Eyles:
Hi everyone, and welcome to the Next Big Thing in Health, a podcast from AHIP. I'm one of your hosts Matt Eyles.
Evans:
And I'm Laura Evans.
Eyles:
Health care for our aging population is critical. It needs to be accessible, affordable, and reliable. But too often patients who are homebound or who have complex medical needs are unable to access the care they need. Currently, there are 7 million homebound or home-limited people living in the United States who would benefit from home-based primary care. But of the 7 million, nearly 85% are not able to access it for a variety of reasons despite being qualified to receive care.
Evans:
So today we're joined by Dr. Paul Chiang and Julie Sacks from the Home Centered Care Institute or HCCI. Dr. Paul Chiang is the medical director at Northwestern Medicine Home Care Physicians in suburban Chicago. He also serves as HCCI's senior medical and practice advisor. Julie Sacks is HCCI's is president and chief operating officer. And we're going to talk with Paul and Julie today about everything from the variety of services provided by home care to technology and also how new approaches are helping home-based primary care patients feel a little less isolated and better cared for. So Paul and Julie, welcome and thank you so much for being with us today.
Chiang:
Thanks for having us today.
Eyles:
Let's begin today's episode with discussing the growing importance of home-based primary care for the homebound and home-limited. Your organization, the Home Centered Care Institute works to establish best practice house call programs so that this kind of care, home-based primary care becomes the standard for treating medically complex patients who can benefit from it. Can you maybe share a little perspective about why this is so important?
Chiang:
Matt, I'll answer the question in a couple of different levels here. Maybe I'll start by framing the challenge that's before us. You mentioned 7 million people that are homebound or home-limited. Okay. And I was in Texas recently doing a conference for HCCI. Now imagine the metro area of say Houston or Dallas Fort Worth, each roughly 7 million people. Now imagine only 15% of those people have access to ongoing primary care. That leaves about what 6 million people without access to care. And in the age where we talk so much emphasis on equity and access, I don't think any of us would say that's okay. Six million people in those metro areas, no care. I don't think that's acceptable. And that's one of the challenges that's facing us regarding this subgroup of patients and that number is only going to increase.
Chiang:
On the second level is on a quality and cost of care level. Now these patients that we care for at home, they're not the healthy patient that see doctors maybe once a year, once every couple of years, these patients are some of the sickest patients we take care of in this country. A study that we published two years ago, the demographics that we learned from the study, the average age of our patients, 82. Average number of medical conditions, 13. Average number of medications our patients take, 17. Want to pause there, think about 17 pills, keeping track of them monitoring for side effects. What about paying for them? And you wonder why some of our patients don't take their pills? Is it groceries or food or medications? Right? These are very complex patients, high need high utilizers of high cost centers such as the emergency room or hospital.
Chiang:
And the next level I will say will be the professional level. The care that we deliver at home is truly unique. I will say it's unequal anywhere in the field of medicine. I have the opportunity to come to your home, I get a chance to take care of you at home. Not only do I do medical care plan, do a typical assessment and plan that doctors do. I have the chance to see where you live. I do what they talk about in real estate, the walkthrough. I check your kitchen, your bathroom, fall risk assessment. I look through all your pills where they might be hidden in bags or boxes and so on. I get to do what we call the refrigerator biopsy. I open your fridge with your permission and see what's inside. Sometimes it's empty, some times is full of soil products. Or what's on your kitchen counter that might not be beneficial to your diabetes, for example. I get to see things that we talk about in social determinants of health that are so important, that no CAT scan or no MRI, no ultrasound will ever be able to show. And yet they are so meaningful, if not more so than what a CAT scan can show, such as food scarcity or insecurity.
