As America’s senior population grows, so do the challenges of providing high-quality, empathetic health care while also addressing their mental, emotional and social needs. One area that dramatically highlights this balancing act is post-acute care, where choosing the right setting is crucial to recovery.
While seniors overwhelmingly prefer to recover in their homes, that setting might not always be the best place for them to get the care they need. As we reflect on Healthcare Quality Week, health care leaders need to find a balance between high-quality care and the growing desire for seniors to receive home care.
The desire to for home care
The desire of most seniors to “age in place,” as reflected by multiple surveys, has led to widespread support for the Choose Home Care Act, according to a recent story in Home Health Care News. That legislation, introduced by Sens. Debbie Stabenow (D-MI), and Todd Young (R-Ind.), would give Medicare beneficiaries who are eligible for a nursing home more options for how and where they recover after a hospital stay.
The act, endorsed by AARP, Allies for Independence and other advocacy groups, would add a 30-day window for “extended care services” to the existing Medicare home health benefit. Those services might include personal care support; meals; non-emergency transportation, such as to doctor appointments; and remote patient monitoring, among other services.
President Joe Biden also has sought to allow more seniors and people with disabilities to receive care at home instead of living in a nursing facility. On March 31, Biden proposed spending $400 billion on long-term care, though that proposal was excluded from the $2 trillion bipartisan infrastructure bill now being debated in Congress.
Such an investment could benefit untold numbers of a rapidly growing senior population that, according to one projection, will include 14.4 million middle-income members age 75 and older, 60% of whom will have limited mobility and 20% of whom will have “high health care and functional needs.” The report “The Forgotten Middle: Many Middle-Income Seniors Will Have Insufficient Resources for Housing and Health Care” recommends that public policy and the private sector take action to ensure that the 54% of seniors who are projected to have insufficient financial resources to pay for the housing and care they will need as they age and struggle with health problems, cognitive decline and mobility limitations.
Even should Biden’s proposal become law, it “wouldn’t solve one of the biggest underlying problems,” according to an April analysis in The Washington Post. It went on to explain: “Most seniors don’t have long-term care insurance because Medicare largely doesn’t cover it, aside from the first 100 days of skilled nursing care following a hospitalization. As a result, many seniors must spend their way to poverty before gaining access to long-term care via the Medicaid program.”
The need to ensure high-quality care
While the COVID-19 pandemic has highlighted the capacity shortages faced by many hospitals, while also demonstrating the benefits of home care, such care presents its own set of challenges — now and beyond the coronavirus.
Possible barriers at home include:
- Social determinants of health (SDOH) – For many seniors, factors such as safe and affordable housing and access to healthy foods, local health services and public transportation can play a key role in their health. Increased access to these resources is increasingly recognized as essential to improved quality-of-life outcomes and lowered risks.
- Family caregivers – The spouse of a senior patient may well have their own chronic conditions to manage, while an adult child may be forced to juggle caregiving responsibilities with a job and providing care for their children living at home. In addition, many home health care agencies have had difficulties attracting and retaining talented staff.
- Cost of properly outfitting homes – Ramps, guardrails in showers, special beds, lifts and other modifications needed to make a dwelling conducive to home care can bring expenses that stretch a family’s budget to the breaking point. In addition, there may be a lack of durable medical equipment such as home oxygen, according to a Harvard Business Review report on obstacles to home-based health care. The home environment also can pose patient safety risks relating to infection control, sanitation and physical layout of the home, that report found.
- Regulatory environment – A lack of national and state requirements for the quality of home-based care is another concern, according to the Harvard Business Review report, though care provided under the Medicare home-health benefit is an exception. Regulation of how home-based health care professionals are educated, trained and licensed can also pose risks to patient safety, the report found.
Meeting non-clinical needs
In addition to addressing issues such as food insecurity and non-emergency medical transportation, many of which fall under the category of SDOH, there are other concerns such as assistance with telehealth and with prescription refills.
“Barriers to older adults accessing telehealth include access to technology, such as smartphones or tablets; access to reliable broadband internet, which varies greatly by socioeconomic status and rurality; and general digital literacy,” Lauren R. Moo, M.D., and Andrea Wershof Schwartz, M.D., wrote in “The Urgent Need for Rigorous Studies of Telehealth for Older Adults Who Are Homebound,” a commentary for the JAMA Network of the American Medical Association.
Moo and Schwartz, while citing a study focusing on telehealth’s potential for improving medication adherence and mood among homebound seniors, emphasized the need for randomized clinical trials aimed at investigating telehealth’s ability to maximize mobility and align care with “what matters most to each older person who is homebound.”
The ultimate goal
The ultimate goal, of course, is no avoidable readmissions to the hospital. Studies have shown just how effective a non-clinical, transitional care program can be in reducing hospital readmission rates. The proactive use of face-to-face and telephonic interaction along with mobile texting to connect with patients during the care journey was credited with ensuring scheduling and adherence to outpatient appointments.
An effective combination of clinical and non-clinical support has been shown to reduce avoidable readmissions and unnecessary medical spend. Such a combination, through patient support, engagement and follow-up, can also reduce emergency room visits, identify and address SDOH, increase patient satisfaction and outcomes, and foster long-term functional and social outcomes.
There is no one-size-fits-all approach to senior care, and desires and needs will vary from individual to individual. Many challenges remain. But the growing recognition of the mental and emotional components of senior health care, and the role these factors play in a person’s overall health, must not be ignored. Home health care clearly has the potential to improve outcomes for many seniors, lower costs and ease the strain on overtaxed facilities.
Make sure to check out Season Two of the SOAP Notes podcast with naviHealth Chief Medical Officer Dr. Jay LaBine.