Expanding the horizons of home health
Home health is nothing new, but the pandemic has demonstrated the possibilities for new home health models thanks to new tech and new approaches
In the 12 months prior to March 2020, 550 pregnant patients at Philadelphia-based Penn OB/GYN Associates went home from a prenatal appointment with a blood pressure cuff.
Researchers at Penn Medicine had determined that remote monitoring of blood pressure worked just as well as monitoring in the clinic to help patients and providers monitor for signs of gestational hypertension and preeclampsia.
“Prenatal care is a low-tech field of medicine. A lot of it is guided by tradition, including the number of times a patient comes in for a pre-natal visit,” says Anna Graseck, M.D., assistant professor of Clinical Obstetrics and Gynecology at Penn Medicine. “We were aiming to reduce the number of visits for low-risk pregnancies and keep a closer eye on high-risk patients.”
The program received positive feedback from patients, who told Graseck and her colleagues that the ability to send blood pressure readings via text message was more convenient than taking time from a busy schedule for a short office visit.
This combination of remote blood pressure monitoring and text messaging also set up Penn Medicine to maintain continuity of care during the COVID-19 pandemic. “In the early days of COVID, pregnant women didn’t want to leave the house, so an in-person visit had to really be worth it,” Graseck says.
For Penn Medicine and other health systems that had incorporated telehealth or remote monitoring technology into their home health programs in the years before 2020, the pandemic both highlighted the value of care delivery at home and accelerated plans for expanding home health programs.
Supporting primary and urgent care at home
The term ‘home health’ is traditionally associated with older populations aging in place or patients recovering from surgery or hospitalization. Services tend to be more high-touch than high-tech and include skilled nursing, physical or occupational therapy, or hospice and palliative care. ‘Home care’ is a segment of home health that focuses on personal care, such as assistance with bathing or eating.
However, telehealth use patterns during the COVID-19 pandemic reflected home health’s potential to address more acute care needs and to reach more patients. A survey from the Bipartisan Policy Center found that 14% of telehealth users in the United States would have otherwise sought urgent in-person care or headed to the emergency room. Nine in 10 survey respondents were satisfied with their telehealth visit, and eight in 10 said their primary issue was resolved.
The home health approach of insurer Humana reflects this trend. Since the summer of 2020, Humana has launched partnerships with home-based primary care provider Heal and home-based urgent care provider Dispatch. The insurer also acquired Kindred at Home, the largest home health and hospice provider in the country, for $8.1 billion in April 2021.
“We’re working on how to deliver an ecosystem of delivery that can provide services across the spectrum that members need – from preventive to primary to acute to emergency to rehabilitative,” says Gregg Sheff, M.D., chief medical officer and interim segment president for Humana’s Home Solutions division. “Part of that is understanding how technology comes into play. Virtual care is an extremely broad capability; the key is to match the capability with the use case.”
Other experts agree that incorporating technology into home health works best when it is as seamless as possible. “It’s not about changing the way that care is delivered,” says Jenna Kowalski, director of clinical services for telehealth and remote monitoring technology provider Health Recovery Solutions. “It’s about incorporating a new tool into the care model a health system already has. It’s not reimagining what they do but complementing what they’ve already done.”
Finding the right patients for care at home
Humana uses predictive analytics to identify which members are the best fit for home health services – typically, those with a clear care gap, Sheff says. Analytics also helps clinician staff determine where to “double down” on their home health efforts, he added. A common example is a lack of improvement in vital signs being monitored from home, such as a patient who has been unable to lower blood pressure or blood glucose after being placed on a care plan.
New Orleans-based Ochsner Health System takes a similar approach for its home-based fall prevention program. Falls are the leading cause of traumatic brain injury in seniors. “It’s an enormous and prevalent problem,” says Richard Milani, M.D., a cardiologist and the chief clinical transformation officer at Ochsner. “And once you heal, you go home to the same environment, and you’re at risk of falling again.”
Ochsner has developed a predictive model that analyzes electronic health record (EHR) data to identify patients at high risk of a fall in the next 12 months. From there, it reaches out to eligible patients and enrolls those who are interested.
Analytics plays a further role in monitoring ongoing risk: Through an Apple Watch app, Ochsner can monitor subtle changes in a patient’s gait as well as detect a possible fall. “These ongoing measurements can tell us that an intervention is working or not,” Milani says. “Technology is enabling us to not only predict things but also assess in real time how an individual is doing. We’re trying to address all the known treatable factors.”
Other systems, including Penn Medicine and Mayo Clinic, take a more traditional approach to patient enrollment. More than four years ago, Mayo established a home health program to monitor patients in western Wisconsin with chronic conditions who faced challenges accessing ongoing care. Physicians would refer patients to the program and send them home with a technology kit that included a cellular-enabled tablet PC and Bluetooth-enabled scales or blood pressure cuffs.
