Does “no place like home” still apply when thinking about moving acute-care patients out of hospitals and back to their home spaces?
While some forecasts are optimistic about the Hospital at Home concept, we should temper the exuberance by recognizing and addressing the pragmatic realities of healing at home—including the stress and burden on the caregiver.
The Market for and Benefits of Going Home for Health
Let’s first consider the forecasts and market size of the opportunity for Hospital at Home services.
In 2020, the Centers for Medicare and Medicaid Services (CMS) launched a comprehensive strategy to enhance hospital capacity in the midst of the COVID-19 surge, expanding care to patients outside of the traditional hospital setting— namely, to patients’ homes.
Moving care out of hospitals toward care-at-home scenarios could shift as much as $265 billion of Medicare funding from inpatient settings, according to calculations from McKinsey & Company. Confirming this dramatic migration out of inpatient beds to homes is the Chartis Group’s projection that the number of health systems developing hospital-at-home programs could double by 2027.
By September 30, 2022, CMS had approved acute hospital care at home services for 114 health systems operating 256 hospitals in 37 states. Patients with conditions such as asthma, congestive heart failure, gastrointestinal diseases, seizure disorders, and roughly a dozen other conditions may be eligible for hospital-at-home care.
There are many potential benefits for patients receiving acute care at home, including:
- Lower risk of nosocomial (hospital-acquired) infections.
- More comfort with familiar surroundings, less noise and, likely, better sleep.
- Improved cognition, which can be compromised in a hospital environment.
- Greater opportunity for friends and family to readily visit and socially connect
Another benefit may be lower costs. A 2018 study published in the Journal of General Internal Medicine found that the use of substitutive home hospitalization versus in hospital care reduced costs and utilization, improved physical activity with no significant differences in quality, safety, and patient experiences.
Hospitals and health systems that implement Hospital at Home programs can also drive greater patient satisfaction, more personalized care and build the organization’s omnichannel service platform.
The Challenges of Hospital at Home
Considering all the benefits that could accrue to patients, health systems and other stakeholders in moving acute care to the home, we should not assume that every person who could return home from the inpatient setting should return home. Personalized care requires us to get up-close-and-personal with each patient to understand factors beyond their clinical state of health and recovery to get a complete picture of their life in their home setting.
Challenge #1: Caregiver Availability and Bandwidth
Among patient real-life challenges to consider before discharging an inpatient to Hospital at Home care is the question of caregiver availability and their bandwidth to support the patient.
“The Hospital at Home (HaH) model shifts care into the home setting and delivers acute hospital-level care to eligible patients where they live instead of in a hospital,” AARP explained in a report on family caregiver considerations for Hospital at Home. “This means that family caregivers may end up providing increased assistance to the HaH patient with activities of daily living and handling household chores. This assistance may already be part of the routine tasks that family caregivers take on, but it is likely to become more intensive during a patient’s acute care episode that would otherwise occur in a hospital.”
Family caregivers are critical to Hospital at Home success, AARP asserts. The AARP offers four key areas to address to ensure that the family caregiver component of Hospital at Home programs bolster patient outcomes and conserve caregivers’ well-being:
- Ensure choice, access, and equity, seeking caregiver agreement to guarantee their participation.
- Be clear and understandable to both the patient and family caregiver on expectations and services required.
- Recognize and support the family caregiver, who is an essential team member in the hospital at home journey.
- Allow for appropriate levels of research and learning and share data and learnings with researchers on the family caregiving experience.
Caregivers’ stress grew more acute during the COVID-19 pandemic, the Centers for Disease Control (CDC) discovered. Unpaid caregivers of adults, parents and parent-caregivers experienced significantly worse mental health than those not caregiving.
Parent-caregivers, dealing with both parent-guardian roles and adult-caregiving, were 12 times more at risk of experiencing the most adverse mental health symptoms, CDC found.
“While it may be a foundational element to humanity to care for others and to be cared for ourselves, delivering that care can be intense, even more so during a pandemic, and that can have an impact on mental and behavioral health,” Alexandra Drane, founder of ARCHANGELS, told McKinsey in a recent report on the caregiver crisis. “It is important to address the uniquely intersectional role unpaid caregiving plays in impacting all aspects of our lives. Many unpaid caregivers also suffer from financial stress, workplace stress, and relationship stress, and the COVID-19 crisis has heightened the intensity across each of these areas with added health and economic stress.”
