A revolution is sweeping the world of health care, fast-tracking the ability of older adults to receive medical care in their own homes rather than in hospitals and long-term care facilities. The advances can be a timesaver for family caregivers by reducing the number of trips they make to the doctor with a loved one. The advances can also dramatically improve the quality of life for the care recipient.
Even so, many patients are encountering hurdles along the way, from spotty Medicare coverage to limited access to home care outside of big cities.
Spurred on by the COVID-19 pandemic, medical providers are quickly expanding the telemedicine and at-home services they offer to better care for their patients. Some large medical groups have embraced futuristic technology to treat their patients from afar.
Imagine this: A doctor at a Washington, D.C., hospital orders an ultrasound for a patient’s leg and an echocardiogram for the patient’s heart. Both procedures will be done, but not at the hospital. Instead, they’ll happen at the patient’s home.
Or this: A Mayo Clinic doctor finds that a homebound patient urgently needs an antibiotic infusion. The doctor alerts a local pharmacist. Then a health team, aided by software, arranges for the drug and equipment to be delivered to the patient’s home, where a nurse gives the infusion. Time, from start to finish: less than 30 minutes.
Yet such advances are not available for many older adults on Medicare. In fact, only 10 percent of an estimated 2 million homebound Medicare recipients nationally have access to home-based practices, said Eric De Jonge, M.D., director of geriatrics at MedStar Washington Medical Center in Washington, D.C. Another challenge: Most of the hospitals and clinics leading the way are based in large metropolitan areas.
In response, the American Academy of Home Care Medicine has asked federal officials to provide enough money to cover the costs of care groups treating the sickest and most disabled older adults at home.
New providers are entering the home care marketplace, including Amazon and Best Buy. CVS Health is reaching out to older adults with home infusion services and an in-home dialysis project.
The Mayo Clinic already has affiliations nationwide. Now it has teamed up with Oakland, California–based Kaiser Permanente and Medically Home Group of Boston to accelerate its in-home medicine for older adults.
This collaboration can currently perform chest X-rays, abdominal X-rays, bone X-rays and ultrasounds at home, said Michael Maniaci, M.D., a physician leader for the Advanced Care at Home program at Mayo.
And technology is advancing fast.
Bone marrow transplant patients normally recuperate in a hospital for 14 to 21 days. Now they can recover at home, Maniaci said, “and one day, we hope to have bone marrow transplants and chemotherapy done in the home.”
But a looming shortage of workers could slow the growth of home care, cautioned Kristofer Smith, M.D., chief clinical officer at Prospero, a senior-focused care company based in Boston.
“The next five years, I think you’ll see an explosion of interest in this field,” Smith said. “The workforce will be an increasing bottleneck.”
Telemedicine came into its own during the early days of the COVID-19 pandemic. In March 2020, federal officials acted to make telehealth services more accessible for Medicare patients. A key step was the decision to have Medicare cover the costs of routine follow-up visits via telehealth.
Now telehealth has become a routine part of health care. During a telehealth session, patients can report their vital signs to their doctors using simple tools, including:
- Automatic blood pressure cuff for blood pressure and heart rate
- Touchless thermometer
- Pulse oximeter to take pulse and measure oxygen
- Learn to measure respiratory rate
Mobile health clinics
Mobile health clinics are growing increasingly popular as a source of general health screenings, mammograms and lung cancer screenings. While they typically don’t do house calls, they may offer a handy neighborhood spot to get tests or a physical exam.
Fully 2,000 mobile units are operating today, said Mollie Williams, a Harvard Medical School lecturer who oversees the Mobile Health Map, an online tool for locating such clinics nationally. She anticipates that number climbing to 3,000 in the next five years.
Williams is also executive director of The Family Van, a nonprofit mobile clinic affiliated with Harvard that serves underserved Boston neighborhoods. Two similar vans in Montgomery County, Maryland, operated by the nonprofit MobileMed, treat patients outside churches and a community center, said spokeswoman Michele Levy.
Clinics like these are represented by the Mobile Healthcare Association, a St. Louis-based nonprofit.
“What unites our membership is that our members are mission-driven,” said executive director Elizabeth Wallace. “They want to decrease disparities. That can mean going to a homeless camp or doing mammograms at a supermarket.”
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11 Questions to Ask Your Doctor
If you or your loved one is new to home care, don’t hesitate to ask your doctor or other care providers what to expect. Here are 11 questions, suggested by physicians and other experts.
- Who is in charge of my home care?
- Who will be coming to my home?
- How much time will they spend here?
- How often will they come back?
- What training have they received?
- How much will this cost, and who will pay?
- What training do my family and I need?
- What equipment will I need?
