Healthcare at home is not accessible to all
Home care has been touted as the panacea in healthcare, with a proven track record of reducing costs, improving outcomes, and enhancing the patient experience. From telemedicine to virtual care to same-day delivery, the pandemic has teleported our ability to provide care at home. What has been lost in this development is a serious discussion of the basic services required to effectively deliver this type of care at the individual level.
Like many of my colleagues, I’ve been volunteering at the hospital across from my home during the pandemic. During the first week I was assigned a “resident” to look after – not a medical worker, but a patient. It turned out that this patient was homeless and had no formal home to discharge from, so politics dictated that she had to remain in the hospital. She had previously been able to find a temporary home but found herself back in the emergency room weeks later.
For many, the hospital serves as a standard place of residence, raising an important question about how we define “home”. One’s home can be a crowded apartment, a rural setting, an RV, a long-term care facility, a shelter, or worse, the street.
There are half a million Americans who are chronically homeless, but equally worrying are the millions who are underserved.
What does it mean to be underprivileged? Internet access, electricity, care support, transportation, digital literacy and safety (nutritional and physical) are just a few of the benefits that home care makes possible. But too many people live without these resources. Before the pandemic, 57% of those enrolled in Medicaid lived in poor or inadequate housing. In the US population, 6% of people currently do not have broadband internet. Of the over 60s, 27% live alone and many may have difficulty navigating medication.
There is a wide spectrum of accommodations, which means we have the opportunity to redefine and reimburse a new era of non-clinical services that impact health and access to care. Many home healthcare facilities could be categorized as hardware or software technology – we have physical human resources (household, caregivers, transportation) and the “operating system” or software services (internet, power, water, remote monitoring). But these non-traditional medical assets aren’t generally covered by insurance in the same way as medical items like diabetic pumps and oxygen.
Earlier this month, North Carolina Medicaid launched an effort to fund non-medical interventions like food and transportation. It’s about time other states and insurance companies took a similar approach.
In fairness, this movement requires a debate about the integration of upstream policies and resources (housing, labour) while at the same time building a body of evidence for measuring the returns on these investments. It also requires a reality check: this will not solve our broader healthcare challenges. Heading into the pandemic, 28 million Americans were without health insurance; Inherited systemic flaws (uninsured, inequality, mental illness) impede the success of caregiving in any setting; and to some extent a combination of home and residential care will always be required. But improved access to home care has the potential to fill gaps in healthcare – and it’s crucial we don’t leave those under-resourced behind.
When healthcare innovations disregard socioeconomics, their success is often weakened and weakened. For many patients, the new online world is alien or unreachable; In contrast, there are those who fluently traverse the metaverse. To put it bluntly, those who are elderly, underserved, or suffering from multiple chronic conditions still need some level of human support at home.
The good news is that the private and public sectors are working to keep up. The White House has presented a sweeping response to address mental health access and funding, and just this week Congress passed regulations to continue telemedicine. Many states have initiated value-based systems of care that incorporate the social determinants of health (SDoH). On the labor side, there is a resolution in New York to pay a minimum wage for home care workers, which can help address the 20% of this workforce pool that lives on the federal poverty line. Several foundations and companies provide free cell phones or tablets to those in need. Many technology companies have now positioned themselves vertically in the healthcare sector and are focused on making home care more efficient.
Not all homes are created equal — and it’s important to ensure the assets in each home extend beyond clinical care. Our $4 trillion system, fraught with massive limitations and challenges, is ready for new models and locations. Ultimately, the right patient, receiving the right balance of clinical and non-clinical care, will enable home care to reach its full and necessary potential.
Meghan FitzGerald, DrPH, MPH, RN, is an adjunct professor at Columbia University Mailman School of Public Health and a private equity investor. She has decades of experience ranging from frontline patient care to executive positions at Merck, Pfizer and Cardinal Health.