Home is Where the Health Is

This article is reposted from a piece I bylined for Hospital News Canada - published on 29 November, 2018.

Many years ago, when you asked someone what image comes to mind when they think of healthcare, they might have said ‘hospital’, ‘H logo’, ‘red cross’ or ‘stethoscope’. Today, there is a shift towards associating health(care) with the home. This is a return to how healthcare was designed over 100 years ago with midwives and doctors doing house calls. Innovation scholar Clay Christensen elegantly and accurately predicted this phenomenon in his book, The Innovator’s Prescription. Although the book was published a decade ago, his theory of disruption and decentralization stands the test of time, and we are seeing many of his predictions becoming reality for healthcare in this coming decade.

As Christensen predicted, heath systems around the world, including here in Canada, are shifting focus to the home and community. The home is seen as a care setting that is well positioned to address the significant unmet needs of people, families and healthcare providers, while maximizing precious public resources. A great recent example of this shift was shared by Dutch public servant Erik Gerritsen at Singularity University’s 2018 Exponential Medicine conference. He said, “We are moving care from waiting rooms to living rooms”. This vision statement has been backed by major policy reform where the Netherlands removed €2B from the ‘cure’ (hospital) budget and reallocated €1.5B to home, community and primary care.

“The home setting and health services will become so synonymous that they may not be called home care; rather, they will just be modern health care” Steven Landers, MD, MPH, CEO - Visiting Nurse Association Health Group [1]

The future of healthcare is the Home

This year SE Health marks 110 years of bringing care to people in their homes across Canada. As we work towards our next century of impact, we are systematically sensing and mining the signals and trends reshaping healthcare to help drive our mission of Spreading Hope and Happiness to people wherever they live.

In early 2018, I was recruited by SE Health to establish a Futures team to guide the organization, our clients and the health system towards creating a brighter future of health at home. With the appropriate title of ‘Future Strategist’, I spend a lot of time watching, digesting and translating what is happening around the world. I am looking at the changing preferences of people as they age, emerging technologies, decentralization of services from institutions into homes, and new business models to unlock value for individuals, families and the health system.

The home setting offers a greenfield of opportunity to challenge old assumptions about how people want to – and can – receive health services, and self-manage with their families and communities in the face of health challenges. Accelerating the shift to the home means letting go of deeply-held beliefs and constraints about what people are able to do in the home – for example, beliefs around privacy, tech savviness, quality of home care services, and constraints of time, distance and space.

Exciting changes coming in 2019 & beyond

Within this context, here is a roundup of emerging and exciting ways that the boundaries between traditional formal institutional care settings and the home are blurring in 2019.

• Hospital-to-Home programs: In the US and Canada, bundled care models in areas like hip and knee or cardiac surgery are allowing earlier discharge of patients to the home, supported by proactive home care and virtual supports. The INSPIRED hospital-to-home model for patients with COPD supported by the Canadian Foundation for Healthcare Improvement is a great example that has been scaling across Canada.
• The hospital without beds: A growing cohort of hospitals like Bellevue Medical Centre in Washington and Women’s College Hospital in Toronto, are shifting their operating model to exclusively offer outpatient care – even surgery – to thousands of patients a day, with no overnight stays. These models greatly rely on robust virtual care and remote monitoring capabilities, as well as strong partnerships with service providers in the community.
• The hospital without patients: The next step up from the hospital without beds, is the hospital without patients! Mercy Virtual hospital in St. Louis has been the hallmark case study for this rebasing of the hospital model: fully decentralized locations where patients are cared for either in hyper-localized satellite sites or directly in their homes.
• The home-spital: The quality and variety of care services available in the home is approximating (and even surpassing) that of many hospitals when they were first built more than a century ago. Although services such as chemotherapy, infusion, dialysis, phlebotomy, palliative care, clinical trials and rehab therapy have been ‘available’ in the home setting, they are still largely accessed in physical clinics or institutions today. With emerging availability of supports in the home coupled with technologies for remote monitoring (sensors), self-management tools, and new business models, patients will increasingly see the home setting as a viable alternative or adjuvant for these services. LifeLabs, a major community lab provider, is now piloting an in-home lab collection servicein Canada.  Science 37, an upstart in the US, has pioneered a fully decentralized clinical trial model in the home setting, with significantly better rates of recruitment and retention rates compared to legacy institutionally-based models.
• From hospital to health village: Many hospitals are reinventing their operating and business models to shift from a focus on ‘sick care’ to a more mission-aligned focus on ‘creating health’. This is manifesting in a few interesting ways. Some hospitals like Bruyerein Ottawa have been acquiring nearby real estate to create new home and community models such as affordable seniors’ living. Others are partnering in creative ways with community agencies to create and deliver new value propositions well upstream of sick care, tackling issues such as transportation, employment and housing.
• Neighbourhood models of care: New models of home care are evolving to support people with complex medical and social issues in ways that traditional fee-for-visit transactional home care cannot. The Dutch Buurtzorg model of neighbourhood care is getting traction globally, with more than 20 countries now replicating aspects of the model. The key is a ‘management-free’ organizing model wherein self-empowered nursing teams form and work autonomously with community supports in a given neighbourhood to holistically meet the patient and family’s needs.

The future of healthcare will continue to form around shifting client preferences and expectations, fiscal pressures and opportunities presented by budding new technologies. These changes are narrowing the gap between institutional and home care, and we are seeing new and innovative partnerships emerge to meet patient needs and alleviate pressures. It is an exciting time to be in healthcare as we watch the signals and future trends emerging in Canada and around the world.

Reference #1: Home Care Could be Heart of the U.S. Health System by 2024, Leaders Say (2015)