This panel will discuss new care models such as home hospital, community paramedics and on-demand services. We will dive into the impact of technology innovations such as RPM and telehealth, as well as how logistics and infrastructure, such as supply chain and equipment, enable the timely administration of care.
Good morning and welcome to our panel on home healthcare! I'm looking forward to the discussion and am excited to hear from your experiences in this space as it's becoming such an important model to provide care, especially given how we've shifted modes of care throughout the past year. I'll start by asking what general trends have you noticed in home healthcare? Which ones are you particularly excited about?
Hi Laura, thank you for the fun question. I am most excited about the shift in the site of care from institutional settings to the home for our most vulnerable patients. This is happening both for chronic care (Landmark Health, Caremore, Concerto Care, many home-based geriatric programs) and acute care (Medically Home, Contessa, Dispatch, Ready Responders, Heal, many others). There is just an increasing realization that the institutional approach does not work for many vulnerable patients and that the more we bring care to vulnerable patients, the better we can drive improvements in patient satisfaction, quality, safety and ultimately utilization and cost. - Taki
Thanks Taki, I'm wondering if you can share specifics. What data is influencing the realization that the institutional approach isn't working - how are decision makers defining the problem?
How are we defining vulnerable patients and how are we measuring the improvements to their care?
Hi Amanda, great question. I think if we look at our top 5-10% most ill patients who tend to drive 50-60% of total medical expense (across payers), there are common features that include (a) common severe illness phenotypes (severe mental illnes, frail elders, end-stage oncologic diagnoses, involved disabilities, etc.) and (b) total failure of the ambulatory primary care system to care for these patients in a way that focuses on health. As a result of (a) and (b) above, patients essentially become institution-dependent (hospitals, SNFs, etc.) with associated decrements in quantity and quality of life. Home-based chronic and acute care is not - alone - the silver bullet for (a) and (b) above but is a critical component to support a more robust home-based and ambulatory primary care structure for the above patient populations that are poorly served by existing ambulatory fee for service primary care systems (you have to be able to get to clinic first and a 15 minute visit with a provider is just massively inadequate against the above). Taki
I agree with Dr. Michaelidis. It is exciting to envision how achieve “Home as the new site of service”. We will all need to be willing to think outside the box and be innovative on how we achieve this. Technology will certainly play a key role. And, given our growing caregiver shortage, we need to consider new care models that incorporate low/no-credentialed care providers.
I always like to think about the "moonshot" vision. I believe what we're working towards is the attached picture. This is the medical bed from the movie "Elysium" starring Matt Damon. It's a sophisticated machine that diagnoses and treats the individual.
Obviously, there's many steps before we get there, but I truly think in 10-15 years hospitals should only be ICUs and operating rooms. Put another way, this is a boomerang back to how medicine was practiced 100 years ago where the doctor came to you.
I agree with my friend Dr. Michaelidis that we need to first support the underserved and most vulnerable populations. Ultimately, this can be the solution for everyone.
The VA system has quietly been excelling in this area for the last 20 years! They have a full set of programs including HBPC, Hospital in Home, Telehealth, Remote monitoring (they were doing this before anyone), and Emergency Room video visits for lower acuity complaints. They've been doing Hospital in Home since 2013 so they have a huge reservoir of institutional knowledge and have now expanded this program to 12 VA sites.
I think the general trend is more towards the idea of a "distributed care" model, where people can get the care they need whenever and wherever they are. I agree with the above that the hospital should in the future really only be for high acuity, ICU and OR type of care. The technology can exist and should exist for allocation systems for distributed healthcare resources (i.e. people) to find and go to people's homes. This means a few things
1) A clear data dictionary for what it means to have a need. For example, if someone has atrial fibrillation, it also likely means they complain of palpitations. That terminology and automated data entry doesn't quite exist yet
2) A clear data dictionary for what it means to be a provider. Nutritionists, doctors, physical therapists, nurses, paramedics all have different capabilities and while it seems obvious what roles each do, its not clearly coded in a way that can be matched to #1
3) Matching algos, dynamic, that allocate the supply and demand per above.
I've seen emerging companies seeking to address all aspects of care in the home, from wellness/recovery (both virtual and in-person), to primary care, to urgent care, to ED diversion, to hospitalization, to post-acute - basically everything other than trauma, surgery or ICU care. Incumbent providers will need to decide whether to work with these emerging providers, build these services themselves or stick to their existing business models (and COVID isn't making it easier for them to reflect on this strategic imperative).
Looking ahead, I believe there will be increased vertical integration and consolidation among these service providers as the benefits to scale increase (including payor contracting). As these companies span multiple markets, the concept of "all care is local" may change - with truly national providers emerging.
I agree completely with Jon's point around the increasing vertical integration and consolidation that is happening (both provider up as they take on risk and payer down as they take on delivery capabilities). Intuitively, I have a strong sense of excitement that this could improve quality and cost but also have to be very humble that most of the data around vertical integration is really very mixed. It's hard to study well but there is definitely no data that vertical integration is a "slam dunk win" for patients from a quality, safety, utilization, patient satisfaction, etc. perspective.
Lots of great points have already been made by all. One question I focus on is: is the "institutional approach" doing worse than before, or has it always been failing in the care quality triad? I think it is a mix of both, and on top of this there are increasing recent economic drivers in the form of cost containment mechanisms of value based contracting and penalties for medical recidivism which are making all involved pay more attention to the breakdowns in care delivery. Patients are now more complex, and more empowered through information sharing and cultural shifts. Treatments are more numerous, and the evidence base defies human comprehension in it's scope. Payers and employers are more empowered to second guess spending and outcomes. All these have pushed the institutional approach to its limit.
Love the comments above. Very insightful. The opportunities are endless. To complete the list, range of other in home care services including
- Home based primary care
- Home based transitional care
- Home based Palliative Care
- Home based Urgent Care
- Home based Remote Patient Monitoring
- Home Based Mobile Phlebotomy
- Home based mobile imaging
- SNF at Home
- Preference bridge program
- Home Infusion program
- Home Pharmacy program
- Home based bridge clinic
Most patients love the opportunity to be taken care of in the comforts of home. Caregivers play a major role in supporting home recovery. Caregiver burnout needs to be be closely monitored and addressed with additional home supports as needed.
I agree. The satisfaction amongst patients about not having to come into the hospital is huge! I don't think many people realize how antithetical to recovery the hospital environment can be (e.g., vitals every 4 hours, multiple needle pokes, loud noises).
As Dr. Goodman mentioned, it's important to make sure caretakers are able to handle the extra work associated with taking care of someone sick. Sometimes they need respite, and that's an ok reason to either admit the patient or bring them additional help to the home for a short-period of time.
As someone whose career has moved from patient safety, to broader patient experience of care, and into innovative care delivery models, the patient perspective is incredibly important here. Are we on the healing path with our patients? Or are we delivering treatment to them? Important distinction fo sure! And while in home models of acute care offer and opportunity for patient-centeredness, the deliberate design in terms of those aims is critical and can't be assumed. At DispatchHealth, we have consistently placed patient centeredness as a core process and outcome metric and are proud to boast our best-in-class NPS metrics. This has been a core element to our build out of hospital level care in the home as well with astounding results and praise form patients, their families, and their broader caregivers. This is a new moment in time for designing care around the patient and their context - let's not squander that opportunity!