A variety of forces push care out of hospitals, including fear of the next pandemic. Photo credit: Alamy

The pandemic fast-forwarded a long-standing trend toward treatment of even seriously ill patients at home. Now, the healthcare industry, including entrepreneurs, funders and professionals who are working on innovations in the space, are grappling with how much of that new home care should stay at home as the pandemic wanes.

Many of the most serious questions revolve around care for the elderly, who receive much of the hospital care and are almost all of home health agency patients. People aged 65 or older were about 82% of home health agency patients in 2015, according to the Centers for Disease Control and Prevention. People 65 and older accounted for about 45% of all days of hospital care, despite being only about 20% of the population, according to the CDC.

It’s easy to conclude that telehealth visits are a good idea for certain kinds of visits, like routine follow ups, or the day-to-day concerns of parents of healthy children. Those changes are expected to stick, albeit with some turmoil as permanent changes in billing and payment ripple through the system. Much of the U.S. healthcare system is controlled by rules set by Medicare for what procedures can be billed, and at what rates.

It’s hard to see health care going back, though. The pandemic brought profound changes at places from Mount Sinai in New York City, which began releasing more patients home within hours after surgeries after Medicare changed the payment rules, to home health agencies, like one in Omaha, Nebraska. Right At Home was able to offer therapy to its patients for the first time during the pandemic, potentially replacing some of the emotional support patients receive in doctors’ offices.

Meanwhile, one of the wild cards is the fast-rising specter of microbial resistance, which some are highlighting as the next worldwide health threat. Microbes resistant to drugs thrive in institutional settings.

“I think the notion that care delivered in facilities is inherently safe, I think that’s something that has taken a hit and I think that hit is likely to persist,” said Dr. Bruce Leff, the director of The Center for Transformative Geriatric Research at Johns Hopkins University. 

The flood of funding into the space is getting a lot of attention. The consulting firm McKinsey recently estimated that as much as $250 billion of the U.S. healthcare spend, or a quarter, could be virtualized. Following a record year in 2020, tech companies focused on health care continued raising massive sums in early 2021, including Clarify Health, Unite Us, Strive Health and Insitro. But the effects are likely to extend far beyond the world of venture-backed startups.

A Recovery At Home, Enabled By IV Antibiotics Delivered There

In the wake of the pandemic, Mount Sinai Hospital System in New York City was flooded with COVID-19 patients. Like many hospitals in the city, it set up hospital beds in its lobby and tents in Central Park to treat the community that was hit so hard and so fast by the virus.

As people rushed into the emergency room and personal protective equipment grew scarce, Mount Sinai at Home, a program at four of the system’s seven hospitals that offers hospital care at home for elderly people, doubled its services, said Linda DeCherrie, director of the program. Before the pandemic, patients were accessed when they entered the Emergency Department whether they fit into the program for their entire care. The increased capacity expanded the program so patients who have been in the hospital for a number of days could finish their treatment at home, which allowed the program to treat more people, she said. 

DeCherrie recalled a man who came into the hospital for a toe infection, but was reluctant to get surgery because he was the primary caregiver for his wife with dementia. The program gave him the option to have the surgery then recover from home. Meanwhile, it sent home caregivers to his house to care for his wife during the surgery.

Mount Sinai has been part of the innovative program launched out of Johns Hopkins called Hospital at Home since 2014. It’s an alternate choice to traditional hospital services for older patients with acute illnesses which allows them to receive services such as antibiotic IVs, x-rays and respiratory therapy from their homes. That program became central to the health care offerings during the pandemic, accelerating a change that otherwise might have taken years.

Being in the hospital can be especially stressful for elderly people, a group that makes up a large portion of hospital patients: the unfamiliarity can be uncomfortable or even cause delirium in patients, DeCherrie said, and so being treated at home allows patients to be in their own environment. The shifts were catalyzed by  lifted regulations for virtual and in-home visits, which increased the types of appointments that could be charged for the same as in-person. The Center for Medicare and Medicaid Services released a waiver for hospital at home programs, which 139 hospitals have received , including Mount Sinai, according to its website. 

The Baby Boomers Are More Receptive

Right at Home, the Omaha, Nebraska-based global private duty health care service, introduced tablets into the homes of their clients years ago, but mainly for supplemental features such as uploading photos of family or favorite songs, said Margaret Haynes, the chief operating officer at the agency. But, sometimes they were used for check-ins between visits, too, she said, a use that accelerated during the pandemic.

As Baby Boomers start to shift into the oldest generation, there’s more ability to include technology, she said, as they’re typically more accepting and understanding of its use than the older Silent Generation. It’s a way for patients to feel more connected.

Right at Home, which cares for about 25,000 people, has begun using technology more to track its patients day-to-day — has the client taken his or her meds? When was his or her last bath? The goal is to be able to predict a problem before it becomes too late. This is especially helpful when patients have nurses or doctor care at home too, working alongside Right at Home’s care.

Other innovations have expanded since the onset of the pandemic. As CMS began to reimburse telehealth services, Right at Home began partnering with Hamilton, New Jersey-based Forefront Telecare to provide therapists for their clients, she said. The partnership aimed to help patients who experienced increased isolation and depression as a result of the virus. 

Right at Home also recently partnered with TruBlue Total House Care, a company that helps to fix patient-identified problems around their homes — such as securing a loose stair railing or repairing a busted pipe. 

Leff notes a similar program out of Johns Hopkins.

