Hospital At Home, Home Infusion Remain Untapped Opportunities For Traditional Home-Based Care Providers

On Thursday, the American Journal of Infection Control released a troubling study on home infusion delivery.

The study’s findings seem – at the surface – like bad news for care-at-home progress. But after speaking with one of the study’s co-authors, what I’ve found is an opportunity for home-based care providers.

Some believe that home health and home care providers can become the “quarterback” of all types of home-based care delivery. The AJIC study is one example of why that may be necessary.

Broadly, the study suggests that many individuals helping administer home infusion therapies turned out to not be health care professionals. Even if they were, oftentimes, they were not well trained in best practices.

The study is sure to direct more criticism of shifting care to the home.

Infusion therapies are among the many services that have begun to rapidly shift to the home. Others include acute hospital care (hospital at home), emergency department (ED) in the home, cancer care and behavioral health, among many others.

Specifically, home infusion is running the risk of higher central line-associated bloodstream infections (CLASBIs). While hospitals have strict rules and regulations around infusion due to the risk of CLASBIs, which are extremely dangerous, they do not apply to the home setting.

But while CLASBIs from outside the hospital may be increasing, there is still – surprisingly – not enough evidence to suggest that there are more complications in the home setting.

“What’s really amazing is that the rates of complications are as low as they are [in the home],” Sara Keller, associate professor in the division of infectious diseases at Johns Hopkins University and a co-author of the study, told Home Health Care News. “And it’s possible that home care may actually have some things it could teach hospitals about how to keep patients safe.”

In this week’s members-only, exclusive HHCN+ Update, I consider the potential dangers of more care in the home, and how those can be hurdled.

Guidelines and labor arbitrage

The home is an appealing setting of care for various reasons. But one of them is undoubtedly reduced costs for payers and health systems.

For higher-acuity care in the home, current practices seem to teeter on the brink of labor arbitrage. In fact, some health systems only allow a patient to be admitted into their hospital-at-home program if they have a family member or friend that can help care for them.

“In the hospital, no one but a trained nurse would be allowed to even touch one of these central lines,” Keller said, referring to infusion practices. “And in the home there is … family members, neighbors, [fellow church congregants] and co-workers that are doing a lot of these tasks.”

That leads to the issue broken down in the AJIC study, which is that surveyed administers of home infusion were often under-trained.

“Questions posed to the staff – all of whom perform surveillance activities – focused on their surveillance training, barriers to and facilitators for CLABSI surveillance and barriers to training in CLABSI surveillance,” the study summary read. “Researchers found that many [home infusion therapy] staff who perform surveillance received no formal training on CLABSI surveillance.”

In a hospital, many of the components of home infusion delivery would not be allowed.

It could be that home-based care providers are leveraging unpaid family members or friends to help take care of these patients, thus reducing costs even further.

But most of the time, these new home-based care players – whether it be health systems or home infusion agencies – do want more structure for the services they provide.

Take hospital at home, for example.

Dr. Stephen Parodi is a major proponent of hospital at home’s proliferation in the U.S. Officially, he is the executive vice president of external affairs, communications and brand at The Permanente Federation, as well as the associate executive director of The Permanente Medical Group.

Kaiser Permanente’s hospital-at-home programs have grown steadily over the last few years. He has vied for the Acute Hospital at Home waiver to be extended, but more so, he has vied for a sustainable future for hospital at home.

“There are basic quality measures that we currently have in brick-and-mortar facilities,” Parodi told me this week. “The Medicare Stars program actually outlines a number of those. We want to hold ourselves to the same level of accountability in the home.”

With newer home-based care models, some health care experts are focused on fixing the problems with them “before the plane is in the air,” as Keller put it.

“I think care in the home is great, and I don’t think we should shy away from it,” she said. “But as we’re trying these new models, what this research suggests is that we need to also consider things like measuring complications, so that if we are starting to notice patients having particular complications, appropriate quality improvement interventions can then be put into place.”

The “quarterback” of care

Traditional home health and home care agencies are excited about care shifting to the home. But they also need to find a way to get involved with services being delivered that are outside their respective wheelhouses.

There are many examples of this already. In fact, Elara Caring – a home health and hospice provider – was responsible for the first mention of the home-based care agency as a “quarterback” – at least on HHCN.

“We’re looking at how to partner with primary care or psychiatric providers to do a total cost of care from either an episodic perspective, or a full total cost of care perspective, where we are essentially the quarterback of their care,” Joe Cramer, the president of hospice and behavioral health at Elara Caring, said last month, referring to behavioral health care in particular.

On the personal home care side, Home Instead has partnered with the in-home medical care company DispatchHealth to help deliver acute care in the home.

BrightStar Care, meanwhile, has been working with hospital-at-home programs since the early stages of the pandemic.

“We’re bringing certified nursing assistants, RNs or LPNs, depending on what the level of in-state regulations there are, so that the care coordination is being mapped out,” BrightStar Care CEO Shelly Sun told me last year.

Still, there hasn’t been much momentum for home health and home care providers in these alternative, home-based care models.

That’s despite evidence that would suggest their involvement would help, like the aforementioned study.

“Home care nurses, in my experience, are very experienced, highly trained and really know how to do things when there’s no one else around who can help,” Keller said.

One of Kaiser Permanente’s four hospital-at-home programs, for instance, is working under a home health licensure model.

It also has its own home health arm in house, and Parodi expects collaboration to continue.

“I think the bottom line is that there’s a lot of opportunity for learning and evolving what this needs to look like,” Parodi said. “And I think we should be creative with this.”