Table of Contents:
- Defining connected health
- The current landscape of connected care
- The need for seamless integration with traditional care
- The need for better technology for remote care
- The need for caregivers in the home
- An evolving transition to connected health
Advances in remote patient monitoring, telemedicine, and other technologies are accelerating the transition of healthcare from traditional medical facilities into the home.
As much as $265 billion worth of healthcare services for recipients of Medicare fee-for-service and Medicare Advantage could transfer to the home by 2025, according to the results of a recent physician survey conducted by McKinsey.
This profound shift brings with it the need for further development and improvement of technology, as well as other aspects of connected health, such as caregiving and managing the costs of care. Despite these challenges, healthcare experts say the future is brimming with opportunities to transform the landscape of care through innovations like remote patient monitoring and related services that allow for continuous care.
Defining connected health
The cornerstone of the future is connected health — an existing model of care that allows acutely ill patients to be treated at home instead of being admitted to a hospital for longer periods of time. Some of the patients who are currently being treated using this approach include those with chronic conditions such as community-acquired pneumonia, heart failure, and chronic pulmonary disease (COPD). For example, if a 68-year-old patient is diagnosed with community-acquired pneumonia, their provider may be able to discharge them on day one or two to receive care from home, instead of having them stay at the hospital for three to five days. There are several advantages associated with connected healthcare at home, ranging from up to 30 percent in cost savings to a reduced risk of hospital-acquired infections.
This care model was originally developed in the mid-1990s by researchers at the Johns Hopkins University School of Medicine, in order to provide hospital-level care in the home to older adults with acute illnesses. Between 1996 and 1998, a pilot study involving 17 patients ages 65 and older demonstrated that the model worked, reduced cost, and was safe. Then, a 2000-2002 study of 455 patients in the same age group, across three institutions, confirmed the promising results of the smaller trial.
Moreover, when offered the option of connected healthcare at home versus traditional acute hospital care, 60 percent of all patients who participated in the 2000-2002 study chose the former. The benefits of the model include shorter stays, lower rates of complications, and higher levels of patient satisfaction.
To replicate the success of the concept, a variety of other institutions — including Mount Sinai in New York, Centura Health in Colorado Springs, and many Veterans Affairs medical centers in the country — have implemented their own versions of connected healthcare since 2002. In addition to community-acquired pneumonia, heart failure, and COPD, conditions that can currently be treated using this approach include the bacterial skin infection cellulitis, urinary tract infection, dehydration, deep venous thrombosis, pulmonary embolism, and even moderate COVID-19.
Some experts predict that eventually, most, or even all, of non-surgical, non-ICU, and non-emergency care will transition into the home.
“My own sense is that in the future, what we call the hospital now is going to end up being a big emergency room, operating room and intensive care unit,” said Dr. Bruce Leff, a professor at the Johns Hopkins University School of Medicine and the lead author of the pilot study, in an interview with Home Health Care News. “I think everything else will ultimately end up getting pushed out to the home and community. I don’t know if that’s 10, 20, or 30 years from now, but I think everything will start to move in that direction.”
Dr. Ted Feldman, Chief Medical Officer at Cadence, similarly predicts that the connected health model will be greatly accelerated by advances in new technology, including remote patient monitoring technology which Cadence provides.
“As Medicare and insurance companies expand the diagnoses and expand the type of monitoring that they will pay for and reimburse, and as it becomes clinically indicated and proven, you are going to see more diagnoses and more remote patient monitoring opportunities in the future," Feldman said. Currently, insurance covers remote patient monitoring expenses for certain diagnoses whose management requires collection of physiologic data such as blood pressure and glucose readings. Examples include COPD, congestive heart failure, hypertension, and diabetes.
While patients still have to go to traditional hospitals for surgeries, Feldman predicts that pre-operative and post-operative care will eventually be conducted virtually, all via remote patient monitoring. For example, pre-op care can be conducted remotely by uploading images of X-rays, laboratory tests, and medical records. Moreover, once a patient has undergone surgery, a physician assistant or nurse practitioner can visually monitor remotely how well the wound is healing using remote patient monitoring technology.
The current landscape of connected care
Many companies, including Cadence, are using remote patient monitoring technology to help treat a variety of conditions, such as measuring blood pressure and weight in patients with hypertension and congestive heart failure. The technology is also currently being used to measure blood sugar levels and weight in patients with diabetes as well as oxygen saturation levels in patients with COPD.
