Urgency has been the defining condition of the COVID-19 pandemic. Overnight, home healthcare workers became the front-line force for COVID patients as hospitals, long-term care facilities and skilled-nursing facilities were devastated by the virus. More than 130,000 LTC residents died of COVID-19 and occupancy rates dropped to historic lows. Any way to keep patients home became the go-to medical order, and it required home healthcare companies to respond with a level of coordination and clinical sophistication that the severity of the public health crisis demanded.
My home-care nurses were scared. Patients would potentially die in their care. Would they be infected? Would they be putting their families at risk? Their fears were justified. But we quickly realized we were called to make the home the safest place to heal in an unsafe time. Now, our pandemic experience is making clear we're in the midst of a major shift for how and where people receive care—migrating from the institution to the home.
When I began my home healthcare career 20 years ago as an occupational therapist, it would have been unthinkable that post-acute home-based care could be a viable alternative to hospitals or SNFs. Home healthcare was characterized by limited clinical services, uneven training and staffing; it was largely considered a billing concept for Medicare and Medicaid patients rather than an option for post-acute care. As I progressed to become the owner-operator of a home healthcare provider, home-based care consisted mostly of physical therapy, basic nursing skills for insulin and Lovenox injections, and some simple wound care. A physician would not recommend a hospital-to-home discharge for a patient requiring more specialized care.
Yet, as the SNF industry reels from COVID-19's devastation on the larger nursing home industry, advances in at-home care, along with the soaring patient demand for remaining at home, have enabled a transformation in where and how care is delivered. It would be a mistake to say SNF@home can someday fill the void that has hollowed out facilities—it already does.
Not enough skilled-nursing beds
Ten thousand baby boomers are turning 65 every day. According to AARP, 90% of people age 65 and older want to remain in their homes and 80% believe they always will. The sheer size of this "silver tsunami" would crash the existing long-term care system. There just aren't enough beds. However, while staying home could theoretically provide a safer healing environment than a facility, can people get appropriate care at home? Eighty percent of the older population has at least one chronic condition and 60% have at least two. There's a world of therapeutic difference between giving an insulin injection and administering vacuum-assisted wound closure or chemotherapy. Can interventions like these be effectively delivered in the home by trained professionals?
At-home care has evolved with more complex interventions: clinical services for surgical wounds, stage 4 ulcers, IV antibiotics, infusions and other therapies have become standard, with home-care nurses receiving training and certification that gives doctors greater confidence for direct-to-home discharge.
CMS has taken notice, too. The number of Medicare Advantage plans offering supplemental benefits for "in-home support services" for 2021 is 93% higher than in 2020, with 430 plans offering the services versus 223. CMS is also supporting introducing acute care in the home, launching the "Acute Hospital Care At Home" program to enable eligible hospitals to provide home-based services.
The transformation of home health I've witnessed has been both astonishing and inevitable. Despite the proliferation of occupational therapy and physical therapy in SNFs, home-based care has always provided the real thing rather than a simulation. SNFs rely on their own bathrooms, beds, stairs, even cars that are stand-ins for patients' actual environments. A nurse in a patient's home can, however, make environmental assessments that bring the patient into the reality of navigating and correcting everyday living rather than simulated environments. Clinically, the home has emerged as a safe and beneficial choice.
There's no turning back. Enhanced home care will continue to evolve, augmented with Bluetooth technology for monitoring blood sugar, blood pressure as well as other medical alerts. Health plans don't generally pay for remote diagnostics now, but the incentive to do so may not be far off, given CMS' burgeoning interest.
The transformation of the home as a center for post-acute care has arrived, a welcome change for the millions of people who want healing at home as a way of life.
