Home-based care has long been an area of interest for the health care industry. Patients often prefer to receive care in their homes, and several models have demonstrated the ability to lower health care costs while providing the same or better quality care.

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The Covid-19 pandemic created more urgency to shift all types of care to the home, from acute to primary care. It may be tempting to rush into the market and capitalize on the traction home-based care initiatives have right now, but for all the potential benefits of home-based care there are just as many, if not more, potential setbacks. 

Don't go into the home blindly

This does not mean that stakeholders should avoid entering the home-based care space, but it does mean they should not assume that an initiative will be successful simply because it provides care in the home.

If a stakeholder rushes into home-based care, there are three major potential challenges to success. A home-based care investment may independently experience one, multiple, or all of them.

1. A provider cannot successfully scale their home-based care model to be financially sustainable.
2. The home-based care program is unable to reach key patient populations due to structural barriers, exacerbating existing equity challenges.
3. The home-based care model successfully delivers care in patients' homes, but this care isn't necessarily appropriate for patients' needs—resulting in additional health care days, either as in the form of a hospital readmission or as additional downstream care. 

1. A provider cannot successfully scale their home-based care model in a financially stable way

Because home-based care involves providers, equipment, and other medical necessities traveling to the patient's home, home-based care models need to be scalable to reach a significant enough patient population to fund the program.

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Both large and small organizations can achieve this necessary scale, but they are also susceptible to the same challenges. Scaling issues include workforce shortages, scheduling inefficiencies, and reimbursement structure.

These challenges raise messy questions with no easy answers, such as: How will I recruit, retain, and train sufficient staff? How do I ensure I am scheduling care efficiently? What is my process for getting necessary supplies and equipment to patients' homes?

Finding the right reimbursement model is critical to achieving scale. Hospital-at-home has been a concept for decades but was limited to pilot programs until risk-based reimbursement became more prominent.

Now, hospital-at-home is typically funded through a risk-based contract with a Medicare Advantage plan. Hospital-at-home companies such as Contessa Health use this payment model, which has opened up the door for them to invest in their workforce, technology, and other necessary aspects to provide hospital-at-home. While there are many moving parts that have allowed them to scale, the first step was ensuring the payment model would provide the right incentives and sufficient funding.

2. Structural barriers to access exacerbate equity challenges

To receive home-based care, patients must have stable, safe housing located within a defined service area. These requirements can lead to disparities in access, disadvantaging non-dominant groups. A  2020 study found that Black and Hispanic patients are less likely to receive a timely first home health visit than white patients.

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It also found that those living in high-unemployment zip codes are less likely to receive a timely first home health care visit than those living in low-unemployment zip codes. These findings raise a serious question for home-based care stakeholders: How can we provide equitable access to home-based care?

Furthermore, many models of care in the home require the patient to have internet or broadband access and be technologically savvy. However, internet access can be a barrier for some populations, and seniors in particular may struggle with technology use.

Lack of access or the ability to use technology can render some home-based care programs useless or even dangerous for these populations. As such, when creating a home-based care model, stakeholders must consider the different levels of tech support patients may need and be prepared to solve this challenge.

Solutions could range from using tech products that work on 2G and offering redundant hubs to training patients and caregivers. To learn more, see our cheat sheet on digital inequities. 

3. The model doesn't provide appropriate care, generating additional health care days

Home-based care models need to be able to safely care for patients in the home, a setting without easy access to other medical professionals or equipment. This means that specific criteria must be met to ensure a safe environment.

First, patients need support and assistance. Depending on patient acuity, they may need up to 24/7 support provided by family or a privately hired caregiver. Having a family caregiver who is both available and willing to care for the patient is not guaranteed.

Private caregivers are not covered by Medicare fee-for-service, and can be prohibitively expensive to pay for out-of-pocket. As such, home-based care programs should consider providing monitoring and assistance for activities of daily living, which can be covered under risk-based models.

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Until home-based care programs are more widely able to provide and fund non-medical support, the population of appropriate patients will be limited by the ability to access a family or private caregiver.

Second, home-based care programs need to have a screening process to determine patients who are medically appropriate to receive care in the home. An example of admission requirements for hospital-at-home can be seen on page five of How Three Providers Scaled Hospital-at-Home Amid the Covid-19 Pandemic.

Third, if a patient experiences a clinical escalation, there needs to be infrastructure to respond in a way that reduces the risk of poor outcomes and unnecessary readmissions. This could range from a remote patient monitoring system that triggers an alert for the patient's providers, to a 24/7 nursing hotline, to a drop team of providers ready to provide emergency care.

Where do we go from here?

To avoid these pitfalls, stakeholders should ask the following questions before investing in home-based care:

• What type of care do I want to shift home and for which patient population?
• Why do I want to shift that care home for this patient population?
• What barriers might this patient population face in receiving this care at home?
• How is my model prepared to safely treat the target patient population in the home?
• What outside factors (regulatory change, staffing shortage) could affect my investment?
• How is my model prepared to deal with escalations?
• What are my most important outcomes metrics?
• What process metrics should I be tracking to see if I'm on course?