Cadence is unique because in addition to providing patients with easy-to-use devices that transmit data to providers using cellular technology, the company also incorporates in-person enrollment and has a clinical care team serving as an extension of partner hospital physicians' practices.
There are a number of other companies offering telehealth for weight management, ordering medications, and at-home lab testing for issues like COVID, abnormal hormone levels, or food sensitivities. There are also companies currently developing cancer-detecting breathalyzers, which are paving the way for an early at-home diagnosis of the disease.
Even a more traditional technology company such as Apple is now offering a feature through the Apple Watch notifying users of irregular rhythms, which may indicate atrial fibrillation, or AFib, which is a type of irregular heartbeat that may increase the risk of blood clots, stroke, and heart failure.
The COVID-19 pandemic accelerated the connected health trend, as both hospital systems and patients were forced to adapt and grow more comfortable with this type of care.
But while COVID-19 helped to accelerate adoption, over the longer term, Feldman predicts that patients will come to embrace connected healthcare at home as a common sense and better alternative to traditional inpatient care — for example, by helping those patients with heart failure and COPD avoid crowded hospitals and potential COVID-19 exposure.
“You are in the comfort of your own home. You are sleeping in your own bed,” Feldman said. “What could be better in that regard?”
The need for seamless integration with traditional care
Despite its host of benefits, connected health is still in its infancy and needs increased investment in order to become a long-term and viable alternative to traditional hospital care.
Chitra Nawbatt is the Global Head of Health Assurance Partnerships at General Catalyst, one of the leading healthcare investors behind many of the cutting edge connected care companies, including Cadence.
Nawbatt said she would like to see an expansion of the conditions and activities that can be monitored at home using technology. For example, she noted that technology companies could eventually evolve to track how patients are feeling throughout the day, how well they are sleeping, and whether they are taking their medications.
This approach, however, runs the risk of flooding physicians with raw data which could be difficult to parse through. Hence, Nawbatt believes it will be important to develop new algorithms and technology solutions to help analyze data and provide actionable insights for clinicians.
“What data do clinicians need to pay attention to?" Nawbatt asked." When do they need to be alarmed? When do they need to be able to get proactive or preemptive versus [conduct] an intervention with the patient?”
Nawbatt painted a picture of the future, where both the raw data, as well as clinical insights, are accessible through a dashboard, which could even be customizable for different stakeholders, such as: clinicians, caregivers, and for patients themselves.
Outside of remote patient monitoring and data capture, Nawbatt also emphasized the need to create more seamless connections between caregivers, patients, and providers, including via enhanced communication. If a patient has an issue that they need to notify their doctor about right away, Nawbatt said, they should have access to modes of communication that are immediate and more efficient than, for example, calling their doctor's office.
Finally, she stressed the need to address the issue of technology literacy, both for caregivers and patients. As the use of remote patient monitoring broadens, so too will the needs for educating users about how the technology works. “How do you make that technology literacy and education process as easy as possible, and how do you make it as easy on the patient and caregiver as possible?” Nawbatt said. In the moment, when the patient is not well, and the patient or caregiver feels overwhelmed, or a sense of anxiety or urgency, the technology has to work and be very easy to use.
The need for better technology for remote care
How will technology continue to transform connected care in the future?
According to Dr. David Feldman, a medical advisor at Cadence, we're still in the early innings of what is possible. However, Feldman expects that wearable technology, medical devices and phone or web-based applications will transform how we deliver medical care. For some of these technologies, the clinical impact is already apparent. He believes that with these technological advances, encounters that have historically been limited to the hospital or clinic will transition to the outpatient or at-home settings, which will reserve in-person encounters for the sickest patients.
For example, smart stethoscopes are already being used in RPM programs as a way to triage cardiac and respiratory complaints of patients to better determine if an in-person evaluation is needed. Such stethoscopes are being provided to telemedicine patients in Europe, to identify pathological sounds in the lungs during self-examinations, and thus catch early indicators of respiratory problems. The data gets sent to a physician, who decides whether an in-person visit is needed or whether remote supervision can continue. Also, with enhanced video cameras and toolkits of different medical devices, a thorough clinical exam can now be conducted remotely during telehealth visits.
“Once the technology is fully matured, meaning it protects patient privacy and is validated as clinically useful, then we can reliably extend our at-home services beyond just blood pressure cuffs and weight scales, for example. This will support remote data transmission to support a wide range of chronic diseases and acute illnesses, which will allow clinicians to meaningfully progress patient care while patients are in the comfort of their own home,” Feldman said.
The authors of a report by Rock Health anticipate that telemedicine delivered via non-video means, such as audio-only and asynchronous services, will also become more common over time.
