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The 5 barriers to implementing home-based health, according to HBR

Home-based care has been shown to reduce costs, hospitalizations, and ED visits, yet implementing a successful program poses "significant risks and challenges," write Pooja Chandrashekar, Sashi Moodley, and Sachin Jain for Harvard Business Review.

Chandrashekar is an MD candidate at Harvard Medical School, Moodley is a medical director at CareMore Health, and Sachin Jain is president and CEO of CareMore and Aspire Health. They identify five barriers to implementing home-based care programs, as well as how to overcome those challenges.

1. Patient preference

According to the authors, it's important to consider whether a patient would prefer to be treated at home or at the hospital. One study of older adults found that 54% said they preferred treatment for acute illnesses in the hospital rather than at home.

And there are several reasons patients may prefer hospital-based care to home-based care, the authors write, such as wishing to avoid reminders of illness and treatment at home, concerns about elder abuse and neglect, embarrassment about living situations, or a desire to socialize by receiving care away from the home. "These preferences should be respected and not disregarded," the authors write, and providers should "engage patients in shared decision making about whether home-based care is the right choice for them."

To navigate these preferences, the authors recommend that home care programs "establish strong relationships with outpatient facilities, hospitals, and other long-term facilities to accommodate patients' changing preferences and facilitate handoffs."  

2. Clinician concerns

Clinicians may also be hesitant to put their patient in home care for a number of reasons, the authors write. For example, since home care visits take longer, care teams are not able to see as many patients as they would in a hospital or office setting. In addition, clinicians devote more time identifying and addressing their patients' social determinants of health—factors that disadvantage providers working "under traditional fee-for-service models that tie payment to number of patients seen and procedures performed," the authors write.

To enable home-based care models to scale up, payment models need to "reward, not penalize, clinicians for spending extra time coordinating and managing care," the authors write, and clinicians should be allowed to "share in the savings accrued from preventing unnecessary hospital and skilled-nursing-facility stays." Payers should also get rid of "outdated restrictions on the technologies (e.g., remote patient monitoring, telehealth) and equipment eligible for reimbursement," the authors write.

Another clinician concern to address is safety, according to the authors. They note that some clinicians feel uncomfortable visiting patients who live in areas with high crime rates, which can make it "difficult to embed home-based care programs in some medically underserved areas." The authors recommend home care programs prioritize clinicians' safety, citing as an example CareMore Health System. According to the authors, CareMore trains clinicians on safety protocols and de-escalation techniques, and provides security escorts as needed. Clinicians also have access to emergency response through a "panic button" on their mobile devices.

A third clinician issue is medical training, the authors write, noting that both medical schools and residency programs must prepare future physicians "for the inevitable shift from hospital to home by integrating home-based care into required curricula and training."

3. Supporting infrastructure

The authors also address a dearth of supporting infrastructure for home-based care models, particularly for patients with acute-care needs who may not be able to access the necessary "life-sustaining and assistive durable medical equipment (DME)." To increase access to DME, the authors recommend that payment models incentivize suppliers "to improve service and produce high-quality equipment" by "reward[ing] companies for speed and reliability."

Home-based patients with fewer acute-care needs also require infrastructural support to "remain independent and safe at home," the authors write. The authors call on health systems and insurers to collaboratively improve the availability of such "non-skilled in-home care services," including help dressing, bathing, cooking, using the bathroom, and moving around safely, to help "drive adoption of home-based care models."

Health systems also need to ensure that "an entire ecosystem of care" is available, the authors write. For example, CareMore has a "network of vendors" for the different aspects of home care, including mobile labs, mobile radiology, and at-home medication delivery.

4. Patient safety

According to the authors, home-based care programs also must "rigorously assess and mitigate" risks to patient safety in the home setting, including environmental hazards like sanitation, a dearth of continuous health monitoring, the challenges of navigating patient autonomy and risk, and a lack of education among patients and family members about care needs.

To address these risks, the authors recommend that programs develop "clear inclusion and exclusion data to assess the suitability of a home-based solution," and embed into clinical care considerations of the safety factors involved in every patient interaction. More broadly, health systems must establish consistent safety standards for home-based care, as well as methods for sharing best practices.

5. Regulatory environment

Currently, "[t]here are no national or state requirements for the quality of home-based care," aside from care provided under the Medicare home-health benefit, and there's little regulation of the education, training, and licensure of home care professionals, the authors write.

To curb the safety and liability risks stemming from such "'unregulated' care," the authors urge health systems to "commit to consistent regulation and more stringent enforcement of home-based care," including:

  1. A standardized set of assessment and reporting requirements for home care quality; and
  2. Certification programs for all home care workers.

And in addition to "addressing the barriers to delivering safe, effective, and patient-centered medical care at home, administrators and policymakers must prepare for the broader impact on the U.S. health care system—for example, the growth of home-based care may reduce the need for hospitals—and change how we define success in health care," the authors write.

According to the authors, "Adjusting the payment and regulatory environment in which health care delivery organizations operate will be crucial to the success and growth of home-based care—at a time where we need disruptive new models of care delivery more than ever" (Chandrashekar et al., Harvard Business Review, 10/17).

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