High-Level Care-at-Home Coordination Offers Patient and Health System Advantages

By Megan Headley

While the COVID-19 pandemic may have forced health systems into providing care at home through virtual care solutions, ample evidence suggests that consumers don’t want to see the care-at-home trend end. If anything, digital natives are being joined by aging baby boomers who want to see a broader range of healthcare happening in their homes.

“This is not just for seniors anymore, or patients with medically complex or socially determined needs,” says Ashish V. Shah, CEO of Dina, a digital health company focused on bringing a care-at-home platform and network to market. “COVID showed us that there are many people who would prefer to access home-based services, everything from blood draws for your annual physical all the way down to chronic condition management and using the home as the new hospital-based care setting.”

The shift toward care at home has already overcome some of its biggest obstacles. An explosion of remote monitoring solutions, wearable technology, and virtual care connections make it easier than ever for individuals to bring certain elements of care home. Funding, too, may be more easily accessible in the future, thanks to the Choose Home Care Act of 2021 that was introduced in October 2021 to support in-home care alternatives to skilled nursing facilities. If enacted, the bill would enable some Medicare patients to receive covered extended care services for 30 days following a hospital stay as an add-on to the existing Medicare home health benefit.

However, this shift toward providing more acute care services at home still requires health systems and care providers to holistically assemble the wide-ranging assets needed to support such care. “You need durable medical equipment, in-home nursing care, med transport, nutrition, etc.,” Shah explains.

Dina was designed to coordinate the transitional care experience and manage logistics around the shift to acute care at home. Shah describes the service as akin to “traffic control” for healthcare. “Just like you have people monitoring the care and health of people in hospital beds inside of hospitals, that’s now happening in the home and community. It’s a paradigm shift and needs new tools and new resources to make it happen,” he says.

For Dina, this began with a focus on coordination across vendors and partners, including skilled nursing facilities, rehabilitation centers, and home health agencies. The platform aims to create a digital network that organizes all of the partners in the home care and community ecosystem. Within this network is information about the programs each partner offers and the insurance each one accepts. It also provides dashboards that automatically track resource availability, such as number of open beds at a given facility.

“That is a big challenge today, especially with the staffing crisis,” Shah points out. “And we saw this really exacerbated during COVID. You couldn’t find which facilities had available beds or the resources to take care of [patients]. You had the same challenge with home care agencies, where so many of their nurses were out with COVID or other issues that you couldn’t find out who had staff available to see a patient within 24 to 48 hours, one of the riskiest periods of time when somebody returns from the hospital to home.”

While the insight available through platforms like Dina is invaluable for care providers, this digital high-level coordination also points to a vision of how future care networks might look. Shah defines this as the “postacute 2.0 experience.” As he explains it, the broader availability of healthcare at home, increasingly being covered by Medicaid and Medicare Advantage plans, is pushing demand for more types of nonmedical home care and the assets to support them.

However, in the course of the platform’s evolution, Shah and his team have begun thinking about care coordination even more broadly. The need to unite multiple vendors to support care at home may present an opportunity to bring in additional partners, including community-based organizations, family support services, and other organizations that can provide care grounded in addressing social determinants of health.

Through Dina, Shah explains, providers are able to collect data from the home care continuum and community-based organizations, then use that data to reveal needs around social determinants of health. In addressing transportation and nutrition, for example, investigations uncover whether the patient lives alone at home, is having trouble with activities of daily living, or has any health or safety concerns in the home or community.

“We’re finding that data is incredibly important moving forward as Medicare has rolled out a brand-new strategy around promoting health equity and addressing social determinants of health. I think our model is unlocking data that’s never really been online before to complete that picture,” Shah says.

Health systems on the fence about making an investment in care at home should note that this strategy not only has the potential to provide better care for patients, but may also offer advantages for forward-thinking health systems.

“We’re finding a few overarching trends around this service,” Shah says. “One is patient choice. If you don’t offer this, your neighboring health system most likely will. Second, many hospitals are overwhelmed and understaffed. They’re losing revenue by not having an available bed. If you can redirect some of that traffic into the home safely, it allows systems to grow, even in the difficult financial environment right now. Third, as we move along the journey on value-based care, trying to reduce the total cost of care per person in your ACO or other value-based care arrangement is also aligned with shifting care into the home, if you can do it safe and reliably.”

Care at home is an ideal direction to head in, but creating a care-at-home ecosystem won’t happen overnight. Shah advises creating a multiyear plan for offering more care at home. He suggests setting goals toward three key steps:

1. Start organizing your postacute care network. Establishing a postacute care network with preferred providers can help health systems control their costs and maintain a consistent quality of care for post-discharge patients.
2. Integrate your postacute care network into virtual care investments in telehealth and remote patient monitoring. Seamless care with your preferred providers will depend upon the ability to access data at every transition of care and simplify communication across partners.
3. Bring your data and network connections together to unlock new services, such as hospital at home.

“I would advise providers to not be overwhelmed,” Shah says. “They don’t have to do a complete overhaul overnight. A gradual, multistep plan over the next 18 to 24 months is just fine.”

Megan Headley is a freelance writer and owner of ClearStory Publications. She can be reached at megan@clearstorypublications.com.