The Return Of The House Call?
My wife and I come from families of doctors and nurses spanning several generations. Her 95-year-old grandfather, a retired physician, recently regaled us of his first house call in 1945. As a young intern at Columbia’s College of Physicians and Surgeons, he was handed his “delivery pack” and sent out to deliver a baby in an apartment in Manhattan.
Clearly, this was a critical house call.
Today, my sister-in-law is a home health nurse for a regional health system, and every day she is responsible for coordinating the home care for six to eight patients, including the work of various other specialists such as physical, occupational, and speech therapists. All of this care is delivered in the patient’s home, which seems to me to be on the extreme opposite end of the acuity spectrum—or is it?
Is acute healthcare returning to the home? She spoke of the types of patients she cares for, their diseases and multiple medications, and the various lifestyle changes necessary for them to become healthier and more self-sufficient. She said that many of the same patients she sees in their homes were actually critical care inpatients a year earlier.
Inside the hospital, the clinical staff has complete control over the patient’s environment of care, including nutrition, hygiene, medication compliance, rest, therapies, visitation, and safety. All of these aspects of the patient’s hospitalization are geared towards optimizing clinical outcomes, yet few of these elements are available in the home. So how can a patient’s condition be expected to clinically improve better than they would—or at least as well as—if they were in a hospital?
The limited research conducted on home healthcare over the last five years has revealed that for certain types of care, there are actually few differences in patient outcomes between home health delivery and hospitalization.
A study of a Johns Hopkins home care program published by Cryer et al. in 2012 revealed an increase in positive outcomes for home healthcare patients and a slight decrease in readmission rates and mortality rates compared to hospitalized patients. The program used technology to remotely monitor and observe patients while in their home environment, with 24-hour staff availability, and recorded satisfaction ratings that were 10 percent higher than hospitalized patients and a reduced cost of care due to shorter lengths of stay.
Additionally, a study published by Shepperd et al. in 2009 found that home healthcare resulted in a 38 percent reduction in mortality compared to hospitalizations.
Even if research is limited and there are many variables resulting in multiple outcomes, initial studies do suggest that home health is comparing favorably, even better, than hospitalizations. So what does this mean from a hospital planning perspective?
It might suggest that accommodations should be made for remote organizational control of all of this decentralized care delivered by home health. Hospitals will need a cadre of specially trained clinical care coordinators to oversee the process—where will they work and will this take place virtually? Maybe patients will be provided an iPad to use for their physician assessment and hospitals will house a virtual care center where specialists will consult with one another and provide patient consults remotely—potentially from all over the world. This increased virtual access to specialists might also improve outcomes.
If this tactic stands to improve outcomes and finances, then home health will continue to expand and the network of on-foot-providers and virtual consults must be worked into the overall strategic master plan of each provider network.
We might also conclude that the growth of home health will ensure that only the highest acuity patients will be treated in hospitals. To create a complete continuum of care for population-based health, home care plays an increasingly important role. It would seem we are in fact returning to the house call—where medicine began.