Insights from the Future of Home Health Care: IOM-NRC Forum on Aging, Disability and Independence Workshop
(Written by Merrily Orsini. Reposted with permission from Axxess.)
The first step in any recovery program is to admit that you have a problem. The health care system is no different. It has to admit it has a problem in order to recover. So, here is the problem: Medicare was designed to help pay for health care costs for the elderly. Currently, and since its inception, Medicare has focused on reimbursing costs incurred when an older adult utilizes the services for post-acute care. Those services are not only expensive, but designed to be short-term solutions, and in the case of nursing homes, not where older adults want to be. They would rather be at home.
That doesn’t mean post-acute care needs to go away. In fact, the need for short-term post-acute care will remain. However, America’s aging care issues are much different today than when Medicare was conceived. Adults now become “seniors” at the age of 55 and stay “seniors” well into their nineties and beyond. This new longevity brings with it a number of chronic health conditions that will require management over time – not in a post-acute care setting where an older adult will quickly exhaust all of his or her resources, but in an older adult’s home through the use of home care.
And, what about the money that is being thrown at the problem? Did you know that Medicare and Medicaid are second only to the national defense in spending? If so, you realize that we are on an unprecedented spending trajectory that is unsustainable.
When we look at the future of healthcare through this lens, it is clear that the problems are how we created our health care delivery system and how we have failed to advance it – until now. Instead of skirting the issue, both providers and consumers are beginning to take a stand, take action, and search for solutions. Axxess has funded a study through the Alliance for Home Health Quality and Innovation (AHHQI) that was instrumental in creating the platform for the hearings on the future of home health held September 30 and October 1 at the Keck Center in Washington, DC, and convened by the Institute of Medicine and the National Research Council.
It is this type of support that will make the difference for the future; because in order to solve a problem, you first have to admit and understand the problem you have. You also need to understand where you are in the continuum of problem to solution; and then take the necessary steps to correct the problem or start over. You then need to measure, evaluate and repeat.
CMS has been awarding grants for innovative projects. The Veterans Administration has been using telehealth, among other focused coordinated services, to serve the five percent of the population using most of the resources. Barbara McCann, from Interim Healthcare, phrases the issues clearly: “Medicare is an acute illness benefit in a chronic care world.” The main question most people ask when they become frail is: “Can I live in my habitat longer?” Care transitions are not just for a post-acute setting; rather, there are care transitions at each touch point in receiving care in the health care delivery system; and ensuring proper care for the elderly or chronic disease patients at home can reduce costly transitions and rehospitalizations.
Steven Landers, an MD and MPH who currently works for the VNAA Health Group and is President of the Alliance for Home Health Quality and Innovation (AHHQI), has some ideas for how to better address the long-term needs of our population. He feels that home care can cost less, is more desired and is safer. He also says that it can be vibrant and impactful. His ideas are to create home-centered health strategies and focus on home-centered care that will reduce undue suffering and eliminate undue spending.
As stated in Dr. Landers’ presentation, “In building the future, let’s not forget some of the basic, common sense advantages of home care that are as true today as they were when Lillian Wald and her colleagues from the house on Henry Street ventured out into the squalor of the lower east side of New York City at the end of the 19th century. When we take care of patients at home, there’s an enhanced view of patients and caregivers that leads to a better understanding of important issues like how they manage medications and nutrition. Home visits are an access intervention that is most relevant to patients with physical and socioeconomic barriers to care. During home visits, a more intimate, clinician-patient relationship can be established. Home care clinicians sit beside their patients in their bedrooms and at their kitchen tables. The home visit is an act of humility that demonstrates to the patient the clinician has left their comfort zone to be on their turf, that they are worth being truly known and visited. Home care can cost less while being desired more by many patients, and care at home is sometimes safer for frail elders.”
Dr. Landers says there are four main clinical ingredients for the future:
- Physician and advanced practice nurse developed and overseen interdisciplinary home health care plans; plans informed by the well-proven concepts of holistic geriatric medicine, palliative medicine and rehabilitation medicine assessment.
- Enhanced support around care transitions; support that addresses self-management, care coordination, information transfer and clinical stabilization.
- Advanced capability for escalating intensity of medical care and palliative care at home in times of decline or exacerbation (including escalation to hospital-like services at home).
- The thoughtful use of advanced information technology to fill the white space between encounters, to aid in the management of unscheduled home care patient problems, and to improve triage and the overall efficiency of care.
Histories are often fraught with mistakes and missteps, which seem troublesome and even overwhelming at the time. It is, however, past mistakes that can serve as meaningful lessons in how to improve the future. The history of health care delivery is no different; our past issues or shortcomings can help us pave the way to a brighter, safer and healthier future, with more care centered in the home.