The advancement of telemedicine and home-based technology presents both opportunities and challenges with respect to improving health care and making it safer.
Trending Toward Home Care: Is Our Health System Ready?
In a recent essay, a woman writes about her father being sent home after radical prostatectomy with instructions for how to remove his own catheter and surgical staples. a That may sound extreme, but with today’s shorter lengths of stay, leading health systems may evaluate patients’ abilities to handle such tasks on their own.
Those with no surgical complications or complex health needs may be able to complete tasks normally performed by physicians or nurses. Having these patients do so can save the health system money and spare the patients the need to travel to and from their physicians. Such outcomes are possible, however, only if patients have the resources, tools, and support needed to do these tasks at home. Otherwise, unintended problems could occur that, ultimately, could cost the system more.
Health care—whether for procedural follow up or for treating chronic conditions—is increasingly being delivered in patients’ homes. From the 1960s to 2012, the average hospital stay shrank from eight days to 4.5 days, in part because of payment changes implemented by the Centers for Medicare & Medicaid Services (CMS). Advances in technology, such as wearable sensors and telehealth, are enabling more care to be provided in the patient’s own environment.
Home health agencies (HHAs) currently service more than 3 million Medicare beneficiaries, according to CMS. Unlicensed caregivers provided care for an estimated 2 million people in 2016. As the population ages, those numbers are expected to grow. The National Center for Health Statistics estimates that 27 million people will need some form of long-term care by 2050.
Comforts and Risks of Home
It’s important to note that patients often are safer and more comfortable in their own homes. They sleep better without the noise and disruption of a hospital bed and are less likely to contract infections. Yet patients at home are not free from the risk of harm. Chief concerns include adverse drug events, falls, pressure sores, poor nutrition, and infection. These issues cause harm, and lead to the need for further care, evaluation, or treatment. A recent report looking at harm in ambulatory care, including the home, found that the three most frequent consequences of harm are hospital admission, additional primary/ambulatory care, and additional diagnostic investigation. b It goes without saying that any of these outcomes takes a toll on patients and families and adds to the costs of care.
Nonetheless, there is a continuing trend toward home care for not only the aging population but also the growing numbers of Americans with chronic disease. Are we as a country prepared for this trend? Not completely. Healthcare leaders and policymakers would be wise to think and plan more effectively for ensuring the safety of patients, families, and caregivers in home care.
Recognizing the relative lack of preparedness, the Institute for Healthcare Improvement (IHI), with funding from the Gordon and Betty Moore Foundation, recently convened an expert panel to look at the issue of home care, specifically with regard to patient safety, and to develop recommendations for future work. c This work builds on other recent work focused on assessing the home care landscape and laying out recommendations for policy makers, health systems, HHAs, health practitioners, and others. d Initial steps recommended as a result of these efforts are as follows.
Support research to develop standard definitions and taxonomy for harm in home care. As a condition of Medicare participation, HHAs must submit reports to the Outcome and Assessment Information Set (OASIS). The data do not include information from unlicensed caregivers or family caregivers, however, and may not be readily available to other providers (e.g., emergency department clinicians). Ensuring safety in home care requires standard measures that are relevant across various home settings and can be used and accessed by multiple levels of caregivers.
Revamp financing of home care. The current payment models for home care vary widely by personal circumstances and by state. For example, patients eligible for Medicare may receive prescribed skilled care at home, but personal care (i.e., help with activities of daily living) is not covered. Commercial insurance generally provides coverage similar to that provided by Medicare, but it can be expensive. Many middle-class families cannot afford home care—and lack of access is itself a safety issue. Moreover, current payment models largely cover specific services, leading to care that is fragmented rather than focused on the whole person.
Take a new look at regulations regarding home care. Although unlicensed personal care providers are largely unregulated, agencies that participate in Medicare and Medicaid are required to meet OSHA standards for worker safety and CMS standards for quality and safety. Quality and safety data are available through the Medicare Home Health Compare website, which can serve as a foundation for how other levels of care might be regulated and overseen.
Aim for person-centered care. Person-centered care looks beyond the “patient” and his or her “disease” to broader issues, such as the patient’s beliefs, wishes, and autonomy. Caring for the whole person—physically, emotionally, spiritually—is being done effectively in the hospice field. HHAs—and large health systems that furnish home care—can learn from hospice providers, particularly around coordination of services, use of skilled and unlicensed caregivers, and respect for the patient’s preferences.
Improve communication and care coordination across health settings, including the home. Even within healthcare settings, miscommunication often is at the root of harm. It becomes even more of a challenge in the home setting, which is out of the control of healthcare professionals. Although some HHAs have done outstanding work in this area, the current landscape is a mixed bag. Too often, patients and their family members are left to coordinate their own care. Although some may be up to the task, the system should not accept that as the norm. Again, better outcomes and lower costs will result when information is shared broadly with all who are caring for the patient—whether at home or in a healthcare setting.
A Sensible Option
Allowing patients to be cared for in their own homes makes good sense for everyone. As telemedicine and home-based technology continue to advance, opportunities for improvements will develop, as will challenges. Policy-makers and health system leaders can help by encouraging the growth and expansion of existing efforts being made in home health care to ensure the safety of patients, families, and caregivers.
Tejal Gandhi, MD, MPH, CPPS, is chief clinical and safety officer at the Institute for Healthcare Improvement, Boston.
a. Peltonen, A., “ Why Patients May Be Put in Charge of Their Own Post-Operative Care,” WBUR.org., Sept. 1, 2017.
b. Slawomirski, L., Auraaen, A., Klazinga, N., The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind , Paris: OECD, 2018.
c. Institute for Healthcare Improvement, No Place Like Home: Advancing the Safety of Care in the Home, Boston, Massachusetts: Institute for Healthcare Improvement (in press).
d. Carpenter, D., Famolaro, T., Hassell, S., Kaeberle, B., Reefer, S., Robins, C., Siegel, S., Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities,” Cambridge, Massachusetts: Institute for Healthcare Improvement, August 2017.