Medical care at home is emerging as a “disruptive innovation” on the US health care scene. New models of home care offer the promise of better service, higher quality, and a better experience at a lower cost compared with nursing home and hospital care. A tall order, indeed! Pioneers like Dr. Bruce Leff, however, have already shown quite convincingly that “hospital at home” programs can be implemented and can deliver on these promises for patients who are eligible for hospital admission. 1,2
In their essay “Bringing home the ‘medical home’ for older adults” in this issue of the Cleveland Clinic Journal of Medicine , Landers and colleagues discuss the opportunity of extending the medical home model to home health care as an integral part of the medical neighborhood to improve care coordination, reduce expensive hospitalizations, and improve the patient experience by caring for patients in their own homes. As a part of health care reform, the Center for Medicare and Medicaid Services intends to fund demonstration projects to determine to what extent home care can achieve these lofty goals.
A modernized, efficient, and effective home health care system would be a welcome improvement on the patchwork system we have had in the United States for the past 30 years. From my perspective as a family physician, this new legislation may provide the opportunity to get home health care right.
It did not start off on the right foot in the United States. Many home health agencies were established as independent, for-profit businesses detached from the primary care doctors who were ultimately responsible for patients’ care. Signing orders once a month on long forms that conveyed little useful information about my patients never seemed like adequate care oversight on my part. Communicating well with a dozen nurses I did not know or see on a regular basis was a daunting if not impossible task.
IT TAKES TWO TO PASS THE BATON
If home health care got off on the wrong foot in the United States in the 1970s, what then is the right foot?
To me, the key is a tight linkage of home health care to hospitals, physician offices, and nursing homes. Most elderly and frail people do not live out their lives in one venue. They move from home to hospital to nursing home and back again, often several times during their lives. These care transitions are fraught with the dangers of medication errors and forgotten test results. Home health care agencies can become experts in managing these dangerous care transitions.
Home health nurses and physicians can be experts at passing the baton without dropping it. Parenthetically, all physicians must become experts at passing the baton. It takes two to pass the baton successfully, whether it is from hospitalist to primary care physician, from home care nurse to primary care physician, or from primary care physician to hospitalist.
CHALLENGES: REIMBURSEMENT, COSTLY TECHNOLOGY, COMMUNICATION
What are the challenges Dr. Landers and his forward-thinking colleagues face in implementing modern medical care in the home?