Chiang:
And a final comment, I'll make is this, is very much on a personal level. A lot of our caregivers take care of these complex, sick patients at home. Now imagine if you are taking care of your loved one, and you call your doctor's office and say, you know, mom is not feeling well, needs to be seen, or mom's running out of medication, needs a refill. Right. But the doctors say you have to bring mom in. But Mom is debilitated, homebound, wheelchair-bound, on oxygen and so on, and it is really difficult to get mom in. You may have to take days off of work, arrange for transportation, fight through the bitter cold here in Chicago, right, fight through snow when for a 10- or 15-minute visit. Imagine the distress that might be going to you as you tried to do your best to take care of your complex mother and her conditions. So those are some of the reasons I think the care for the homebound is so important for society. Julie, anything else you would like to add?
Sacks:
You did a great job. I don't really have anything to add to that one.
Evans:
Well, Julie, let me ask you, because I'm Dr. Chiang, you make such a great case for this need. It's just massive in this country. And I know HCCI is really working to make home based primary care, a national standard. So Julie, maybe you can address how you're trying to do that how you're trying to make this a national standard?
Sacks:
Absolutely. We started about eight years ago, is when we were founded. And at that time, there were really not that many house call programs, there were a number of partners that we worked with or academic medical centers across the country that had done this for education and training purposes, they'd had home-based primary care programs for many years. And there were some kind of spread out here and there. And what we found was that each time somebody was starting a practice, they were sort of reinventing the wheel, they were trying to figure out how to do it most efficiently and how to do it with the best health outcomes. And what we realized was that there's a number of experts in this across the country, including Dr. Chiang, including our founder, Dr. Tom Cornwell, and others who had been doing this, even though it didn't make financial sense, really, up until recently. And we pooled their knowledge. And that is what became our curriculum.
Sacks:
And we not only educate, Paul just mentioned how complex these patients are, we educate on the clinical how to take care of such complex patients. And we also educate on the practice operation side, because you do have to be efficient, it obviously is more costly to drive to these patients homes, you can't see as many patients a day. So how do you do that in a way that makes sense financially. And so we teach all of that. And our goal is to grow not only the current workforce, so current providers that are doing this, and maybe can do it more. Maybe office-based practices that are interested in adding this home-based primary care to their services to take care of some of those homebound patients that they're not seeing. And also reaching out to the future workforce. So those who are in the pipeline, those who are in medical school, or nurse practitioner school, we also work with physician assistants who do this work. And in fact, nurse practitioners and physician assistants are the fastest growing professional group doing this work. It really fits with sort of their holistic training. And so we work with those professional associations, those professionals and the students that are coming up through those programs.
Eyles:
That's a tremendous shift. And it's really important, I think, to keep that in mind as we figure out ways to help expand the way that you're able to provide more care in the home. Paul, maybe you could share your perspective on just the patient experience and how different it is for those individuals who are able to get home-based primary care, what does it mean to them and how has it helped bridge some of these gaps, especially those with respect to equity that you've highlighted or those who are are most vulnerable in our society?
Chiang:
Yeah, well, when we teach residents and learners that come through our practice here, one of the comments that often I hear from these learners is that it is such a personal experience. Like I said before, when I come to your home, I'm a guest to your home, I'm on your turf, you are not in the office, not in the ER, or the hospital, or the traditional arena of house calls of medical care, if you will. So it's a very personal experience that I have, and our patients have as well.
Chiang:
Going back remember, without home-based primary care, these patients have really no access. What are their options when they get sick, is the emergency room or the hospital. Now the ER and the hospitals, they do great things, but they are not set up to provide longitudinal care to the sick and complex patients. We know they're broken parts in our health care system, and the ER and the hospital, they are the wrong solutions to the problems that we face. So again, I just want to emphasize that without home-based primary care, these patients really have very little options especially in the age of equity and access.
Chiang:
One other comment I'll make is this, we do use telemedicine to help facilitate visits as well. But technology sometimes can be challenging for our seniors, whether it's the interface with the device, or the internet connection they may or may not have. So we do use technology as an aid. But sometimes there's really nothing like a face-to-face visit with our patient that really allows us to do a better assessment and plan for them.
