Hill Dickinson senior associate Gemma Badger reviews current moves towards healthcare at home provision through a value-based focus
The concept of healthcare at home is receiving increasing focus worldwide. This focus is twofold driven by both the ‘carrot’ of providing higher quality services focussed on patients who may be more comfortable in their communities and potentially receive more comprehensive and reliable services away from hospitals and other medical facilities. It is also driven by the ‘stick’ of healthcare systems under intense pressure to deliver financially-stretched services and reduce the pressure on hospital-based services and their increasingly burnt out staff. Yet through multiple healthcare system stakeholders working together to design appropriate pathways, there are clear opportunities to pursue a value-based approach to healthcare incorporating home-based ways of delivering healthcare and related services.
What is healthcare at home?
Broadly speaking, healthcare at home could refer to either:
• Nursing or other care or treatment services being provided to an individual within their home (or potentially local to their home or provided in a mobile unit) or
• Self-managed home services – for example home monitoring via a traditional medical device such as a blood pressure monitor, or through other medical technology such as an app.
Why would we need it?
Healthcare at home has been referenced increasingly in recent years. COVID-19 may have driven some of the initial focus; however, there are now many more drivers fuelling the expansion. Systems, including in the UK in which a new 10-year plan for healthcare is expected in early 2025, and in the Middle East, for example in KSA with its Health Sector Transformation Program, are signalling a direction of travel with the ‘left shift’ of care from hospitals to communities to include home healthcare solutions.
Drivers for change include:
• Geography – in some places, the journey from home to hospital is substantial either in terms of physical distance; practical distance, in nations where road or other transport infrastructure is underdeveloped; or social distance, where the prospect of travelling out of community to, for example, a city centre health provision is unachievable for a multitude of reasons: from the impact of physical or other disabilities, cultural factors limiting freedom to travel, or economic factors making doing so unaffordable.
Where these factors are present, there is significant risk of communities being disadvantaged and failing to receive a good standard of healthcare. This in turn exacerbates existing inequalities, reduces quality of life and economic activity and may ultimately result in higher healthcare costs longer term if uncontrolled chronic conditions, such as diabetes, result in complications. In these circumstances, designing approaches which enable healthcare to be delivered at home by physical carers, or incorporating remote monitoring to help self-manage conditions and flag deteriorations at an earlier stage, can be beneficial to both healthcare systems and populations.
• Planetary health – linked to geographical distance are the CO2 emissions involved in travel to healthcare facilities. Limiting these, through providing alternatives to travel for patients and their caregivers, is beneficial as nations worldwide move to achieve net zero emissions (with healthcare systems such as the English NHS targeting ambitious timescales for doing so), and as we understand more about the circular health impacts of not limiting those emissions.
• Hospital capacity / disease transmission – shifting healthcare home releases capacity in acute hospital settings and reduces the risk of vulnerable patients acquiring further infections. Virtual wards are increasingly being used for a range of patient cohorts – from older people being enabled to get home earlier to emergency care being carried out at home to avoid admission, or to direct patients to the correct part of the system. Hospital staff also feel the benefit of being able to care more comprehensively for patients who really need to be physically with them while others remain at home and, through remote monitoring, obtain more information to be able to treat them better.
• Patient outcomes / agency – some patients will be better served receiving healthcare at home and achieve better outcomes, including cancer patients, possibly because home healthcare eliminates the added pressures of travelling to a hospital setting and allows them to stay closer to family and friends for support. Equally it reduces the risk of picking up added infections, especially for elderly people at higher risk.
With remote monitoring, people may feel more in control of their conditions and less anxious, knowing they can manage symptoms, monitor changes and that healthcare staff are also monitoring them more frequently. Monitoring becomes a way of life rather than attending anxiety-inducing regular appointments while medications can be refined more regularly. For another group of patients such as those awaiting surgical treatments or recovering from them, carrying out interventions such as pre-operative monitoring or physiotherapy in the home environment will be beneficial – they may even engage better with treatments such as physiotherapy at home and experience much better outcomes as a result.
Are there any downsides?
It is probably fair to say that there are limited downsides to moving healthcare to the home environment, providing that this happens in an appropriate way for an appropriate cohort of patients. To ensure home-based healthcare can be delivered appropriately, careful thought needs to be given not only to individual instances of care, but to the whole pathway. Likewise, sufficient resource is needed to ensure that care provided or enabled within the home setting is high quality.
We cannot, for example, expect primary care providers to simply take over care which was previously provided in hospitals –there is unlikely to be staff capacity to enable this. Likewise, social care needs to be funded and coordinated in tandem with healthcare for physical home services to be effective. Resource must also be directed to the developments necessary to deliver home monitoring type services, scaling those which exist already and ensuring that they integrate effectively with other healthcare systems and records.
Where technology is being integrated, existing inequalities (which home healthcare services may be targeting to reduce) should not be ignored or exacerbated; digital literacy may be low in some communities. Where patient-owned devices such as smart phones are involved, measures should be taken to ensure all have access to these. On the plus side, identifying these challenges offers an opportunity to tackle them through appropriate initiatives too.
Capacity and understanding are also needed to manage the risk of greater numbers of potentially sicker patients receiving care at home. This includes putting in place guardrails to identify when more traditional inpatient care may be safer, setting it in motion quickly. Patients and their caregivers must be provided with sufficient training and remote support. For patients at home receiving care from multiple professional caregivers and potentially around wider family members, the need for confidentiality and privacy must also be borne in mind.
Interestingly, a perverse benefit has been identified in some instances – where initiatives have been so successful in using at home monitoring to target groups who may not have previously engaged with healthcare services, overall demand has increased with earlier disease detection. Clearly, this is not a bad result, especially where early detection presents opportunities for preventative care to reduce longer term burden on systems. However there does need to be awareness of this potential, with measures in place to deal with any additional demand created.
Enabling the shift and maximising value with appropriate legal underpinning
There are already many excellent examples of healthcare being delivered in the home environment – so how do we ensure that these are maintained and maximise the value of them, to both healthcare systems and patients?
From the legal perspective, a few day-to-day challenges are flagged in the downsides section above – ensuring that the risk of patients deteriorating at home is appropriately managed while maintaining confidentiality and effective communication of personal health information outside of a healthcare setting. Managing these challenges effectively will maintain the integrity of these approaches.
On a broader level, the success, for both patients and systems of healthcare in the home environment, will be dictated by the way in which it is designed into pathways or forms the basis of them, rather than just being ‘bolted on’ to existing services under pressure. Used and scaled carefully, these approaches will relieve that pressure, practically and financially, and contribute to much improved patient outcomes. But they need upfront consideration and investment to do so.
To achieve maximum benefit and seamless working between stakeholders, we can design pathways using a value-based approach focussing clearly on and incentivising patient-centred outcomes rather than the inputs involved in operating them. Healthcare at home approaches involve collaboration between multiple stakeholders, each understanding their part in making them work and sharing the benefit of doing so, even if within traditional operating structures these may be felt by a different stakeholder party; for example, the acute care provider benefitting from patients being cared for in the community or by social care services.
Finances and budgets must flow and be shared to avoid siloed working and ensure everyone is incentivised towards the same patient-centred outcomes. Using a value-based contract, built collaboratively and incorporating mechanisms for risk-sharing and rewarding optimal outcomes, along with bundled payments instead of traditional fee-for-service models, will support this approach (while not pitching stakeholders against each other). Layered onto this approach is the need for effective monitoring of outcomes as reported by patients and analysis of this to inform constant
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