What do investors and hospital systems need to consider before initiating home-based chronic disease management?

Background

With an ageing population, the global conversation about reforming health care for those with chronic illness is becoming more urgent. Geriatric medicine research has repeatedly found that the hospital environment, more suited for acute care, can be associated with more harm than good for elderly patients. Chronic care facilities are associated with a very poor quality of life and isolation of patients from their communities, not to mention worse clinical outcomes compared to home-based care₁.Nosocomial infections (hospital-acquired infections), delirium (confusion) and medication errors due to lack of continuity of care are some of the common issues that affect elderly patients when they are hospitalized₁. The psychological benefit of being treated at home and receiving community support is synergistic with the reduced cost of care when chronic disease management is effective in keeping patients out of the hospital_1,2. An important goal in senior care then, is to try and keep patients out of the hospital as much as possible.

The psychological benefit of being treated at home and receiving community support is synergistic with the reduced cost of care when chronic disease management effectively keeps patients out of the hospital.

The Finances

Home-based care was repeatedly proven to be financially more affordable than institution-based care, whilst also improving patient outcomes. As home-based care draws on support systems already available to patients in their home environments and communities, the financial benefits can be significant _2,3.

Managed care settings for chronic disease management make the investment in home-based care even more viable. Emergency room visits and hospital admissions, in addition to their high cost per patient, have been shown to be related to an overall deterioration of the patient's clinical condition. Delirium and deconditioning requiring prolonged rehabilitation for example, are common issues during and after hospitalization that significantly increase the cost of care. Investing in earlier detection of chronic disease and more robust monitoring and management also reduces the frequency with which a patient might need to access emergency services and of hospital admissions ₄.

Managed care settings make the investment in home-based care even more viable. Constructive partnerships with insurance companies have the potential to create win-win scenarios for all stakeholders in a care system.

Partnerships with insurance companies can create a care system with win-win scenarios for all stakeholders. Investing in preventative care with local partners, and in home-based care for chronic disease management can align the interest of insurance companies with patients, policymakers, healthcare institutions as well as with related localised support services. All would stand to benefit from high value care with improved patient outcomes, at lower cost and with sustainable funding.

The Pillars of Home Based Care

There is a lot to consider for any healthcare institution planning to invest in creating or expanding in-home services. We outline four key dimensions here.

The Patient:

Patients with chronic illness are vulnerable and often struggle with understanding their disease. Patient education and empowerment is a very important aspect of successful in-home care management. Considerations such as a patient's ability to self-administer medications, ability to communicate with the care team when needed and family and community support available to them are crucial.

The intensity of required monitoring for their condition is also a factor (can the patient measure their own blood pressure and blood sugar for example or does someone need to do that for them). Finally, the patient's feelings about in-home care must be addressed. Some patients feel abandoned when a hospital team attempts to discharge them or refer them to in-home care teams. It is important to work on the patient's buy-in so that they are engaged with the process of transitioning their care outside the hospital walls. Working with family and community support is crucial so that this transition is as smooth as possible.

Some patients feel abandoned when a hospital team attempts to discharge them or refer them to in-home care teams.

Chronic disease often goes hand-in-hand with depression. For some patients who may already be experiencing isolation, signing them up for home-based care might take away their rare opportunity to socialize. It is important that such patients receive more support, for example in terms of home-visits by care providers and support workers. Although not strictly necessary for their chronic disease management, such support would improve their psychological well-being; improving mental health serves the goal of improving their long-term outcomes.

The Provider:

In-home care can be challenging for providers as well. Clinicians can get a lot of information by seeing a patient in-person beyond the physical exam. Doctors in particular tend to spend the least time with the patient compared to other members of the care team and in-home care can reduce this time further. Specialists like geriatricians are trained to coordinate specialized teams of nurses and physician assistants who can assess the patients at home and discuss cases with geriatricians on a weekly or bi-weekly bases.

Provider safety must also be considered before enrolling a patient into home-based chronic disease management.

Provider safety must also be considered before enrolling a patient into home-based chronic disease management. Initial assessments must be conducted by a multi-disciplinary team of providers who assess the home for the patient's needs in addition to the ability of providers to safely conduct home visits. Working with community leaders or representatives might be appropriate in some areas to ensure a cohesive system of care is in place for the most vulnerable patients.

The Technology:

Some models of in-home care rely heavily on telemedicine. Availability of HIPAA compliant software and affordability are sometimes a barrier to entry to establishing effective telemedicine solutions for a healthcare system. Trust and confidence in the ability to care for patients using telemedicine is still gradually growing amongst doctors and institutions who might have to spend time and effort to train physicians and establish buy-in for telemedicine solutions.

