Home Healthcare is Broken, and People are Dying

People like my Dad

In 1988, when I was five years old, my father successfully had a valve replaced in his otherwise healthy heart. I can remember my brothers and I running into my parents’ bedroom and jumping on him as he lay on his side of the bed. We didn’t grasp the seriousness of the surgery until he showed us the long, vertical scar that ran down his chest, still vaguely yellow/green from iodine and bruising. Dad was somehow cooler.

The surgery was a success. I hardly noticed any restrictions for him as I grew up, and he never complained. He was a normal, happy, healthy Dad for me, my brothers, and my sister. Modern Surgery gave Dad his life back. A miracle.

Trouble Looms

By the mid-2000s, Dad’s heart began to give. A-fib would lead to recurring 2–3 day hospitalizations for monitoring. Dad’s symptoms were managed by medications and exercise regimens. He ate better. He was never much of a drinker, but stopped anyway.

Those 2–3 day monitoring sessions at the hospital became ablation procedures. Ablation procedures became pacemaker surgery. Pacemaker surgery became defibrillator insertion. The scars were adding up, but were no longer cool.

By needing to visit the Emergency Room three or more times per month, Dad had become an ER Super User. A less noble distinction than it might sound.

Staring Into Home Healthcare’s Black Hole

Upon discharge from the hospital, Dad would be passed off to a local home healthcare company (HHC) or Visiting Nurse Association (VNA) to be seen by a Registered Nurse (RN) or Nurse Practitioner (NP). The idea was that they would be there to check in on him, perform medication reconciliation, check vitals, and answer questions. But the reality was something different.

Dad would go days without hearing anything. His calls were often routed to voicemail, or sometimes someone at the call center would take a message and say that they would get back to him.

This was agony for us, and absolutely unacceptable healthcare. Dad would usually be back in the ER before he even received his first visit.

The Technology Sucks

To be clear, the problems with medical home healthcare do not lie with the practitioners. I have yet to meet an RN or an NP that doesn’t want to be more efficient while providing better care to patients. The problems are entrenched within the business models and reimbursement processes of the companies for which they work.

When a patient is transferred to a HHC from the hospital, care coordinators at the hospital typically have to print the necessary Patient Health Information (PHI) and fax it to the HHC. In 2017.

Many HHCs take 36 hours just to process that info well enough to figure out where the patient lives and what practitioners might be in nearby zip codes. The HHC then needs to coordinate the practitioner’s schedule with the schedule of the patient by phone. Again, in 2017.

These processes lead to high levels of administrative overhead and low efficiency, pushing patients back to the ER where they know that they can receive care. In fact, over 20% percent of Medicare patients are readmitted to the hospital within 30 days post-discharge, costing CMS $25 billion, of which they estimate $17 billion is preventable.

Unfortunately, the incentives are wrong. When a HHC is employed to see a patient, it effectively separates them from their MD. HHCs’ responsibility is to the payer, be it private insurance or CMS, as that is who deems what they have done for a patient worthy of reimbursement. Therefore, HHCs haven’t spent the time to go the extra mile to integrate technology into Electronic Health Records (EHRs) to push and pull PHI or provide a platform for MDs to log in and see up-to-date information on their own patients. Because, technically, they aren’t required to. This patient-doctor separation in visibility and communication is a direct cause of readmissions.

The Strain

Added up, these factors increase pressure on the healthcare system and its costs. Because of home healthcare’s administrative bottlenecks, patients receive visits to the home spaced on a schedule, rather than as-needed. This pushes patients back to the ER, 38% of which are at or over capacity in the United States, forcing clinicians to rush and putting lives at risk. Furthermore, in a domino effect, those costly ER bills are paid by CMS and insurers, which are funded by the American taxpayer and high premiums.

As 10,000 Americans are turning 65 every day, there will be a drastic increase in healthcare needs through 2050. Coupled with this rising senior population, there are RN and MD shortages in this country that are projected to get worse.

We are in the early stages of a Perfect Storm.

With practitioners, ERs, and hospitals stretched thin, the home has to become a viable alternative for healthcare. It must be more efficient, and it must be done for less than it costs today. Unfortunately, there is no prescription to cure Home Healthcare as it stands today. No bolt-on technology solution. Rather it requires an overhaul of the home healthcare business model, and CMS knows it.

