Specific Training Is Crucial To Prepare The Next Generation For Home-Based Care

Home care medicine has expanded significantly since the COVID-19 pandemic, with increasing demand from patients and improved payment models – in some cases. This shift has increased the need for a larger home-based care workforce, one filled with individuals that understand the ins and outs of treating people in their homes.

The number of hospital-at-home programs providing acute inpatient-level care increased following the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home waiver, as hospitals sought to enhance capacity, reduce readmissions and cut costs.

In addition, the shift toward value-based care and technological advancements, including in-home diagnostic testing and remote patient monitoring, has contributed to the growth of this specific type of care.

“Home-based medical care is a vital piece of the puzzle we need to solve in today’s health care delivery system,” Cory A. Brown, senior community medical director at WellBe Senior Medical, told Home Health Care News. “There are many factors in today’s system that increase the need for home-based care in the future. We are witnessing a rising cost of care, specifically in the gaining patient population with multiple chronic medical conditions.”

Rochester, New York-based WellBe Senior Medical works with health plans to provide home-based medical care to patients who are facing multiple complex health challenges.

Access to primary care is a struggle for this patient population, leading to more care being delivered through emergency rooms and hospital admissions.

“The demand will be high for a patient care model and a care delivery system that is focused in the patient’s home,” Brown said. “Our patients and their families deserve to have access to high-quality care, at the right time, with the right provider, in the right place and at the lowest cost. An innovative care delivery model that is patient-centered with a team approach to patient care in the home will successfully meet this increasing need in the future.”

The population of older adults is growing and long-term care is increasingly community-based – rather than institution-based – yet only 11% of homebound Medicare beneficiaries receive home-based medical care, according to a study by researchers at the Icahn School of Medicine at Mount Sinai, New York. Medical residents exposed to home visits during training showed increased interest in incorporating these visits into their future practices.

However, researchers found that these trainees generally did not have formal training in all the skills necessary to care for patients in the home and lacked knowledge of the range of services that can be provided. Providing home-based medical care requires skills in working with an interdisciplinary team, managing complex patients with multiple comorbidities, providing primary palliative care, performing functional and cognitive assessments, performing home safety assessments, and performing telehealth and remote patient monitoring.

Current medical training usually occurs in the hospital, outpatient clinic or classroom, not in the communities where patients live; therefore, it is uncommon for trainees to interact with patients across the post-discharge continuum.

Home health organizations have begun creating their own nursing pipelines due to this issue.

A survey of internal medicine program directors by the Alliance for Academic Internal Medicine showed that only 60% of respondents reported a house call experience for residents in their training programs, and 59% of the time, that was a one-time experience. Among programs that implemented home health training education, most stated this training occurred via lecture or small group discussion, totaling less than five hours per year.

Medical schools and residency programs must prepare the next generation of physicians for the inevitable shift from hospital to home by integrating home-based care into required curricula and training.

“It is estimated that we need an additional 9,000 providers to meet the growing demands of patients who are home-limited or homebound so that we can adequately care for their needs,” Dr. Paul Chiang, senior medical & practice advisor for the Home Centered Care Institute, told HHCN.

The Schaumburg, Illinois-based Home Centered Care Institute addresses the unmet needs of those who are homebound, home-limited, or living with severe illness and do not yet have access to best practice house call programs.

“I don’t think the current medical training programs are training, equipping or even exposing residents with the skills that are necessary to do home-based primary care,” Chiang said.

Two essential skill sets are necessary to be a good house call provider, according to Chiang. One is being comfortable with complexity and the other is comprehensive communication.

“A lot of these older patients have multiple medical problems that need to be addressed, and a clinician needs to be knowledgeable in addressing not just one chronic condition, but multiple chronic conditions and how they may be interrelated to one another and how all the medications that are being used, may interact with one another,” Chiang said. “The other important skill is communicating comprehensively.”

In his practice, Chiang takes residents in training with him on house visits to expose them to what it takes to be a house call clinician.

“When I debrief with them, one of the comments I receive is that they didn’t know we could do so much at home for patients,” he said. “They are amazed at what is available to care for patients at home. They also tell me that by being at home, they can better understand who our patients are. I encourage learners to walk through the door and look around. This helps them to understand that our patients are more than just a collection of diseases; they have a story. They are people that need us to take exquisite care of them because they are complex.”

Chiang said that while patients are in their own homes, they feel more comfortable sharing things they may not share in an office or hospital setting.

“Patients are more comfortable talking about their faith or goals of care, which is so important because we want to align the recommendation and intervention with the goals and the care our patients want,” Chiang said.

