining 20% will be escalated for in-person examination. This will ensure that clinic and hospital resources are less stressed will maintaining quality of care. The trickier thing to measure is value of physician time. It seems that physician's spend as much time seeing patients in telehealth as in in-person appointments and any attempt at differentiating across them will get pushback from them.

* Rather than looking at the last year's watershed moment as the new normal for Telehealth, I see this as the jumping-off point for an entirely new paradigm. What the last year did demonstrate is that the healthcare system no longer needs to be tied to physical assets and the colocation of large numbers of people. In the near term, Telehealth volumes may retreat a bit as people seek "normalcy" by returning to their clinicians in-person, but over time we're going to see an explosion of new models of care unleashed by the fact that so many of us - patients, clinicians and administrators alike - saw that Telehealth and other remote/distributed models are viable options in many (though not all) cases. This means that companies like Medically Home and Contessa, Ready and Dispatch are just the start of a more distributed care model.

At the same time, we have to be mindful that, in the words of William Gibson, the future is already here - it's just not distributed evenly. That means that payors and providers will need to invest significant resources into digital literacy, and to work with communities to make broadband (and device) access universal.

Kathleen, I see a future where we will stop arguing about tele health as a separate care modality, its utility and get to the point where digitally-enabled care will be just called "health care". The trend began before the COVID pandemic. The epidemic has made stakeholders realize that the health blockbuster model has come to its age, and now is the time to adopt Netflix model. This article by Mckinsey further quantifies telehealth post COVID opportunity mckinsey.com/industries/health...#

Hi Greg, I love this question and if I was smarter I might have a better answer than "it is fuzzy!" A few thoughts. (1) We (myself included) remain very much anchored on our hospital-centric construct and (2) there is a spectrum of acute from acute uncomplicated urinary tract infection (managed 99% of time in office or home-based settings) to severe urosepsis (managed in hospitals). I think one way to describe it is what is the minimum service threshold required to care for that patient safely. With this construct, acute home hospital care is required for patients who have an acute complaint that would otherwise have been triaged to the ED and ultimately judged to require to inpatient level med-surge floor, admitted to med-surge and will meet payer inpatient criteria (Medically Home enables health systems to provide this care). Home-based urgent care is required for low-acuity, non-life/limb threatening processes that would otherwise be cared for in urgent care and primary care settings (Heal, Dispatch Heath, Ready Responders). Most of the data suggests that about 30-40% of ED ambulatory presentations could be cared for in urgent cares and this lower-acuity urgent care replacement for non-life-limb threatening processes is certainly amenable to Health, Dispatch, Ready Responders, Home-Based Geriatric NP Programs with prescription pads and diagnostics.

Would love to hear what you think!

Yes, I agree this one is fuzzy! But I like Dr. Michaelidis implication of trying to get at why the question is relevant. I agree that safety is the first priority. The question really is a side effect of our fractured, episodic healthcare system. Could the distinction fall apart in the new Home Health world?

When you do house repairs, you may have one main person or contractor you call first. He/she may then call in help as needed (e.g., the electrical person, plumbing expert). Could that general contractor be the PCP? Could the PCP regain their prominence in this new Home Health world?

Home Care spectrum ranges from care for low acuity care to higher acuity, and from chronic diseae to more acute care. The four principal factors driving the development and use of these spectrum-of-care approaches are payment, technology, policy, and demographics. It also moves from models in which there is little or no provider involvement in the home toward models in which MD involvement is substantial to direct to home telehealth. As per an estimates suggest that somewhere between 10 million and 15 million people currently receive informal home care.An estimated 2 million Americans receive these formal personal care services: that is, paid-for services—for people who need additional help or who do not have family at home to help them. Skilled home health care, which is used for post-acute care, as well as for people in the community who are homebound, according to the definitions of Medicare, and have skilled home health care needs. More than 3 million Medicare recipients use those services.Home-based primary care, which is a longitudinal medical care, which is often team-based care and which is often provided in collaboration with social services providers to a population that is essentially homebound hospital-level services provided in the home, including care provided through hospital-at-home-type models. .
Some of the models include
- Community-Based Care Transitions Program
- Geriatric Resources for Assessment and Care of Elders
- Program of All-Inclusive Care for the Elderly
- Home-Centered Primary Care
- Independence at Home
- Hospital at Home
- etc

I believe that the answer (by no means simple) lies in looking at a different industry undergoing a "home" revolution: retail. It is clear that consumers like getting products they order arrive at their doorstep. The challenge has always been: how do we get a complex assortment of products, potentially stored in many different warehouses to a consumer within a very short period of time without breaking the bank. Amazon has managed to achieve this and a similar set of principles applies in home health as well. In theory, we can get many things into the home of a patient, but doing so at scale with consistent service is a challenging problem. Even before we get into the machine learning and optimization details, there are a few basics that we need to adhere to. Every service activity (dialysis, providing oxygen etc.) needs to have a "bill of materials and labor" that precisely maps the activity to a list of equipment and materials as well as the kind of skills required. This can form the basis for understanding which services we might be able to pilot first. For example, services that have fewer dependencies and require simpler skill sets should be prioritized first. Once we undertake a pilot for a service, we need an understanding of where these materials and labor will come from (this is equivalent to understanding the location of the warehouses in retail). This then forms the basis for analyzing time and cost metrics. For a patient at a given address requiring immediate oxygen support, is it easier to push available equipment + personnel into the home or better to pull the patient into a hospital? The metrics will answer. Getting to this level of granularity is not easy but definitely possible given the current state of technology and indeed might be crucial to the eventual large scale adoption and success of the home healthcare model. Please forgive me if I make mistakes in the description of medical procedures. But the operations / supply chain analogy holds!

Here in San Diego, we just rolled out one of the first Hospital in Home programs. The group other than RN team I've worked the closet with in the last 6 months has been pharmacy. They are indispensable.

A few thoughts:
1) Making sure pharmacists practice at top of their license. This means they should be allowed to manage hypertension or diabetes medications.
2) Continue to provide oversight over drug interactions and kidney issues.
3) Think about medication adherence in a new way. Once you go to a person's home, it's eye-opening and humbling to understand how someone lives. You quickly can tell what road blocks exist for adequate medication adherence. I think there's an opportunity for pharmacy teams to join on some of these visits to help troubleshoot and come up with creative solutions to overcome these barriers. Often, the solution is easy and something like a pillbox can do the trick.

Pharmacists have played a critical role in improving access to clinical services. A claims data analysis from the Veterans Health Administration revealed that provision of telepharmacy services was substantially higher in rural clinic patients compared to medical center patients.A study from Australia within the inpatient setting demonstrated that telepharmacy was as effective as face-to-face medication reviews in identifying problems related to medication. We have developed care models including RPM that integrates pharmacists in the core of care management team.

Find more information on the role of pharmacists with the review article below ncbi.nlm.nih.gov/pmc/articles/...