Evans:
I'm curious, though, with this, going back to the pandemic, which really exposed this gap in the country, and the need to strengthen home care, which the COVID pandemic really hit seniors harder than any other group. We also saw from the pandemic, the impact of the isolation on so many people. So with regard to seniors, I'm curious, and, Julie, let me direct this to you. And Dr. Chiang, please weigh in. How do you make sure that these people are as protected as possible, but also with the care that they need, but then also are not feeling isolated?
Sacks:
It ties into what Paul just said about the relationship, how special home-based primary care is. We see a really significant relationship that gets built when you are a guest in someone's home. And when these patients who may have been forgoing primary care altogether, are suddenly cared for, they have somebody to call in emergencies. They may or may not have family. And so that relationship with their primary care provider and the primary care provider's practice then they have somebody to call when they have a question and they have a need, really helps address that isolation, that sense of isolation. They feel like they have a person in their corner.
Sacks:
And one thing that's interesting about the pandemic, you're absolutely right, it made the professional community, the medical community, as well as the general public more aware of how important it is to keep very complex patients, immunocompromised patients, out of situations like an emergency room or a hospital, which is really the worst place for them to be. We saw a number of the practices that we work with actually got started during COVID. There were we know of a couple of nurse practitioners. One in particular, a nurse practitioner, her grandmother couldn't get a shot and couldn't get an injection. Her neighbors, her friends from church couldn't get the vaccine. And so this nurse practitioner, said why, you know, I can do that. And she started going around to people's homes, and she now has a home based-primary care practice. And so it really flagged for people that need and that lack of access, and we're seeing it continue to have an impact on you know, bringing new people into the field.
Chiang:
Laura, if I could just add a few comments to Julie's comments. Early on in the pandemic. I can't imagine it's been three years now right. In terms of staying connected with our patients, we did use telemedicine as many practices did, but we also went into the homes fully dressed and protected in our PPE. Again staying connected with our patients, making sure that their needs are being addressed that we are a lifeline to them, we are here for them to take care of their needs, regardless of what's going on with the pandemic and in the world, that we are a reliable source of medical information and advice for them to get them through their chronic illness and also overcome some of the loneliness that they may be facing, as well as trying to understand all of the recommendations that were coming early in the pandemic, from the government and the CDC and so forth. We are that connection, we are there to help our patients and Julie's absolutely right. It's very much a personal relationship that we have with our patients.
Eyles:
How do you think about the issues with respect to the workforce, and we know just what a challenge we've had with respect to provider burnout. And I'm sure there's no segment of our health care system that's immune to that. But at the same time, it was nice to hear you mention those who are in training now, we only have an older population that's getting older and sicker, where the demand for these services are going to be greater than ever. How are you thinking about ways that we can solve some of these workforce shortage issues.
Sacks:
And then you mentioned this student population, you know, very few students have historically been really even exposed to home-based primary care. And what we hear from the students who do from the people that are new into the field who do choose this, it turns out that they had an opportunity to go on a house call during their training, hearing about it as one thing, experiencing it and seeing the impact it makes on patients is another. And it really can make a difference in somebody's career choice. And so we are currently adapting our curriculum that was originally designed for current providers, for students.
Sacks:
One of the big ways that HCCI is trying to address this is we've seen a lot of interest from hospice and palliative care organizations that are interested in adding home-based primary care. And so we help them either establish or grow that service line. And then they're able to help patients further upstream. And there really is an opportunity for cross training, in my view, that you could have a hospice and palliative care worker who's interested in or willing to take on more responsibility for that patient, and maybe transition into home-based primary care and vice versa. You might have a home-based primary care nurse practitioner or physician who would like to be a little bit more on the palliative care consultative side. So we talk a lot about how to best integrate those two disciplines, and how to cross train.