The FRND Way

Over the past year and a half we have been operating in beta in NYC, digging in deep with a select numbers of partners to master exactly what they need. Our goal has been to develop the platform of the future for medical home-visits by giving institutions and MDs access to a cloud-based portal to request care and see real-time updates on visits and patient information. This, coupled with a subscribing network of RNs and NPs, can extend a doctor or care team’s protocols and methods into the home, on-demand.

This removes two critical home healthcare deficiencies:

  1. The processing time associated with calling and faxing information to the HHC call center, which results in poor communication and days of delays
  2. The transfer in patient oversight from the MD / Hospital System / Payer that knows the patient and their history (and is ultimately responsible for their care due to new Value Based Care initiatives) to a HHC that does not have a patient-doctor relationship

Here are some things we have done/learned:

  • By shedding administrative costs, the cost of a visit to a home can be reduced by 40% while practitioners can receive 150% of what they make per hour on average
  • By eliminating the call center, and allowing requests to go straight to practitioners in the field, visits are scheduled within seconds, and turned around in less than an hour, versus 3–14 days for HHC companies
  • By leveraging the underutilized excess capacity in the nursing world, RNs/NPs are not removed from their full-time hospital jobs, thus increasing the effective number of RNs in the American workforce and relieving the pressure of a nursing shortage in the US
  • Millennial RNs and NPs understand the on-demand economy and are attracted to how we operate: flexible work schedules, smartphone and mobile processes, and the opportunity to make an impact in their work
  • Millennials are a critical group for the future of HHC with 1,000,000 RNs approaching retirement age, and 55% of the RN workforce over 50 years old
  • With Value Based Care, hospital systems, ACOs, and insurers are becoming proactive about finding solutions to bring them closer to the patient, for whom they are becoming increasingly responsible, effectively reducing the desire for traditional home healthcare
  • By automating our platform and notifications, we can give a doctor or care coordinator more information about their patient through our portal, while reducing the time it takes to review and schedule care by 90%
  • Bringing something as simple as a B12 shot to the home of a patient with Parkinson’s disease has allowed us to save payers anywhere from $400 — $10,000 with a single visit as we eliminate the need for an appointment to a Primary Care Physician, or admittance to the ER
  • While the number is certainly higher, we can affirmatively say that two lives have been saved by escalating care from an on-demand visit when they saw troubling signs during triage

The Future is Not Home Healthcare

Over the next 10 years, the hospital will be more efficiently utilized for surgery and emergency services.

Technology will allow patients and care to be transitioned to the home and monitored by payers and providers, who will increasingly assume financial risk for patients due to Value Based Care.

As institutions and clinicians assume more risk, diagnosis will be performed by clinical teams at payers, providers, and Primary Care offices assisted by data aggregated via wearables and devices in the home, Artificial Intelligence, and practitioners in the field. Not by home healthcare companies.

By utilizing remote-monitoring techniques and patient-uploaded data via smartphones, mobile technology, AI, and a flexible, on-demand workforce, practitioners will respond to what is happening to patients at home, on-the-fly, for any payer, provider, or clinician anywhere in the country. They will administer patient-specific protocols set by their doctor and report back as to the patient’s status and vitals in real-time via the technology platform.

A platform sitting in the patient data stream, flagging abnormalities and automatically scheduling visits with a flexible, on-demand network of practitioners is what we are building at FRND, not a home healthcare company. We are a Population Health logistics platform empowering clinicians and patients to take control of their health together, outside the walls of the office, ER, or hospital.

By setting protocols alongside doctors and allowing software to do the heavy lifting, MDs will have less work than before, with greater transparency and actionable data. Doctors will be able to see homebound patients at the tap of a button via videoconference and have a practitioner on-site to perform any necessary tests, draws, injections, etc.

With this model we can keep people healthy in their homes, where 90% of patients want to stay, and out of offices, ERs, nursing homes, and other soul-crushing locations.

Why?

Because my Dad did not make it off the heart transplant list. His last visit to the ER left him in a coma. My siblings and I were by his side for 10 days while his cardiologist and doctors did everything they could to get him back to us. As his heart and kidneys began to fail, his surgeons made a last-ditch effort via open heart surgery. It didn’t take.

A few days after we let him go, I went to Dad’s home. The first thing I noticed was a table covered in pill bottles from years of ER visits. It must have been impossible for him to decipher. Having a professional visit to do a simple medication reconciliation while keeping his doctors in the loop could have saved his life.

I can’t help but wonder about what life would be like today if, when his uploaded vitals had shown something was off with his heart, an RN was dispatched immediately, days before he knew he needed to go to the ER.

I believe Dad would have gotten his new heart.