Full Care Spectrum Will One Day Be Provided In People’s Homes

The full continuum of care will likely be provided in people’s homes in the not-so-distant future.

That includes everything from informal and formal personal care services to skilled home health and home-based primary care, experts say. It even includes emerging hospital-at-home models, though the lack of an existing supply chain may present a serious hurdle.

“Home-based medical care will get mainstreamed into the U.S. health care delivery system,” said Bruce Leff, director of the Center for Transformative Geriatric Research and a professor of medicine at Johns Hopkins University. “I don’t know how long that’s going to take, but I’m pretty certain about that.”


Leff made his comments about the future of home care during an opening presentation at the American Academy of Home Care Medicine’s (AAHCM) annual meeting, held recently in the Chicago suburb or Rosemont, Illinois. Based in Chicago, AAHCM represents physicians, nurses, physician assistants, social workers and other health care professionals dedicated to working in the field of home care medicine.

In addition to his roles at the Center for Transformative Geriatric Research and Johns Hopkins, Leff also serves as a clinical advisor to innovative companies looking to shake up the home-based care space.

Those companies include Huntington Beach, California-based Landmark Health, a medical provider group that specializes in caring for patients with complex conditions, and Denver-based DispatchHealth, a provider of mobile health care. They also include Boston-based Medically Home Group, a tech-powered startup trying to shift advanced medical care from hospitals to patients’ homes, and San Francisco-based Honor, a company that partners with home care agencies to help manage caregiver staffing, scheduling, payroll and back-office logistics.


A key to home-based medical care’s success is its ability to offer holistic and continuous care that other settings simply can’t compete with, Leff said.

“You’re focused on medical and social issues because you know you can’t take care of people like the homebound unless you’re attending to both of those realms,” he said. “It’s impossible.”

Where home-based care is heading

The current spectrum of home-based care, according to Leff, starts with informal personal care services and ends with hospital-at-home models. Formal personal care services, skilled home health care and home-based primary care fall somewhere in between, in order of ascending degree of patient acuity.

Some likely see hospice care as an important part of that spectrum as well, evident by the robust M&A landscape and high deal valuations the industry is currently experiencing.

In terms of patient population, skilled home health care providers serve millions of patients every year, according to data from the Institute of Internal Medicine. In contrast, home-based primary care providers and hospital-at-home models provide care for about 500,000 and 5,000 patients per year, respectively.

New players looking to fill gaps between the traditional pillars of home-based care are starting to disrupting that spectrum, however.

“Over the last few years, we’ve seen incredible disruption in our mental map,” Leff said.

New apps and mobile tools now allow patients to schedule services carried out by informal caregivers who speak different languages, for example. Similarly, a handful of nascent programs are attempting to fill gaps between formal personal care services and skilled home health care.

The Johns Hopkins School of Nursing’s CAPABLE is one such program, Leff said. CAPABLE’s approach teams a nurse, an occupational therapist and a handyman to increase mobility, functionality and capacity to age in place for low-income older adults.

For every $3,000 of program expenses, CAPABLE has been found to yield medical cost savings of more than $20,000 by reducing both in-patient and outpatient expenditures.

“When the handyman goes into the house, they don’t fix the whole house,” Leff said. “If a patient says, ‘I want to get down the front steps and get my mail,’ but there’s no bannister on the front steps, that’s where the handyman will do the work. It’s an amazing model.”

Additionally, telemedicine and sensor technologies are also leading to disruption within the spectrum of home-based care, though both are still in their “early stages,” Leff said.

The Centers for Medicare & Medicaid Services (CMS) recently unveiled a proposal to expand telehealth benefits in Medicare Advantage, a move that will likely lead to more opportunities in the future.

Disruption is also coming from paramedic-at-home and at-home urgent care concepts, Leff said.

Hospital-at-home holds business promise 

Although Leff has experience working throughout home-based care, much of his focus and professional expertise lies in the hospital-at-home model, which, as its name suggests, brings hospital-level care into private residences.

Early research into the hospital-at-home model started in the mid-1990s, picking up steam throughout the past couple decades.

New York City-based Mount Sinai Health System is among the groups leading the hospital-at-home charge today. Mount Sinai launched its own hospital-at-home program in 2014 as part of a three-year CMS Innovation Center grant.

Patients who participated in Mount Sinai’s hospital-at-home model between 2014 and 2017 had shorter hospital stays, lower readmission rates and fewer emergency department visits, a recent study found. Past research projects looking at other hospital-at-home programs have highlighted similar results.

“Hospital-at-home is actually one of the best-studied health service delivery models ever,” Leff said. “There are dozens of randomized control trials of hospital-at-home in various stripes.”

There are currently hospital-at-home programs in California, New Mexico, Texas, Louisiana, Wisconsin, Ohio, Tennessee, Florida and several East Coast states.

“If this were a drug, it would be a blockbuster drug,” Leff said.

But there are several barriers to making hospital-at-home mainstream, experts say. The lack of an existing supply chain is particularly troublesome, as hospital-at-home patients often need access to IV fluids, oxygen tanks and other specialized equipment — sometimes on short notice.

“There is no supply chain yet for acute care at home,” Leff said, joking it can be easier to order Chinese food in winter than order an oxygen delivery. “That logistics piece is very hard.”

The lack of a dedicated hospital-at-home payment model is another barrier.

Last year, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) recommended implementation of a new hospital-at-home alternative payment model that bundles acute episodes with 30 days of post-acute transitional care.

PTAC recommended a separate but similar hospital-at-home model in May.

Once it does secure a steady place in the continuum of care, hospital-at-home will likely mean more opportunity for home health companies as well, Leff said.

Written by Robert Holly

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