Kathy Duckett, Vice Chair of the American Telemedicine Association’s Home Healthcare Special Interest Group, said she would like to see additional advances to improve care at home, such as technology to provide an earlier glance at pulmonary impairment in patients with COPD. Providers can currently look at a patient’s oxygenation levels, but that’s a late indicator of oxygen issues, Duckett said. She would instead prefer a way to detect such problems before the patient’s oxygen saturation levels are affected. One solution could involve mobility sensors that could detect patients’ self-limiting behaviors as they get short of breath.
Additionally, Duckett envisions a future in which more advanced technological equipment will be brought into the home, such as better portable X-rays, multi-lead EKGs, and technology to perform a complete blood panel through a finger prick in the home.
The need for caregivers in the home
As the number of conditions and patients who can be treated at home continues to increase, a growing challenge will be how to keep up with the increased demand for professional caregivers to take care of patients in their homes.
Traditional hospitals, inpatient rehab facilities, and nursing homes offer the benefit of constant caregiver availability. For connected healthcare at home to take root, patients’ family members or non-traditional caregivers can only go so far. Medical professionals will need to be hired to fill the gap in care, a reality which may become especially challenging due to the growing and urgent health worker shortage.
Mercer predicts a shortage of more than 400,000 home health aides, 95,000 nursing assistants, and 29,400 nurse practitioners by 2025, while the Association of American Medical Colleges estimates a shortfall of up to 124,000 physicians by 2034. Moreover, about 1 in 5 health workers quit their jobs during the pandemic, according to a survey by Morning Consult.
Paying for care at home
For patients and their families, an additional problem is the scarcity of available options to pay for professional caregivers, which plays into the bigger issue of how to cover the cost of connected healthcare at home in the future.
Medicaid does currently provide for home health care — medical care in the home delivered by health professionals such as doctors and nurses — and for home or personal care, which is non-medical care to assist people with their daily activities like grooming or bathing. However, these kinds of assistance are only available to those who are eligible for Medicaid. Families of patients who are not eligible are instead forced to search for other ways to cover the cost of care for their loved ones — a problem that will only grow as care continues to move into the home and as America’s population ages.
The Urban Institute estimates that the number of people ages 65 and older will more than double over the next 40 years, increasing to 80 million by 2040. In 2000, only about one in eight people in the U.S. was 65 or older, but by 2040, as many as about one in five Americans will be in this age group.
Similarly, the cost of connected healthcare at home must be taken into account when considering its future. Nawbatt, for example, noted that while providers may wish to transfer care into the home — which will ultimately help to cut costs for them — patients also want to ascertain whether their insurer will cover these expenses and ensure that they don’t have to pay for connected healthcare at home services out of pocket.
When it comes to remote patient monitoring, for example, Medicare and other insurers currently provide for devices that collect physiologic data, such as blood pressure monitors, weight scales, glucose monitors, and pulse oximeters.
However, activity trackers are not currently covered, even though they are an important part of remote patient monitoring. More research would need to prove that their use is linked to improved clinical outcomes, in order for the Centers for Medicare & Medicaid Services to consider reimbursement.
As a result, there is a growing chasm between how fast the technology is advancing versus what is being covered by insurers. According to Nawbatt, “The level of innovation and where the market is moving is at one speed, and the regulation and evolution of payer economic models and risk appetite — and thus the insurers covering the costs — are at another speed."
A report by McKinsey proposes several solutions to the issues of pay, including a value-backed Care at Home strategy, where care at home is recommended for specific cases. This approach applies to scenarios in which the amount of money saved through a reduction in medical costs and gained through an increase in revenues will exceed the cost of reimbursement. The report also recommends that reimbursement policies be expanded and that benefits be redesigned to enable care at home and services that make it possible, such as remote patient monitoring and assistance with day-to-day activities.
An evolving transition to connected health
Finding new ways to pay for care at home and continuing to refine technological advances may ultimately help to transform healthcare in the United States.
“We are in the infancy of this huge transition of care, from a pure brick-and-mortar strategy to welcoming medicine to the information age,” said Dr. Ted Feldman. “Any virtual care needs to have remote patient monitoring as the basis, because you need data to make clinical decisions and to manage chronic conditions or resolve acute care conditions.”
Remote patient monitoring and other technologies will help physicians and institutions navigate the ongoing shift toward a world where patients and caregivers will feel more empowered, by having access to evidence-based, high-quality healthcare directly in the comfort of their own homes.