Apps that allow patients to input daily parameters like blood pressure and blood sugar can give real-time data for providers, who can be overwhelmed without such systems of practice that support their effort to manage such a patient population outside of scheduled visits to the clinic.

Patients or their caregivers would also have to get comfortable with the available technology necessary to facilitate such sustainable care. Culturally and personally appropriate educational methods that can help patients and caregivers on the journey to effectively using telemedicine technology whilst feeling engaged and supported by the healthcare institution, would also need to be identified.

Patients or their caregivers would need to develop comfort with the available technology that would facilitate sustainable care.

The interface itself of telemedicine apps needs to be user-friendly for different kinds of stakeholders. Patient portals might look completely different from the medical records that data is plugged into. Ensuring adequate beta testing and seamless performance are crucial before rolling out telemedicine platforms more broadly, as poor initial experiences for both patients and providers can seriously impact long term buy-in and support, and ultimately the success of the institutional initiative.

The Data:

One of the key challenges facing home-based care is finding an effective means of monitoring and acting on pertinent results in a timely fashion. While technology has significantly increased the viability of home-care systems, data-handling can make or break such a system₅.

Alert fatigue for example, is a serious issue systems designers must account for when setting up home-based care systems. Designing workflows with redundancies and clear hierarchies of responsibility across the system is also essential for the success of in-home chronic disease management.

Robust data sets can support predictive modelling that helps health care systems identify at-risk patients who might need closer attention.

Having access to real-time information which improves the system’s understanding of the patient population would create more relevant benchmarks for direct care provision and for continuous quality improvement. To further support the improvement of patient outcomes, predictive modelling ought to be applied to the dataset of the actual patient population being managed, ideally in real-time. Robust data sets required for predictive modelling can help health care systems quickly and effectively identify at-risk patients who may need closer attention, and significantly improve the care system’s response time and prevalent clinical outcomes for the patient.

Moreover, stakeholders across the care system have different data requirements related to the decisions they have to make. Effective data management can ensure that the right information, using overlapping and related datasets, is routed to the right stakeholders at the right time, whilst respecting any data access privileges and data privacy considerations and guidelines in place. A well-clarified data architecture, therefore, has the potential to directly relate the prevalent cost of care to the clinical value for the individual patient interacting with the care system.

Continuous assessment and improvement of the system to keep-up with the ongoing needs of the patient population is essential for the sustainability and success of the system. Effective data management is therefore a fundamental building block for designing and deploying an efficient and effective managed care system.

Conclusion

In our view, in-home chronic disease management is the future of healthcare, as it can facilitate improved clinical outcomes and reduced cost of care. Successful home-based care programs, however, must consider multiple aspects of care for sustainable results to achieve these two goals ₆. Four key dimensions must be connected and explicitly understood if a home-based chronic disease management system is to succeed. Specifically, the interplay between the patient, the provider, the technology and the data in the care system must be clarified and agreed upon before effective planning and optimisation can take place, and the dual goals of cost-reduction and improved clinical outcomes can be realized.

Patient and provider factors must be addressed independently, while technological solutions need to be appropriate for both the patient and provider populations. The data requirements underpinning the system can then be clarified and mapped in order to design an effective technological solution. Data management systems are crucial to the improvement of quality of care as providers require real-time data for decision-making. Moreover, real-time data is also crucial to any predictive modelling looking to effectively identify high-risk patients.

Home-based care-management models are ideal as they have the potential to optimize crucial aspects of patient care without having to simultaneously overhaul more complex hospital systems, thereby allowing for improved clinical outcomes at reduced and more distributed costs across networks of care providers and supporting services.

References:

1. Health Quality Ontario. In-home care for optimizing chronic disease management in the community: an evidence-based analysis. Ont Health Technol Assess Ser. 2013 Sep 1;13(5):1-65. PMID: 24167539; PMCID: PMC3804052.

2. Kelsey Waddill; Health Payer Intelligence; The Impact of In-Home Chronic Disease Management on Spending. December 10, 2021

3. Natascha Dixon Edelin; Avalere; Home Care Services Reduce Medicare Spending for 30 Chronic Conditions, December, 2021

4. Debbie Singh; Health Systems and Policy Analysis, Policy Brief; WHO; How can chronic disease management programs operate across care settings and providers? 2008

5. Emely Olsen; HealthCare IT News; How tech support can encourage in-home chronic condition management, senior care; March 11, 2022

6. Garnett A, Ploeg J, Markle-Reid M, Strachan PH. Self-Management of Multiple Chronic Conditions by Community-Dwelling Older Adults: A Concept Analysis. SAGE Open Nursing. 2018;4. doi:10.1177/2377960817752471