If the COVID-19 emergency has made anything clearer, it’s the need for investment in care that takes place in home- and community-based settings.
While it took a global emergency to open people’s eyes to that reality, Dr. Bill Thomas has been preaching its importance for decades. Thomas is a thought leader in elder care who currently serves as a senior adviser at Lifesprk, a Minnesota-based home-based care provider.
Thomas is a senior care innovator who is also known as the co-founder of Minka, a company that makes 3D-printed tiny homes and communities. He also co-founded ChangingAging, a publishing platform that covers a variety of topics surrounding aging.
Home Health Care News recently caught up with Thomas to discuss the long-term impact he expects the coronavirus to have on senior care and why he believes the COVID-19 virus is a home- and community-based emergency.
Below are highlights from HHCN’s conversation with Thomas, edited for length and clarity.
HHCN: The senior care industry is on the front line of the COVID-19 emergency. Have you ever seen anything like this before?
Thomas: The COVID-19 emergency is really a home- and community-based issue. When we’re watching the news, we get the pictures and stories of what’s going on in the hospital, but according to the best evidence we have, only about 10% of the cases actually wind up in the hospital.
Overall, about 90% of this global pandemic is unfolding in people’s homes and in their communities. I find it kind of interesting that our health care system is so unbalanced in its approach. We have devoted tremendous attention to ensuring adequate hospital resources, but there’s been no comparable effort to-date to ensure adequate resources at the home- and community-based level.
How does it compare to other major outbreaks we’ve seen in the past?
Well, the most important thing about COVID-19 is that it’s what’s called a novel virus — novel not in the sense of a fictional book, but meaning no human being before the first case had ever encountered this virus before.
We have strategies for dealing with viruses that are known to us, but we are struggling without access to any of those same tools for the coronavirus. No vaccine. NNo effective medications. And furthermore, no chapters in textbooks explaining what to do.
This is a brand new thing in the experience of humanity. That makes it unlike say, a bad flu season or an outbreak of Ebola. We understand Ebola, we know what to do, we know what works, and we can manage outbreaks effectively. None of that is true for this virus.
Can you break down the current challenges and opportunities that you are seeing in home care?
For too long, home care has been relegated to sort of outsider status in terms of the health care system. As I was saying before, that’s where 90% of the outbreak is.
The challenge there is, when it comes to the resources — the tools, the technology, the protective equipment and the systems that are needed to manage [those] cases — providers have largely been left to their own devices to figure out how to get that stuff.
That’s in contrast to some of the much more structured programs you see for hospitals and other parts of the health care system.
In essence, the biggest part of the outbreak has been offered the least support and assistance in terms of meeting the challenge. I think that’s a big mistake that we’re going to regret going forward.
Over the past few weeks, we’ve seen CMS make moves that focus on other health care settings. Do you think that in-home care takes a back seat when it comes to CMS’s priorities?
If you look at the numbers, it’s pretty clear that home health care has been the lower priority. I can kind of understand that in the early phase of the epidemic.
But that’s a bad idea going forward. Let’s say that the intense focus on hospitals, ventilators and ICU beds was the right thing in the early weeks of the outbreak. Maintaining that focus, going forward, is actually counterproductive. If we’re going to control the virus in the months before we have a vaccine, it’s not the hospitals that are going to get control of the virus, it’s the home. That’s where we will hold the virus at bay.
What we have to do as we get through the most acute phase of the first wave of this virus is begin to balance our efforts. The more we put into effective home- and community-based responses, the lower the surge that hospitals have to deal with. It’s really about an ounce of prevention being worth a pound of cure.
During this public health emergency, does the in-home care setting have natural advantages over other care settings?
A couple of weeks ago, there was a really powerful article in the New England Journal of Medicine written by physicians in Italy.
They argued in their article that their own hospital-centric focus had worsened the epidemic. All these people were being poured into the hospitals, which became sources of cross-contamination. The hospital itself was accelerating the pace of the outbreak.
They were saying that, going forward, they need to shift to a community-based focus and empower providers to deliver supportive services in the home.
I saw an [HHCN] article that said the epidemic is accelerating some of the existing changes in the field. I endorse that.
A couple of things will come out as strong winners after this initial phase of the crisis. One is hospital-at-home. I think hospital-at-home is going to move from, “Wow, that’s an interesting idea,” to a must-have model.
There are health care systems that are moving really aggressively to align with home care providers to stand up hospital-at-home in a way that they never would’ve done before.
Here’s the kicker: We’re talking about COVID-19, but everything I was saying about the distribution of disease and the distribution of the response is also true for chronic disease. Most chronic illness is experienced by people at home. Ironically, by moving faster and getting better at shifting the focus of care toward the community, after the virus, we’re going to have a stronger home- and community-based system for dealing with chronic illness.
This virus is going to rewrite the rules of the health care system. I predict that home- and community-based services — especially those that are really integrated and based on population health — are going to come to the forefront as a result of this COVID-19 epidemic.
That probably would have taken many years to achieve otherwise.
As we go on, how will the COVID-19 crisis impact the home care workforce, something the industry already struggles with?
Tens of millions of people have filed for unemployment. We know that home care continues to struggle to attract and retain talented candidates who can take on the task of doing this work.
In the near term, we’re going to have lots of really skilled people who are going to want to do this work because it’s work that must go on, unlike maybe running that restaurant or working at a car-rental agency. I do believe we’re going to be able to recruit from the, unfortunately, large pool of unemployed people who are really talented and need work.
In the long-term, I believe that as resources and priorities shift from a hospital-centric model to a more community-based model, we’re going to be able to have better funding and offer better pay and have better technology and systems. That’s going to help us recruit and retain a workforce that can meet the needs.
What should home care providers know about caring for older adults that may be cut off or isolated from the rest of the world during the crisis? Any tips or best practices?
It’s very important for home care providers to regard social isolation as a clinical risk factor.
There’s been over the years the idea in our health care system that there’s real medicine and real nursing that deals with real problems. And then there’s that other “squishy” stuff, like loneliness, helplessness and boredom.
Social isolation is an important clinical risk factor and needs to be part of a plan. Home care providers who are supporting older people need to be in contact with that person’s social network. The more robust your social network, the less isolated you are [and] the less lonely you feel. The more connected you are, the more likely you are to have a better outcome. This is especially true for older people.
The irony is that social distancing that protects us also inflames the problem of isolation and loneliness.
How do you think the COVID-19 emergency will change the home care industry after this?
First, we’re going to finally see an awareness from health care systems that home care is an essential part of the equation and not just someone to call at the end of a hospitalization. Home care providers need to be at the table, working side-by-side with health care systems to design responses.
Second, in terms of public policy, there’s been a desire to shift resources and energy away from a system that’s dominated by the hospital and toward something that’s more focused on social determinants of health, population health and support supportive services at home. I think that’s going to accelerate. In order to manage the second, third and fourth wave of this COVID virus, we’re going to need a really powerful, well organized, well-resourced home care system nationally.
Third, this is the dawning of a new era of technology that brings telehealth and telepresence right into the home. Going forward, you’re going to see people putting together bundles of technology that can be deployed in households for COVID-19 or an exacerbation of chronic illness. The technology is going to help us support people more effectively than we ever could before.
Is there any aspect of this pandemic that isn’t on everyone’s radar but should be?
I believe that going forward, we’re going to be finding a significant number of people who have post-COVID complications.
Based on some of the early writings I’m seeing in the medical journals, there’s going to be a significant number of people who have clinical changes that persist over the long-term. That’s going to be expensive and challenging to manage, in addition to the chronic illness burden that our society already has in front of it.