Hospitals remain the centerpiece of the healthcare system, but the trend toward home-based care is clear in the baby boomer generation. Most boomers plan to retire where they are—85% of that generation in the U.S. prefer to age in their current homes, and 63% don’t plan to move, according to a study by the Demand Institute.
At-home care is also cheaper than similar care in a nursing home or hospital, and patients have been shown to heal better at home.
But while there’s demand for at-home services, such as bathing, dressing, and meal preparation, Medicare doesn’t cover them all and doesn’t pay for 24-hour home care at all.
Reimagining Care
Medicare, for instance, doesn’t cover home health aide services unless they fall under skilled nursing care or physical therapy, occupational therapy and speech-language pathology services. It also doesn’t cover long-term care stay in nursing homes—nursing home care is generally not covered by many health insurance plans.
But Scan Group Chief Medical Officer Romilla Batra pointed out that just because some home-delivered services aren’t reimbursed by Medicare doesn’t mean they aren’t an integral part of health management and disease prevention.
For instance, the Long Beach-based health plan, which is also referred to as SCAN or Senior Care Action Network,
is investigating how home care can be incorporated to create an optimum mental healthcare and medication management model for seniors.
“A nursing home is very expensive, and Medicare only keeps [seniors] in their homes,” Batra said. She also heads Scan’s free community-based service, Independence At Home. The program, launched last year, includes Insights, and is offered through Independence at Home, a community service. It connects seniors and disabled adults with licensed therapists who deliver in-home services, and medication safety program C-Meds, which provides support for seniors taking multiple medications.
Scan is one of the largest nonprofit Medicare plans in the country, with 186,617 members in Los Angeles and Orange counties, 75% in the former and 15% in the latter. It said the leading diseases and conditions affecting Scan seniors are vascular disease, diabetes with chronic complications, and mental illness, including depression and bipolar and paranoid disorders.
Batra said it’s difficult to quantify loneliness and isolation but that seniors with four or more health conditions are less likely to be socially active and more likely to suffer from mental illness. The group makes up about 20% of Scan members. Those with chronic complications are also likely to need multiple medications and to need help in filling prescriptions and understanding directions. Approximately 67% of people 65 and older take five or more medications, and as many as 80% of those make mistakes in taking medications and 60% stop medications before they should, according to peer-reviewed industry publication JAMA Internal Medicine.
Leading Conditions
“Home care is the new frontier,” said Sheldon Lewin, assistant department administrator of continuing care at Kaiser Permanente, “if that’s at all possible and feasible.”
Lewin oversees two medical centers, home health care, hospice, palliative care and long-term care in Orange County. He previously served as administrator for hospital medicine, palliative care and hyperbaric medicine and wound care at Aurora Healthcare, a 14-hopsital system in Wisconsin.
He said Kaiser has seen a local increase in the past few years in patients 65 years and older, including the very old, or those over 85, who can need more acute care. When it comes to planning a more integrated continuum of care, five areas require special attention: financial, caregiver support, transportation, nutrition and exercise, and socialization.
“We always evaluate our patients in those five domains, working with social workers to link patients early on with the right resources and in some cases plan a patient’s long-term view of care,” he said, adding that financial considerations are the most challenging. “People are living longer and longer, and sometimes patients are outliving their financial resources. The whole concept of affordable care, financing and planning is a very big part of [services provided by] our team.”
Kaiser is an integrated health system comprised of hospitals, a health plan and physicians. Its local presence includes locations in Irvine and Anaheim, and it’s prioritized certain health needs in both communities: obesity and diabetes, economic security, mental and behavioral health, cardiovascular disease, and access to care.
Community Partners
Approximately 13.5% of OC’s 2016 population was 65 and older, according to the Orange County Healthy Aging Initiative, a subcommittee of the nonprofit Orange County Aging Services Collaborative, which generates data on the senior population. The segment is projected to double by 2040, when almost one in four residents will be 65 or older.
Lewin said providers must think of care in a social model that extends beyond the scope of medicine, meaning bringing in community organizations to improve knowledge and capacity to provide nonmedical healthcare, such as social and emotional support.
Scan funds nonprofit organizations that help seniors in areas of nutrition, critical services and emergency assistance, having provided $190,000 to 13 organizations. Grant recipients include Community Action Partnership of Orange County.
Batra said the goal is to better serve the senior population while maintaining care quality and keeping costs down. “Therapists, volunteers—those caregivers are qualified and at a lower cost. Physician home visits wouldn’t make sense. It’s capacity, resources and cost,” she said.
Scan also offers volunteer opportunities that connect isolated seniors with the community—including GiveBackers, a team of 20 who are all 55 or older—and support for both the seniors and their caregivers. “Our Insight and C-Med programs are also available to caregivers. A lot of times, we neglect the caregivers—it could be the patient’s daughter or spouse—they need support, too. It can be very stressful and challenging caring for someone with a chronic condition who also suffers depression.”
Data Factor
The U.S. health system will face unseen challenges with a population that continues to age, needing more acute and long-term care.
“We are facing a phenomenon. We are seeing 90 years old, 100 years old,” Lewin said, “and we need to think about how to provide better geriatric, long-term care that is more affordable.”
Scan is in the process of compiling two-year data on its Independence at Home program’s effectiveness.
“Our goal is multifold,” Batra said. “We want to meet the unmet need of the problem but also to study [it] in an academically rigorous manner, to publish and disseminate those data to drive innovative approaches [to care], particularly those with very hard loneliness, depression and other chronic conditions.” N
