It appears that the shift to more care in the home is poised to continue long after the COVID-19 pandemic subsides, as made abundantly clear by the Biden administration’s initial infrastructure plan that carved out $400 billion for senior home and community care services. While home-based care is gaining momentum across all specialties and patient populations, there’s been an increased interest in it when it comes to individuals recovering from surgery or medical procedures and those with chronic conditions, many of whom are older adults who require ongoing treatment.
As the aging population continues to rapidly grow — and experience numerous and complex chronic conditions — factors such as mental illness and social determinants of health also must be considered when building and executing effective home care programs. Additionally, figuring out how to best serve this aging population will require new methodologies, revamped tactical processes and increased collaboration to ensure effective, high-quality care for these individuals.
Key components of effective home healthcare program
- Take a holistic approach. A broad range of services are needed to properly care for significant segments of the country’s home health population. Research on home health patients has found that almost 50% have five or more chronic conditions, and over a third have a severe mental illness like depression, bipolar disorder or schizophrenia — making their care needs quite complex. Advanced analytics that can model healthcare risks while also factoring in social determinants of health (SDOH) data provide a holistic view of the patient and allows for the effective coordination of scarce and expensive healthcare resources as well as accurately tracking outcomes and program effectiveness.
It is pivotal that home care maintains the highest quality while being delivered in an efficient manner to this expanding population of individuals. To be successful at this, providers must be able to coordinate care for multiple conditions and address all types of social determinants of health, which requires visibility and enhanced communication. Coordinating care across specialties, like physical or mental health therapists, home-based lab services and telemedicine providers, is also particularly critical for individuals who are referred from the hospital or acute ambulatory settings and must adhere to care plans in order to recover in the home. Patients in this population are often dealing with diagnoses like sepsis, major hip and joint replacements, heart failure and pneumonia according to recent reports.
2. Leverage technology for more coordinated care. Care management solutions are key in delivering high-quality home-based care as they help different providers create and follow coordinated care plans. Some of the most important features of these technologies are the ability to track adherence of care plans and medication, monitor patients remotely and stay on top of follow-up needs by scheduling virtual or in-person appointments with their providers. Effective analytics, automated care plans and prescriptive data-driven decision support tools made available to care managers, providers and caregivers through provider and patient access portals allow the entire inter-disciplinary care team to develop, be aware of and contribute to care plans. Collaborations between the many providers needed by complex patients are maximized by enabling technology platforms.
Additionally, successful home care not only means meeting the patient’s needs, but also supporting their in-field care providers as well. By adopting care management solutions that support offline data entry and enable easy information sharing, for example, health systems, health plans, post-acute facilities and more can easily access patient information for more informed care. And they can decrease the administrative burden faced by home health practitioners and reduce the inefficiencies that so often lead to burnout.
When it comes to delivering high-quality, convenient yet comprehensive care to individuals, the growth in the home health market may be one of the “silver linings” to emerge from the COVID-19 pandemic. Holistic, well-coordinated home health programs that utilize “force-multiplier” technology have the potential to reduce healthcare costs, while also improving outcomes and patient satisfaction — all of which will be critical to success in our evolving healthcare landscape.
Gary Call, M.D. is chief medical officer at HMS, A Gainwell Technologies Company.