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Answering the Call. The Return of Home-Based Care.

Published December 9th, 2019

There’s no place like home. As early as 1813, when the first nurses in our country’s history began entering the homes of sick patients in Charleston, SC, we realized the value of the right care delivered at just the right time and place. These pioneers, who can be credited for inventing home care’s legacy, were met with the same challenges we often wrestle with today.

 

-Who should receive care?

-Who is responsible for that care?

-What type of care should be provided and for how long?

-How do we organize and deliver care in the safest, most impactful, and effective manner?

To answer these questions, and to create new disruptions and solutions for home care delivery, we must first understand how we got here. Let’s consider the history of nursing and care in the home. As you read the ups and downs that nurses have faced when delivering care in the most crucial place it can be received, think about the options we have today. The talent, the technology, and the infrastructure that is now at our fingertips. And the positive outcomes we can create when care is delivered as it should be—in the very place that the patient can respond to it best.

 

The Home Care Movement

By the end of the 19th century, urbanization, industrialization, and mounting concerns over infectious diseases were transforming our view of the way care was delivered, especially in our cities. Inspired by Florence Nightingale, combined with the growing availability of trained nurses, the concept of a visiting nurse became a practical solution to urban threats of disease. Throughout New York, Boston, Chicago, and Philadelphia, nurses were hired to bring care directly to the home, and by 1909, approximately 600 organizations across the country sponsored the work of visiting nurses.

As nurses increasingly found themselves in patients’ homes, often without direct medical oversight, they exercised increasing authority by addressing everything from the patient’s medicine to dietary needs to their home environment. And they were also known to bring the latest portable medical technology to care for women, men, mothers and their newborns, school children, the elderly, and the sick and injured.

Enter Lillian Wald, who invented the term public health nurse. Wald further evolved the practice of nurses in the home by considering the patient’s social and economic context. Credited for professionalizing visiting nurses, Wald argued that caring for the sick requires much more than just medicine. She inspired a new generation of visiting nurses to identify and correct the underlying causes of illness. And along the way, she also established insurance coverage for home care by convincing Metropolitan Life Insurance to include visiting nurse benefits as a way of reducing the number of death benefits paid.

While Metropolitan Life Insurance demonstrated these services saved money and lives, the goals of the nurses delivering care often collided with the insurance company which felt that visiting nurses provided too many visits that lasted too long. Denial of payment began to rise and by the Great Depression, the U.S. witnessed a severe decline of nursing services in the home.

During this time, the hospital, which was once thought of as a place of last resort, began to emerge as the preferred institution for care due to advancements in new technology, diagnostics, and treatments. As caregiving became institutionalized, hospitals started to feel the financial impact when their patients remained too long or if they paid too little. By the 1950s, hospitals regularly discharged these patients and referred them to home care. The industry, however, was reluctant to underwrite the care. As a result, visiting nurses found themselves primarily caring for the ill and poor. During this period, a patchwork of welfare funding, contributions from family, local donations, and fees from patients paid for home care.

Things began to change again in the late 1950s, as the increasing cost of institutional care caused the country to turn its attention back to home care. Perhaps forgetting its own history, the American Medical Association released home care studies in prestigious journals that reinvented care in the home as a new movement. While home care began to enjoy a respected place in the healthcare industry again, the country continued to debate its effectiveness until Medicare legislation in 1965 marked the beginning of a new era for home care. Over the years, legislative, judicial, and regulatory changes have further expanded the home care benefit. True to form, the country again reversed its direction on home care in the 1990s and deemed it unsustainable. As a result, over 3,000 home care agencies closed, and public funding for home care evaporated.

Fortunate for us—as patients, family members of patients, and advocates of care that actually works—history has again turned in our favor. In recent years, everyone from healthcare leaders to policy makers to everyday consumers have come to fully understand and support home-based healthcare. We have in our grasp the ability to use new innovation and infrastructure to finally deliver on the potential of better healthcare experiences that our very first, courageous visiting nurses began 200 years ago.

 

Identifying Recurring Obstacles

As history has shown, we’ve clearly known the value of delivering care at the right time and place since the 1800s. And that place continues to be the home. Yet, we’ve confronted a similar set of core obstacles (and opportunities) for hundreds of years:

Despite the proof that home-based care works, organizing and dispatching the right healthcare professional to the home throughout history has proven to be a time- consuming, manual process with mounting barriers that leave room for error, low throughput, and a high cost to the healthcare organization. Healthcare organizations participating in home-based care—when compared to a hospital or office visit—report that their specialists spend more time with the patient. On average, home-based care specialists see just five to seven patients a day.