The need for specialized training

The workforce in home care medicine faces several significant obstacles including training and education gaps, workforce shortages, and financial and logistical constraints. Many health professional trainees have limited exposure to home-based care settings and lack training in managing complex, homebound patients.

“Current medical training programs are not adequately prepared to equip residents with the skills necessary for home-based care,” Rachel Miller, vice chief of education, Division of Geriatrics at the University of Pennsylvania’s Perelman School of Medicine, told HHCN. “Most medical education still focuses on hospital, outpatient or classroom settings, with limited exposure to home care. Medical schools and residency programs have shown that single and longitudinal home care visits have significantly increased trainees’ knowledge, skills and attitudes relevant to geriatrics and home care medicine.”

A home care curriculum for medical residents needs to include patient home visits, according to Miller.

“This is not just classroom training,” Miller said. “Seeing a home is the key to understanding how our patients and caregivers age in place – the strengths they have and the barriers they face.”

In addition, learning about complex care management and understanding how to address and assess functional and cognitive impairments, home and safety assessments, medications, and focusing on patient priorities, are of utmost priority, according to Miller.

Graduate medical education training programs are variable in their requirements for the training and evaluations of home visits. As more data surfaces on the value that home visits bring to the patient, provider and health care system, more program directors are adding a requirement for home visits to the core curriculum.

“Residents should have a good understanding of value-based care and how to best care for patients with a patient-centered team approach,” Brown said. “Gaining knowledge and experience in interdisciplinary team-based care is an important skill to emphasize in a home-based care curriculum. This can be different from the brick-and-mortar health care approach and requires repetition and experience to master.”

Brown also highlighted the need to build skills around understanding the patient’s surroundings and making seamless transitions.

“Appropriate management of patients during a transition of care is another high-level skill that residents should learn,” he said. “This is a key time to ensure that the patient and caregivers are empowered and knowledgeable about their care plan. It is also a great time to discuss the goal of care, making sure that the care plan matches their goals.”

Miller agreed, adding that interdisciplinary training plays a crucial role in preparing residents for home visits because home-based care is inherently team based.

“Residents must learn to work alongside and communicate effectively with various health care providers,” Miller said. “Care of home-bound adults requires a team. The team includes the patient, caregivers and health care professionals.”

Residency programs can improve hands-on experience by including home visits as a mandatory part of residency training, particularly in fields like internal medicine, family medicine, geriatrics and palliative care, according to Miller.

She also highlighted the need for developing longitudinal rotations where residents visit the same patients over time, which helps them understand the ongoing management of chronic conditions and builds continuity of care.

“Partnering with home health agencies or creating interprofessional teams for home visits allows residents to gain practical experience working alongside nurses, social workers and therapists,” Miller said. “For training programs that do not have a home-based primary care program or hospital-at-home program at their institution or lack faculty with experience in home visits, trainees can go on home visits with advance practice providers, home hospice providers, home care nurses, social workers, or home physical, occupational or speech therapists.”

Also, integrating telehealth into home care rotation allows residents to experience and learn how to manage patients remotely.

“It is critical that all physicians – primary care clinicians, hospitalists and specialists – possess knowledge of the spectrum of home care medicine and understand the resources available to care for our patients at home during both acute and chronic illnesses,” Miller said. “The hands-on experience of a home visit teaches the social, functional and medical complexities that cannot be seen in the office or hospital.”

Challenges of home-based care

While home-based care is desperately needed, according to Chiang, there are numerous hurdles to it becoming mainstream in the U.S. health care system.

Some of the significant obstacles revolve around staffing and care logistics.

“One of the biggest challenges is recruiting and retaining the care team at an appropriate rate to meet the demands of the rapidly growing patient population,” Brown said. “Taking care of the frail elderly in their home is a challenge, and you must select and retain the most appropriate people for the opportunity. This includes both clinical and non-clinical support staff.”

Along with staffing logistics comes the risk of provider burnout. This is an issue across all of health care, and home-based care is not excluded. It is important to have a strategy built into the model that involves building a sense of belonging to something bigger than one’s self, according to Brown. Home-based medical teams must come together to work on solutions and celebrate successes as a team to avoid and mitigate burnout.

Efficiency can also be a factor when it comes to mitigating burnout.

“We need to be as efficient as possible with our scheduling to confirm our visits to maximize our impact and revenue,” Chiang said. “How do you travel most efficiently to make as many daily visits as possible? We don’t want to spend too much windshield time because that is not reimbursed, so we need to be as efficient as possible.”