Are Hospital at Home Programs Forgetting About the Patient?

Healthcare leaders are eager to move services out of the hospital and into the home, but many aren’t taking into account how they impact patients and caregivers.

Amid the move to patient-centered care, healthcare organizations are moving more services and programs out of the hospital and into the patient’s home. But are they really putting the patient at the center of that care platform?

Paurvi Bhatt isn’t so sure.

“Is the home ready?” asks the president and chief impact officer of the Rosalynn Carter Institute for Caregivers. “Most of us would say, ‘Gosh no, not at all.’  They want to take care of (a patient) at home, but the home isn’t ready. And it’s hard even when you’re not [talking about] acute care.”

[Also read: Understanding the Value of the Home as a Healthcare Site.]

Fueled by the promise of remote patient monitoring and the acute care at home (or Hospital at Home) strategy, healthcare leaders see the home as a better place than the hospital room for many patients to recover from treatment. Armed with studies that show that patients heal faster and better at home than in the hospital, they’re crafting programs that include everything from digital health and telehealth technology to in-person visits from nurses, doctors, and specially trained paramedics. Some of the more advanced acute care programs include multiple daily visits and technology designed to bring the ICU experience into the home.

But Bhatt says patients—and their family members are caregivers—aren’t prepared for that type of activity in their homes.

Paurvi Bhatt, president and chief impact officer, Rosalynn Carter Institute for Caregivers. Photo courtesy Rosalynn Carter Institute for Caregivers.

“As we know, when you enter anybody's household, no matter what part of the world you're from, you're in someone else's culture,” she says. “The way we organize taking care of each other changes household by household. It's not the same as hospital room by hospital room. There's standardization that needs to happen for clinical outcomes that need to somehow meet with the reality of what might happen at home.”

For example, care teams might not be familiar with cultural, religious, even family practices or habits, not to mention a patient’s own preferences on everything from sanitation to meals to the daily routine of favorite TV shows. Any disruption in those routines can have a negative effect on patient engagement and satisfaction.

[Also read: How Can Hospitals Turn the Home into a Healthcare Hub?]

And that can affect clinical outcomes. Patients who are disturbed by the commotion around them might not be so inclined to follow doctor’s orders, or they might rush through things just to get everyone out of the house. And already-stressed family members and caregivers might be even more stressed by the intrusion.

To be sure, the home is an intriguing care location, and any health system that doesn’t have a strategy that encompasses home-based care is behind the curve. Earlier this year, a survey of 1,000 U.S. adults and sponsored by digital health company Vivalink found that more than 80% had taken part in some sort of care at home program, 84% said they’d do it again, and 77% said they’d trust their doctor’s recommendation to take part in such a program.

The challenge, Bhatt says, is getting people to think outside the hospital.

Healthcare leadership needs to stop planning these programs solely from a clinical perspective, she says, and look at how the home, its occupants and even the neighborhood are impacted. They need to include patient and caregiver advocates in planning and bring patients and their caregivers into the conversation prior to going into the home.

“Now that the clinical outcomes are starting to demonstrate some value,” Bhatt says, “[let’s bring a] different set of people to the table now and say, ‘OK, now let's look at this.’”

This strategy goes hand-in-hand with identifying and addressing social determinants of health, a popular strategy throughout healthcare these days. A hospital may send someone to the home to assess SDOH, looking at whether the home has broadband and if there’s enough food in the refrigerator, but they too often focus on barriers and pay little attention to how the home—and home life--can shape healthcare delivery.

For example, how can the care team accommodate a patient’s wishes and work with family members and care providers to coordinate activities? How can a care plan be modified to better include family members and caregivers? And what can the hospital do to make sure this program doesn’t create more stress at home?

“Half of the reason why caregivers are unseen is because they believe it's part of their duty to their family,” says Bhatt, who is advocating for a federal Office of Caregiver Health. “We've got to pay attention to them, because if they're not right there and we're not aware of what phase of caregiving are they in, we're going to lose that connectivity.”

Those questions will need to be answered as home-based care programs, such as Hospital at Home, evolve. These strategies may not get much-needed support from payers and the federal government if they end up causing more distress in the home and fall out of favor with the people they’re designed to treat.

“I'm convinced it can work,” Bhatt says, “but I I'm worried about what might happen if we don't start to plan what the [problems] might be and think creatively about how we can [address them].”