“We’re trying to identify the patients with adverse trends and intervene early to drive down emergency department visits,” says Tufia Haddad, M.D., medical director of Mayo Clinic’s Center for Digital Health Remote Patient Monitoring Program.
Overcoming hurdles to adoption, for patients and providers
Mayo’s approach to technology onboarding is simplicity, Haddad says. “Patients can set up the kit in three steps: Plug it in, turn it on, and get started,” she says, noting that the median age of patients in the program is 71. “We need to make it as easy as possible. That’s critical for adoption and engagement.”
On the clinical side, Mayo has created clinical assistant roles that specialize in assessing alerts from participating patients. If something looks amiss, the clinical assistants reach out to patients to take another reading before turning the patient over to a nurse or physician. This proved particularly valuable in the early days of the pandemic, Haddad says, when front-line workers had to focus on patients with COVID-19.
“The last thing we want nurses doing is data mining when they should be using their skill set to care for patients,” Haddad says. “We’re always looking for ways to optimize the efficiency of staffing to make it as scalable as possible.”
After the program’s initial deployment in western Wisconsin from 2016 to 2018, Mayo expanded it throughout the health system in 2019. More than 3,000 patients had completed the program through the end of 2019, with an average of 350 patients enrolled at any given time, Haddad and her colleagues note in a recent paper.
Mayo’s program now covers additional specialties such as oncology care, which is Haddad’s specialty. Here, patients undergoing cancer treatment will complete weekly surveys assessing their symptoms, and the results will be analyzed to alert care teams of adverse trends, she says. In addition, the program also includes lower-intensity monitoring for conditions such as acute infections, pregnancy, or surgery recovery.
Other health systems expanded existing remote monitoring programs to support home care amid COVID-19. Avera Health, based in South Dakota and serving our other states, pivoted a program initially focused on cardiac care to provide 24/7 monitoring of nearly 4,000 patients from April to November 2020. The health system delivered telehealth to patients’ homes, allowing them to track their own vital signs and connect virtually with both nurses and social workers. Florida-based BayCare HomeCare likewise shifted its telehealth program, initially launched in 2016, to monitor more than 4,000 patients with chronic conditions or COVID-19. The health system performed roughly 11,000 virtual visits from May 2020 to May 2021 and estimates cost savings of $6 per patient per day.
Embracing change through data
Ochsner’s Milani says change management is often the hardest part of implementing any home health program. That’s especially true for programs focused on ongoing monitoring of chronic conditions such as diabetes or hypertension. After all, health systems traditionally focus on acute care episodes, he noted; once a broken arm heals, a patient is unlikely to see the same orthopedist again.
Convincing physicians to participate means demonstrating that home health does not lead to more work and does not impact the level of care, Milani says. The way to do that? Data and efficacy.
“Physicians will respond to data. You need to show physicians that the program is working, that patients like it, and that there aren’t any other issues,” he says. “If your data shows that you’re maintaining or even improving quality, and that you’re following evidence-based guidelines and not doing some sort of experimental therapy, then physicians are willing to embrace it.”
Success often depends on underselling and overdelivering the benefits of technology in home health, says David Houghton, M.D., a neurologist and director of the health system’s CareConnect 360 telehealth program. “Patients will give more latitude to growing pains. They’ll try something a second or third time. Doctors or nurses are less willing. They’ll remember if something didn’t work the first time.”
Measuring outcomes and preparing home health for the future
Ochsner evaluates its telehealth and remote monitoring programs on four key performance indicators, says Houghton. Care quality, utilization, patient satisfaction, and cost. Cost consists of several metrics, including the cost to the patient, the upfront cost of standing up a program, and the downstream impact of avoidable costs such as emergency department visits. Ochsner’s telehealth program is more than two decades old, while the remote monitoring program has been in place for five years.
“There are a lot of places where we can have quick wins,” say Houghton. That’s especially true as more of the 15,000 enrollees in Ochsner’s chronic care remote monitoring program achieve positive clinical outcomes such as controlled blood pressure or diabetes. “That sells the program and moves the needle on the value of wraparound services.”
Better use of staff time and resources is another important KPI, Kowalski with Health Recovery Solutions says. Cancellations, appointments running over, and visiting nurses running late all contribute to the inefficiency of in-person care, she says.
After a hospitalization, incorporating virtual home visits into the post-discharge plan allows clinical staff to see more patients in less time, with in-person visits focused on patients with the most acute care needs – a key consideration amid COVID-19.
“This helps the health care organization to use staff appropriately, bring in more virtual care, and decrease the total cost of care,” Kowalski says. “In the past, we assumed that the relationship had to be in person, but now we’re seeing that the relationship can be built virtually.”
Ultimately, care quality and patient outcomes are the most important KPIs for home health programs – even if patients ultimately no longer need them.
“Our goal is to foster self-management,” Mayo’s Haddad says. “We don’t want them to be dependent on the system. We want to educate them, coach them, and help them reach their goals.”