Healthcare organizations throughout history have struggled with getting paid for care at home. Payment has always been a challenge—as witnessed by the first financial support by Metropolitan Life Insurance in the early 1900s (which brought with it an increase in documentation, billing, and cost analysis) to today’s hospitals, like Newton-Wellesley Hospital, currently piloting programs financed by the hospital to bring clinicians into their patients’ homes.

Healthcare organizations, no matter their place in medical history, have reported concerns about the time it takes to travel to and from a patient’s home, the time-consuming task of scheduling home visits, tracking each visit, safety, patient preferences, and the natural barriers that may occur en route. There’s perhaps no better example of the challenges nurses have faced than the photo, “Visiting Nurse Tenement Roof, 1915.” This iconic image shows a dedicated nurse navigating a rooftop in New York City because the building did not have elevators and it was easier to travel rooftop to rooftop instead of up and down the stairs of each building to see patients.

We’ve seen life-sustaining advancements in medical technology, mobile diagnostics, and assistive durable medical equipment (DME). In the past, many of these tools were too large and costly for use in the home. Machines that were once only available in hospitals for diagnosis and treatment are now available in the palm of your hand. Yet, while healthcare organizations can now place better technology directly in the home, most organizations don’t have the infrastructure in place to coordinate and communicate that care. Often called the “cockroach of American medicine,” fax machines are estimated to still account for 75 percent of all medical communication today. Meanwhile, organizations scheduling, managing, and dispatching home-based care struggle with outdated spreadsheets, endless phone-tag, and manual inputs that waste time and money.

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The House Call is Back  

Everything old is new again. “House calls go back to the origins of medicine, but in many ways I think this is the next generation,” says Dr. Patrick Conway, Deputy Administrator for Innovation & Quality at the Center for Medicare and Medicaid Innovation. The days of a dedicated nurse or other healthcare professional arriving at the home have returned. And here’s why—despite the obstacles, it works:

Home-based care has reduced hospitalizations, readmission rates, and emergency visits throughout our history. As an example, results from the Independence at Home study, a five-year Medicare test that gauged the effectiveness of home-based care, showed that all participating programs reduced hospitalizations, emergency room visits, and 30-day re-admissions for patients, saving on average $2,700 per beneficiary per year. Not to mention, patient and caregiver satisfaction soared.

For its part, Medicare reported an overall savings of $25 million in the Independence at Home pilot’s first year.

Housecall Providers of Portland, Oregon, which previously operated at a loss, indicates that it has saved Medicare an average of almost $13,600 per patient through home-based care during its first year of a pilot program. At MedStar Washington Hospital Center in Washington, D.C., the health system was able to cut the cost of care by an average of $12,000 per patient, according to officials last June. From that money, nine practices earned bonuses totaling nearly $12 million, including a $2.9 million payment to a practice in Flint, Michigan.

A pivotal study in the Journal of the American Geriatrics Society, Effects of Home‐Based Primary Care on Medicare Costs in High‐Risk Elders, found that primary care delivered at home to Medicare patients saved 17 percent in health spending by reducing their need to go to the hospital or nursing home.

Healthcare professionals agree that understanding a patients’ social and economic conditions in the home can positively impact their health (just like Lillian Wald taught us).  A recent report from the National Academies of Sciences, Engineering, and Medicine describes how social determinants of health (housing, food security, and transportation) impact the physical and mental health of patients. Our frontline providers, such as visiting nurses and other care professionals in the home, are in a position to make direct investments in home-based initiatives that address these determinants of health far beyond the traditional settings of medical services.


The New Home Care Movement 

While care has moved in and out of the home since the 1800s, both new and established healthcare organizations are now launching and scaling models that are effectively moving nursing, diagnostics, primary, acute, and palliative care back to the home once and for all. Thanks to the return of the modern-day house call, we’re witnessing cost savings, an increase in convenience, and more time with care professionals.

For frail and unhealthy patients, this move to home-based care means they are not only forestalling the need for more expensive care in hospitals and other settings, but they are also able to avoid traveling in their most vulnerable state. In addition, the move to home-based care means less exposure to sick patients, care that is delivered based on the patient’s time and preferences instead of that of the healthcare worker, and no more sitting in waiting rooms and emergency departments.

For home-based care to continue to flourish, we must deconstruct our past, our payment models, and the infrastructure we’ve relied upon over the years. While we’ll need to continue to improve upon and adjust the disruptive new models, tools, and technology we use to deliver home-based care, the fundamentals will remain the same. Patients thrive when care is delivered at the right place and time. How we get there is up to today’s generation of healthcare leaders. Will you answer the call?

Eddie is the CEO of Workpath. The company's tech is the only platform for scheduling and dispatching mobile healthcare teams. See how mobile healthcare companies use Workpath’s HIPAA-compliant platform to cut costs, ensure compliance, improve patient satisfaction and more at Workpath.co.