“The pandemic itself has really accelerated everybody’s adoption of technology,” Haynes said. “It really has opened everybody’s eyes to other ways in which we can use technology to engage.”

All of these changes over the pandemic have led to significant reduction in unnecessary hospitalizations, Haynes said, who added that she believes the changes will be beneficial.

A Powerful Incentive: Cutting Labor Costs

It’s convenient and useful for caring for more people, sure, but are the new models what’s best for patients’ care? The jury is out on that — more data on the outcomes of the shift to more home care is expected — but the industry has a powerful incentive to make the changes stick: Treating patients at home is cheaper than treating them in the hospital, and treating patients via telehealth is cheaper than sending someone out to them.

Incorporating more telehealth technology into home health care could be a way to cope with the hiring difficulties the industry has faced, Leff said. The less time workers spend traveling to houses, the more patients they can check in on.

Many home care agencies have struggled to meet hiring needs, a trend that was only accelerated by the pandemic. The job requires certifications, hard work and long hours, all for a small paycheck. And with its in-person and close contact requirements , the risk was just not worth the reward for many over the last year. “It’s been tough,” said Marla Lahat, the executive director of Home Care Partners in Washington D.C.

“For most of our workforce, it was a lot easier to go work somewhere else where you didn’t have to put yourself at such a great risk and get the same pay as opposed to staying in a field that can be very, very gratifying, but hard,” Lahat said. 

At Home Care Partners, a nonprofit with an annual budget of $10 million, the beginning of the pandemic disrupted both the staffing and demand for services.  Lahat estimates that the agency lost 20% of clients, who cancelled services or made other arrangements, and also lost about 20% of its aids. 

Many home care agencies start at $15, she said, the same wage people can get at a less risky minimum wage position in D.C. (the area’s minimum wage is $15). Home Care Partners start their aides slightly higher than that, though and many are paid much more than that anyways. But that didn’t stop aides from leaving.

Now, over a year since the first cases in the U.S., many aides have come back, Lahat said, but some still have not. At the same time, demand for services is still high as more people want to keep their loved ones home because of the increased risk of being close to others in homes and other facilities.

These realities in the home health agency sector will encourage adoption of technology, Leff said. “I think it’s given some of those agencies that are really thinking about it carefully an ability to leverage their workforce,” he said. “Because they’re not always the easiest people to find. Maybe some people who need more true in person visits, get them and for people who need fewer in person visits, get those and you can optimize a workforce and in theory, at least optimize care delivery.”

Leff notes that of course there’s times when you must be in-person — for instance, an ophthalmologist must perform an evaluation in person because it’s purely test-based diagnosis, a home health aid must be in person to administer medicine or give a bath — but purely symptomatic diagnoses or check-ins don’t require being face-to-face.

Especially for home health care, it’s impossible to transition even mostly to telehealth visits. But incorporating more technology could oil its machine.

“At the end of the day, there’s nothing that’s going to replace the human aspect of being in the home,” Haynes said.  “But I think from an innovation perspective, technology will have a great role in being supplemental to enhancing the experience.” 

Virtual Home Health

Putting health care back in a home setting is in some ways archaic — it’s reflective of the days a century ago when doctors travelled to patients’ homes to treat them. But having a visit in the home– whether in person, or via a video call —  has its advantages, Leff said. 

For one, it’s more comfortable and convenient for the patient to be in their own home versus a doctor’s office, he said. It pushes doctors to connect more with their patients — they can see a glimpse into their lives through their homes. It also shifts the power dynamic, Leff said. Instead of being a stranger in a doctor’s office, it puts the patient more in control.

“That is not to say that hospitals and facilities don’t have a place, they absolutely do,” Leff said. “Hospitals are necessary. No one’s saying get rid of hospitals altogether. But, you know, there’s lots of stuff that can be done in other places.”

There’s a balance to be had, experts say. There must be hospitals, but at-home care has its place; There must be in-person visits, but telehealth is beneficial for some appointments. Finding that balance could be more efficient and productive for both caregivers and patients, they say.

As the U.S. begins the process of stepping out of the pandemic — DeCherrie estimates there’s likely six months left of the official declaration — it’s unseen what will stick. But these health professionals hope that elder care adaptations from the last year outlast its end, in some capacity.

As more people get vaccinated and COVID-19 cases decline in most of the U.S., the goal seems to be to return to normal. This means most doctors’ offices are closing their telehealth portals and reopening their office doors for patients. Leff has resumed his in-person appointments almost to full capacity, he told Times of E at the end of March. Still, he wonders, is this really the most efficient way? Or is it just hard wired? 

“Healthcare in the US at least before COVID was pretty much totally built around the in person encounter, most of that happening in facilities, clinics and hospitals, but also in the home,” Leff said. “I think it’s healthy to start to think about what actually needs to be done in person versus what can be done over telehealth, video wise?” he said.

This story and others on New Builders Dispatch are made possible by a sponsorship from the Ewing Marion Kauffman Foundation. The Ewing Marion Kauffman Foundation is a private, nonpartisan foundation that provides access to opportunities that help people achieve financial stability, upward mobility, and economic prosperity – regardless of race, gender, or geography. The Kansas City, Mo.-based foundation uses its grantmaking, research, programs, and initiatives to support the start and growth of new businesses, a more prepared workforce, and stronger communities. For more information, visit www.kauffman.org and connect with www.twitter.com/kauffmanfdn and www.facebook.com/kauffmanfdn.