Home, Where the Future Is

Abstract

“Health care at home … is something we need more of, not less of. Let us make a commitment to preventive and long-term care. Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.” – former President Bill Clinton The Affordable Care Act envisions a health care system with strong incentives for public and private payers to institute risk-­sharing arrangements with providers and explore care-delivery models that lower costs, particularly for high-cost patients. These service-delivery models have to include home and community care. According to AARP, 89% of people 50 years and older want to receive their health care in their home as they age. But currently, that health care market segment is made up mostly of small local providers. The National Association for Home Care & Hospice claims to represent 33,000 member organizations that provide home care and hospice services. One of the largest home care providers in the country, Interim HealthCare, has under 1% of the national market share. Founded in 1966, the company focuses on home care, hospice care, and medical staffing. Interim operates through more than 300 independently owned franchise locations in 41 states, providing 25 million hours of home care service to 190,000 people each year. Interim's chief industry officer is Barbara McCann. A medical social worker by education and background, Ms. McCann acts as the primary liaison to the Centers for Medicare & Medicaid, serves on expert panels for National Quality Forum (NQF), and is a board member of the Community Health Accreditation Program. Especially since the passage of health reform in 2010, her focus has been the development of new delivery models for Interim. I asked Ms. McCann what she sees as the drivers of change in health care and what the opportunities and challenges are for providers such as Interim. “First and unequivocally,” she said, “physicians have been affirmed by the government as the leaders of health care delivery teams.” Second, the focus across the health care system is accountability, not just for patients' short-term results, but for long-term health outcomes. And that leads to her third point, that “it takes a village.” Long-term outcomes can be delivered only by integrated or coordinated health care teams and systems. Finally, Ms. McCann noted that holistic approaches to care and services – mental, physical, psychosocial health – are receiving much-needed emphasis. All of these drivers are linked. Accountability for patients' long-term health cannot be addressed effectively without integrated, systematic approaches that are holistic. With this easily summarized but monumental change in health care come significant opportunities for home care providers partnering with other providers. There are innumerable opportunities for providers to prevent illness, promote wellness, and manage patients with multiple chronic conditions, at home. This opportunity has dramatically changed the way Interim works with physicians. Today, the franchisees of this company and other providers talk directly with physicians in their practice settings. They talk about patients ready for discharge from the hospital and about how to help patients manage chronic disease themselves. Increasingly, referrals for home services come directly from these physicians, not postacute and long-term care (PA/LTC) facilities. But where there are opportunities, there are also challenges, Ms. McCann surmises. Most health care providers tend to see the system only from one perspective. A challenge for home-care providers, but really for all of us, is to continually think creatively and listen to what the patient and providers in other settings are saying. We all have to catch ourselves when we begin to think or say, “That doesn't get paid for.” Ms. McCann has been a keen observer of international developments that inform what the PA/LTC in this country could look like in the future. In Sweden, for example, she cites the ability of a home health nurse to remotely monitor, via unobtrusive cameras, a patient's medication compliance and functional status. Japan, facing a lack of young caregivers, is developing robotic “nurses” with facial expressions. More robotics and widespread use of other technology will dramatically change the landscape in both community and facility settings, Ms. McCann said. While the applications may not be clear yet, technology's advantages could result in decreased overall costs, wider distribution of professionals' skills, and the ability to check on patients before face-to-face visits. These advantages will need to be leveraged to meet the demands of future health care delivery: systems that are integrated, accountable, and responsive to what consumers want (to remain in their homes as they age). So here's what Ms. McCann, her colleagues at Interim Healthcare, and ­others in the home- and community-care world are saying to the rest of us in PA/LTC: “Can we partner?” What will you say in response?