Drane collaborated on the CDC caregiver study, noting that more than 70% of unpaid caregivers have at least one mental health condition such as anxiety, depression, or trauma and stress-related disorder.
Ensuring a patient identified as an appropriate candidate for moving from the hospital to the home should include an assessment of family caregiver viability, as well.
Challenge #2: The Home Setting
In a 2019 article in Harvard Business Review, Drs. Pooja Chandrashekar, Sashi Moodley and Sachin H. Jain—all physicians with experience providing healthcare to patients at home— wrote about the obstacles to home-based healthcare and how to overcome them. Through their research and personal experiences, they have realized that some patients prefer the hospital because receiving care at home “can be a constant reminder of illness and an unwelcome invasion of privacy.” Other reasons include negative experiences with caregivers, stories of elder abuse or neglect, or being embarrassed by their living situation.
“These preferences should be respected and not disregarded,” the doctors assert.
Once a hospital patient is deemed to be clinically appropriate to return home, with a caregiver identified, the physical setting could prove challenging to providing acute services. There are several factors to consider, from stairs and loose rugs that could pose a risk for falling, to insufficient space for medical equipment or lack of a bathroom on the ground floor of a multi-level house.
Challenge #3: Nutrition and Food Security
Nutrition and food security can also be obstacles, especially if a patient has specific dietary requirements. While complaints about food are often a barrier to a patient’s satisfaction with hospital care, getting fed in hospitals generally conforms to nutritional standards that are appropriate for the person’s condition.
Food security can be a challenge for some people returning to care at home—and it is a challenge that has trended upward in the midst of inflation, Robert Wood Johnson has warned. Rates of food insecurity increased significantly between 2021 and 2022, after we saw progress in food insecurity declining between 2020 and 2021. The rates of food insecurity in the U.S. especially worsened during the pandemic for Black and Hispanic adults.
In the University of Michigan’s National Poll on Healthy Aging published in September 2022 (based on July 2022 survey data), rising food prices were found to hit less-healthy older adults hardest.
In the U.S., 3 in 4 people between 50 and 80 years of age said the rising cost of groceries has affected them “somewhat or a lot,” with one-third of people over 50 noting they were eating less healthily due to increasing food costs.
Food price inflation has hit older adults harder who rated their physical or mental health as fair or poor, as well as people living in lower-income households.
Collaboration and the Supply Side Are Key to Hospital at Home Success
The movement of care to the home is seen as an opportunity for payers to leverage lower cost sites for services while also driving health outcomes. Examples of recent deals in the space including Humana’s acquisition of Kindred at Home, Elevance and Integra, United with Landmark, SCAN and TRG, and Humana/onehome. CVS Health’s planned acquisition of Signify Health is also in this category, along with Walgreens’ buyout of CareCentrix.
Care at home may also be supported through media channels as we consider the broadening out of “connected care.” Samsung, a market leader in smart-connected TVs, recently announced an alliance with HealthTap to deliver virtual healthcare services through consumers’ televisions. For many years, cable TV companies have piloted telemedicine programs through subscribers’ cable boxes. This collaboration joins “two powerful and loyal consumer brands,” Sean Park of Samsung coined in the project’s press release.
Addressing the food-as-medicine front, Albertsons allied with WinnCompanies in September to begin delivering vaccinations, prescriptions and food to older people living in multi-unit dwellings. Furthermore, the White House recently convened a meeting on Hunger, Nutrition and Health during which a long list of grocery store and food industry stakeholders, including DoorDash, Hy-Vee, Instacart, Kroger, Meijer, Publix and Shipt, announced initiatives to address food security in America.
The Chartis Group’s tea leaves assessing hospitals’ digital transformation plans noted that beyond other hospitals and health systems, top competitors in the digital health landscape are shifting toward “disruptors” becoming rivals—namely, virtual health companies (such as Teladoc, Amwell and MDLIVE), large technology companies (e.g., Apple, Google and Microsoft), and retail care providers (especially CVS Health, Walgreens and Walmart).
“These new market entrants, not traditional hospitals and health systems, are setting the pace toward digital transformation,” Chartis Group observed.
The opportunity here is for hospitals and health systems to collaborate with—not necessarily having to “compete” head-to-head—with technology, virtual health and retail health providers.
Imagine the smart TV screen organizing the patient’s data in one convenient place, with clickable links to view videos that explain medicines and how to take them physical therapy instructions for real-time exercise, or cooking instructions for healthy meals.
Going home for health will indeed be omnichannel—in many ways.