- Can I trust small-sized portable equipment?
- What if the power goes out?
- What have other patients experienced?
Most dentists stay rooted in their offices. But some do house calls, including Charles Doring, a dentist in Rockville, Maryland, who travels equipped with a portable cabinet on wheels carrying a portable X-ray machine, a compressor, a suction device and his head lamp.
Mobile dental units have been springing up nationally, many geared for older adults, including some that service assisted living facilities and nursing homes. But they typically don’t visit private homes.
California dental professor Paul Glassman came up with a different approach, called the Virtual Dental Home.
It uses telehealth to link dentists in their offices with dental hygienists who can visit patients at home, said Glassman, associate dean for research and community engagement at the College of Dental Medicine at California Northstate University in Elk Grove.
Laws governing the role of hygienists vary from state to state, but in some states, including California, they can obtain special licenses allowing them to treat homebound patients with interim fillings.
Medicare doesn't cover most dental care and procedures, including cleanings, fillings, extractions and dentures. Some of the Medicare Advantage plans do include treatments, so do a careful review to see if dental care is covered in your plan.
Miriam Godwin is director of health policy for the National Kidney Foundation, based in New York City. Most U.S. residents with irreversible kidney disease must travel to a dialysis center for treatment, she wrote in an email.
“The U.S. has much lower rates of home dialysis — approximately 15 percent — than other developed nations, where home dialysis utilization can approach 80 percent,” Godwin said. But in hopes of turning things around, the previous administration set a goal of 80 percent of patients using home dialysis by 2025, she said.
The two main kinds of dialysis are peritoneal dialysis and home hemodialysis. The prescriptions — how much dialysis someone gets on what schedule — can be customized to fit a patient’s schedule and preferences.
Who benefits most? “Really anyone who doesn’t want to prioritize traveling back and forth to a center three times a week,” Godwin said. That can include people with families, those who care for family members, and those who work, she said, as well as students and frequent travelers.
Patients have been especially vulnerable to COVID-19, due to their underlying health conditions and because most of them had to rely on dialysis centers, where social distancing was difficult, Godwin said.
Medicare pays for most dialysis costs, but it does not cover the costs of staff to assist dialysis patients in their homes. Securing that reimbursement is a key goal of the National Kidney Foundation, Godwin said.
Nathan Cron is president of a nonprofit company that collects samples of blood, stool, urine and sputum. His company, the National Phlebotomy Provider Network, based in Las Vegas, links patients to technicians who visit the patients at home to collect the specimens for testing by separate laboratories.
“Since the beginning of the pandemic, interest in and utilization of our in-home specimen collection services has increased significantly,” Cron wrote in an email.
His firm’s customers include Kaiser Permanente, residential care facilities, and thousands of individual patients.
Other key advances in at-home care
X-rays: Portable X-ray machines have grown in popularity and quality in recent years, allowing patients to stay at home rather than wait in a busy emergency room. Medicare will pay for portable X-rays if certain conditions are met.
Intravenous treatment: This may be needed when a patient arrives home from the hospital after receiving high-level doses of antibiotics, anti-nausea medication or extra fluids. A nurse may come to the home to administer the medicine. Or a caregiver, friend or even the patient can learn to operate the IV equipment. Medicare will pay for home infusion equipment, supplies, nurses’ visits, caregiver training and monitoring.
Chronic care management: Medicare pays clinicians for care management services provided to patients who have two or more serious chronic conditions — say, arthritis and diabetes — that are expected to last at least 12 months and whose care is expected to last that long. These services are classified as physician services under the Medicare fee-for-service program, so the patient is responsible for 20 percent of the cost (unless that patient purchases supplemental insurance to help cover the shortfall).
A doctor typically manages the patient’s care, listing the patient’s health problems and goals and developing a comprehensive care plan. The doctor can coordinate with a home health agency that sends caregivers to the home.
“There is great benefit to ensuring that the primary care physician, home health agency and other providers are all aware of the changes occurring in the patients’ health status, such as medication changes, recent falls, recent emergency room visits or ongoing treatment for a chronic condition,” said Zach Gaumer, a Medicare policy expert based in Washington, D.C.
Help for those with chronic conditions is available from the National Association of Chronic Disease Directors in Decatur, Georgia, whose website offers guidance for such things as measuring your own blood pressure and talking with your doctor about a cancer diagnosis.
Note: Double-check with your health care provider to assure that the treatments listed here are covered by your Medicare plan. The American Academy of Home Care Medicine maintains an online guide of home care medicine practices and providers in every state.
Deborah Schoch is a contributing writer who covers health and science. A longtime journalist, she has most recently done work for AARP, The New York Times and KNBC-TV Los Angeles.