Curbside Consult with Dr. Jayne 8/8/22
In my work with large health systems, some of the projects I most enjoy are those that involve patient-facing technology. In sophisticated organizations, this includes actually bringing patients and caregivers into the product management and development work so that you can ensure that you are developing a solution that meets their needs. A lot of great ideas don’t necessarily resonate in the real world and it’s important to find those disconnects earlier in the process so that the solution can be refined. Otherwise, there is a risk that it will flop when it’s released into the wild. I’ve certainly seen plenty of initiatives go that route.
Healthcare delivery organizations have been in a state of transition for several years as they try to move more care out of the hospital and into the home or other care delivery facilities. Many of these efforts make sense. Getting patients out of the hospital quicker reduces the risk of hospital-acquired infections as well as costs. Patients may recover better in familiar surroundings than they might in an institutional setting. There are numerous other factors and these approaches have been successful for many same-day procedures such as orthopedic surgeries. However, when thinking about these types of programs there is a presumption that patients have family who are not only available to assist but who have adequate health literacy, appropriate physical capabilities (strength, dexterity, etc.) but also the emotional fortitude to assist in caring for a loved one at home.
A friend sent over this piece that was published on LinkedIn, with which I have a love/hate relationship as far as content creation and dissemination. It’s great to be able to share information, but there are a lot of people out there who interpret what they see on social media as being authoritative without fully understanding the background of a given issue. There’s a danger in drawing conclusions from narrow write-ups without fully understanding them or their downstream impacts. I saw this behavior often when working with large health systems that would pounce on an idea that they saw float by regardless of whether it applied to their situation or not. Significant resources were spent researching, evaluating, and assessing before the executive who thought it was a great idea could be convinced otherwise.
The LinkedIn piece is from The Health Management Academy and talks about five barriers to scaling the hospital-at-home concept. It draws in readers by leading with the phrase “digitally-enabled home-based care models” and quickly connects interest in the topic to both the COVID pandemic and to CMS reimbursement allowances. It notes that programs are often small, which makes them somewhat unsustainable, and questions whether programs will be able to continue beyond the pandemic. Below are the barriers the article cites, as well as my comments:
- Low patient enrollment. No surprises here, as patients have to be appropriately referred to the program, which requires time, effort, and coordination. Some organizations only allow patients who are in the emergency department to be referred, and others restrict patients to those who are already in an inpatient unit. This prevents other referrals which might be useful, for example, as an urgent care physician I would love to have referred patients with blood clots to such a program if they weren’t quite candidates to just manage it on their own yet didn’t really need a hospital admission to get started on blood thinners.
- Staffing challenges. This is the universal challenge of all industries right now, from fast food to construction to healthcare. In addition to having healthcare skills appropriate to inpatient care, frontline workers in hospital-at-home programs need other skills, such as managing remote technology and being able to self-support. In talking with several inpatient nurses, they’d be reluctant to give up their current level of predictability for increased volatility and personal risk.
- Provider support. Hospital-at-home workers have to be comfortable going into patients’ home environments, which sometimes have unfriendly living conditions, pets, and people. The article refers to this as “an uncontrolled setting,” and anyone who has ever done home care or rode along with EMS or the fire department knows what we’re talking about. This can be an extremely scary situation and there’s not a good way for those referring a patient for a program to know that Cousin Doug with severe uncontrolled mental illness also lives in the house, or that Aunt Julie has a handgun that she likes to leave on the end table.
- Coordination of services. The article sums this up as transporting providers and equipment along with care coordination. Given the fact that hospital-at-home is often related to a relatively acute situation such as an Emergency Department visit or an inpatient hospitalization, quick and efficient coordination is needed. Having shared the patient experience when a close friend couldn’t get the appropriate durable medical equipment delivered to her home when her surgery had a three-month lead time, I’m not convinced of some organizations’ ability to handle this rapidly. It’s not just equipment, but other medical supplies and services like imaging, phlebotomy, pharmacy, and the care itself that all have to be coordinated effectively.
- Reimbursement uncertainty. To me, this is the largest area of concern. Healthcare delivery organizations aren’t going to invest the resources to build the infrastructure to do all the things listed above if they aren’t convinced that they will be paid for their efforts in the future. Given the state of healthcare spending in the US and the fact that many of these programs are operating under a CMS waiver that provides payment equivalent to inpatient care, it’s unclear how much programs are willing to invest to keep the lights on let alone expand.
The piece the article missed, of course, is the patient piece. Do patients really want this service, or do they feel it’s just another way to get pushed out of the hospital before they are ready? Do they find value in the offering, or do they find it stressful? How do they feel about having outsiders in the home when there are stories every day of scams, theft, and abuse of patients by unscrupulous caretakers? Is the family ready to start delivering nursing and other care? Any health system administrator who is considering this needs to have firsthand exposure to what it’s like to help care for family at home, including assisting with feeding, mobility, toileting, managing surgical drains, and more. Unless a program is going to provide 24×7 support, these tasks will fall to family and friends, and some of them are not for the faint of heart.
What is your organization doing as far as hospital-at-home? How do you feel about it as a patient, and as a family member? Leave a comment or email me.
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The Hot Ones is brilliant. There have been many great interviews, the host does his homework. Also worth looking for…