Evans:
Okay, Dr. Chiang, let me ask you, you addressed some of the barriers to health care for the homebound I'm curious if your house calls can actually fully break those barriers, and especially when it comes to technology, how are you really integrating technology into home care like X-rays and EKG tests? How are you putting all that together?
Chiang:
Yeah, absolutely. One of the ways we overcome the barrier of technology is that we are in your home, we step through the front doors, and we sit in your kitchen and your living room, your dining room or at the bedside.
Evans:
You can bring in all the technology that anybody can get in the health care space.
Chiang:
And so we bring our presence. I talk to my learners about don't ever underestimate the power of your presence in the patient's home. It means so much to them. And as I said before, we do use technology. We do use telehealth platforms for those in-between check-ins where patients may have a concern or may have a question about say a rash or wound or how grandma's legs might be looking. So we do use technology to augment our care to our patients. The question that you raised regarding what do we bring to the home we have the technology that allows us now to do X-rays at home, to do ultrasound at home, to do blood testing at home. There's point-of-care ultrasound equipment available to clinicians. Literally it's a probe that fits in the palm of my hand that hooks up to my smartphone and I can do a scan of the heart or the abdomen and so forth. So there are technology options that are available to us that perhaps 2030 years ago were not available that allows us to do more and provide better care to these complex patients.
Eyles:
And I know that the homebound patients are, as you mentioned, Dr. Chiang, some of the most complex, medically vulnerable populations that we have, and are in need of significant support, whether it be from home-based primary care or in the immediate term, you know, family caregivers. How do you involve caregivers and families in the plans that you work on?
Chiang:
Yeah, I've said it often, the heroes, from my perspective heroes in the care of these complex patients are their caregivers. They do this day in day out, 24/7 365. Because our patients are so sick and complex, they often need somebody to help take care of them. It's what I call a dyad relationship. I need to take care of my patients, of course, but I also must take the time to address the caregiver of the patients and make sure that the caregivers or the family members' questions or concerns are addressed as well.
Chiang:
I will just share two stories. Hopefully that will drive home the point. Not too long ago, I was visiting this patient who was cared for by her daughter. We went through a series of events and the patient wasn't doing well. We made changes with medication, did diagnostic testing, and so on, and the patient's condition continued to deteriorate. And urgently, one afternoon the patient called and said, you know, Dr. Chiang, can you please come and visit? Mom's not doing well. So my medical assistant and I arrived at the back porch. We opened the sliding door. And no words were said. The daughter just came and simply embraced me. And she said, I don't know what I would do without you.
Chiang:
A couple of weeks ago, I was visiting this gentleman who's taking care of his dear wife. They're both in their 80s No children, high school sweethearts. She's now bedridden. She has dementia. She doesn't recognize who he is their relationship, yet he is so devoted to her. He takes exquisite care of her. We talk about how they met, I see the box of love letters that he wrote to her when he was waiting in the ward that she had kept. And at the end of the visit, and I often do it, I close the laptop. And I look at the caregiver and I said, How are you doing? Often that's the point when the lip starts to quiver and the tears starts to flow. And the husband said you know what, nobody, all the years, nobody ever asked how I was doing. And nobody ever took the time to go through each problem, each medication like you did. These patients, caregivers, we need to love them, we need to support them, because we depend on them to help us deliver the care to these chronically sick patients.
Evans:
There are a lot of patients who don't even know that they're eligible for these for these benefits. They're Medicaid, Medicare beneficiaries, enrollees in HMOs, managed care plans. How do you get the word out that they are eligible? How are you raising awareness on this and to reduce health care disparities?
Sacks:
There are a couple of ways, Laura. The the health plans and the ACLs or any organization that is doing value-based care has begun to understand the value of taking care of these complex patients in this way. That it not only provides better care, but it also provides that better care at a lower cost. And so from a health plan perspective, if you're offering home-based primary care, sometimes what we do is we help them identify which patients, which of their members could most benefit, because this is not for everybody. You want to sort of reserve the services for the types of patients Paul's talking about those with the greatest need that otherwise you can't get care.
