Matt Lambert, M.D., Chief Medical Officer, Curation Health
The concept of a clinician coming into your home to provide personalized care brings back a sense of nostalgia. For some, it may even bring to mind a famous image by the painter, Norman Rockwell. These days, that nostalgia has turned into a necessity.
While much hope and hype has surrounded the increased adoption of virtual care during the pandemic, the move to at-home care has been put on the back burner a bit. Still, as the pandemic poses an ongoing threat, at-home care clearly makes the most sense for certain populations of patients – including the more than 40 million seniors here in the U.S.
As population health initiatives have driven healthcare providers, hospitals and payers to look closer at the individual needs of certain populations, home care has surfaced as a viable program for more personalized care and improved outcomes. The compartmentalized care from the hospitalist model often left gaps in care and follow-up, and the shifting landscape of digital health has taught us a lot about what we can do better and where we can do it.
What’s needed both in the home and in the clinic is wrap-around services in a clinical care model; a care team approach that includes pharmacy, social workers and community care—specifically to manage complex populations, which are often the ones homebound and who would benefit the most.
Providing care in the home gives clinicians a 360 degree view of both the medical and social barriers to care. Things like housing security, food security, transportation, also known as social determinants of health, profoundly impact quality of life and health outcomes.
So, we know it’s good for the patient.
The question is, how does at-home care make sense for clinicians?
Considering soaring rates of burnout for clinicians and current struggles with administrative burdens, can they adopt a new model of care that adds travel and time to patient visits? The simple answer is no – clinicians can’t provide this type of home-based care in our current antiquated fee-for-service world.
Home-based care really only works in a value-based care model, where risk is shared between providers and payers. Luckily, more and more providers and payers are prioritizing this transition which will make home-based care a stronger reality for more seniors in the years to come.
One of the key questions to consider as providers and payers look to reduce clinician burden with emerging models of at-home care is what role can and should technology play. When it comes to tech-enabled home care, the following areas are where clinicians can benefit most from support:
- Using Predictive Analytics to Understand Patient Risk – It’s no secret that we are already facing a serious clinician shortage. It’s expected that this shortage will also be exacerbated by the pandemic. With that in mind, it’s critical that a clinician’s time is utilized where it is needed most. Predictive analytics technology can help assess which patients are at the highest risk for adverse outcomes. By segmenting the most at-risk patients, care teams can decide which member of the team is best fit to serve that patients’ needs – freeing up clinicians to care for the most at-risk patients first and foremost.
- Delivering Critical Patient Insights at the Point of Care – The problem with gathering continuous patient data is the inability to search through it and actually make sense of it. Technology can help manage this problem for the clinician. Adding a layer of clinical decision support technology can effectively reduce the time spent sorting through volumes of patient information (time stamps, etc.), and also reduce potential errors that may result from clinicians not having the most important patient insights at the point of care. This type of technology can also support clinicians and care teams in ensuring they are capturing the full value of patient care inline with their risk-based contracts.
As part of a patient care team that is effectively leveraging technology, a clinician entering a person’s home is no more on an “island” than one in a hospital or an office environment. With that in mind, providers and payers need to re-think what tools and support structures are needed to make home-based care work for clinicians – as well as the patients they serve.
To read more from Dr. Lambert, visit our blog.