Sacks:
The other way that we're able to to help get the word out is we have a new data analytics platform called Confer Analytics that is brand new, and just going into the market. And it looks at home-based care services, the supply of those services, and the demand all over the country, down to the zip code level. So what I mean by that is we can look at this data platform that we now have. And we can say, how many people are over the age of 65, or over the age of 85? With three chronic conditions, and where is the most need? We can look at demographics, we look at the claims, it's basically based on Medicare claims data. And we have 100% of Medicare, Medicaid, and Medicare Advantage data. And then we merge that with some other both public and proprietary sources. And we're able to figure out, if practice a wants to expand to a new geography, where's the greatest need for this? And so we can help it plan expansion. And then let's say they want to do marketing. So we know how many people are in any given area, and we say, Okay, why don't you target your marketing here, to make this group aware of your services.
Sacks:
There's also a fairly new home-based primary care directory. So the professional organization in our space is the American Academy of Home Care Medicine. And they have what they call a practice directory on their website, and where you can go and look up who is doing this in your area. So whether people want to reach out to its AAHCM, or to HCCI, either of us can help find a provider.
Eyles:
That's great. I definitely got to look into that because I know different family members, friends, others who really could benefit but haven't really thought about this service. So thank you for sharing that important information. Why don't we go to our last and final question that we always enjoy asking all of our guests? And maybe, Julie, I'll start with you. So what do you think, is the next big thing in health?
Sacks:
I see two things. One is what I just talked about, I think we all know, and see on a daily basis, just how important data is improving outcomes and impact. And we know that this has a positive outcome on health. And we know it decreases cost. And so I do think that being able to have the kind of data platform that we have that not only looks at home-based primary care, but looks at the whole home care ecosystem. So we're able to look at who is performing well in any given area in assisted living, in home health, in hospice and palliative care. And when our clients are able to look at that data, they're able to select partners to help them manage care better. They're able to in some cases, they're able to identify really strong providers that they might want to recruit. And so there's a lot of different sorts of use cases for this data that we have. And we're the only organization that focuses specifically on that home care market. So I think that's kind of the next big thing.
Sacks:
The other thing that we do I sort of alluded to, when I was talking about integrating home-based palliative and home-based primary care, I think we're going to continue to see greater partnerships, the new payment models really require it, that in order to take care of this complex a patient, you need a whole team. And whether that team is internal to your practice, or you create partnerships with behavioral health, or home health, there really has to be integrated plans that take care of the whole patient, including the social determinants of health pieces of the puzzle. And so I really think we're gonna continue to see movement there.
Eyles:
Right. All right, Dr. Chiang, it's yours to finish up. The next big thing in health?
Chiang:
Yeah, Matt and Laura, you know, 23 years of house calls and 37,000 house calls later, the next big thing in health is home care medicine, bringing care to the home. The drivers for this change, are there. Technology is enabling us to do so, we talked about that. Payment reform, going away from fee-for-service, tying our work to cost and quality. That's another driver. The COVID experience, asking us to reimagine care outside of the walls of the clinic and the hospital. And the last driver is the aging population. And these patients are not always aging well, a lot of our patients going to have dementia, Parkinson's, obesity, diabetes, and so on. All of that is going to put pressure on Medicare and insurers to manage their conditions while controlling cost. So the drivers are there. A study from McKinsey and Company estimated that about 25%, or roughly $280 billion of Medicare spend, can be shifted to home by 2025. So I really believe that the next big thing is health care at home.
Evans:
And it makes sense, too, when you see you know the recent AARP survey showed that the majority of Americans want to age in place. So this is definitely a trend. Thank you both so much, Dr. Chiang and Julie Sacks for joining us today for this great conversation.
Sacks:
Thank you.
