ACC workbook highlights possibilities, benefits of home-based cardiac care
Key takeaways:
- A new online workbook offers suggested best practices for cardiac care in the home.
- The COVID-19 pandemic helped spur a shift to home-based care models.
The idea of a clinician making house calls may seem like a quaint one, but research suggests home-based care could offer advantages to expand capacity, reduce costs and individually tailor treatment in novel ways for cardiology.
Several converging factors are leading researchers, clinicians and health systems to look to home-based care as a model to best serve some patients, including an increased emphasis on value-based care, the rise in health consumerism, advances in digital technology allowing for more remote monitoring, and the many changes brought on by the COVID-19 pandemic, according to Nivee P. Amin, MD, MHS, FACC, associate director for consultative cardiology and director of the Women’s Heart Program and Preventive Cardiology at Weill Cornell Medicine and NewYork-Presbyterian. However, in a 2011-2017 survey of fee-for-service Medicare beneficiaries, home-based care was utilized by only about 5%, likely due to decreased reimbursement, Amin said.
That will likely change as more organizations begin to offer home-based care options, Amin said. Increasingly, home-based care could be an option for patients who need follow-up after PCI or an ACS for chronic arrhythmia management and for hospital-at-home services for people with HF.
Healio spoke with Amin, who chaired the American College of Cardiology home-based care workbook writing committee, about why home-based care in the U.S. was declining before the pandemic, the inherent advantages and challenges of home-based medicine and how to best measure success. The ACC’s home-based care workbook was recently published on its website and is available for free download.
Healio: What led to the creation of this home-based care workbook?
Amin: Health care delivery and care models shifted and accelerated dramatically during the COVID-19 pandemic, due in part to the needs of the time and regulatory changes. The ACC felt there was a need to raise awareness of the possibility of home-based cardiac care and to consider what topics should be thought about as one is engaging in home-based care, and also to raise the possibility of different types of home-based care.
Healio: Unlike other countries, the U.S. had seen a decline in home-based care overall before the pandemic. Why is that?
Amin: After around 1997, the U.S. saw a significant decline in the number of house calls, reserving home-based care instead for people who were housebound or receiving palliative or hospice care. The main reason we have this change in the health delivery model has to do with consolidation of health delivery into larger health systems. That traditional or historic model of house calls and home-based clinical care is not well supported by payors and incentive systems.
Healio: What are some of the advantages of home-based care?
Amin: Home-based care allows us to meet patients where they are and monitor and treat patients in their home environment. Home-based care also frees up resources in large health systems — not only in hospitals, but also in clinics and other high-use, high-utility areas.
Within cardiology specifically, we can segment this into chronic care, urgent or acute care as well as transitional care. In terms of chronic care, considering how we have patients with chronic cardiac conditions and patients at risk for decompensation or changes in clinical status based on exposures from one day to the next, home-based care can allow us to monitor and treat those patients with chronic conditions at home. For example, patients with HF may gain weight over time or show signs of shortness of breath. A clinician can assess the patient at home via monitoring tools or an actual visit and prevent a hospital or clinic visit.
Where we see an opportunity is also connected to patient stability and clinician judgment. The post-procedure patient may need a different level of monitoring. With the evolution of our devices and capabilities for home-based care, we can potentially provide that care at home and free up hospital or health center resources for other uses. Of course, safety comes first, and we need to make sure we are not putting anyone at risk. Key performance indicators outlined in the workbook include patient satisfaction scores, patient retention rates, the effect on clinicians’ well-being and clinician engagement, total cost of care and per patient cost per month.
Healio: What might be some of the challenges of home-based care, and how can a workbook like this address those challenges?
Amin: One of the main challenges is awareness of home-based cardiac care that would lead to adoption. Working within this multidisciplinary group, I was inspired by how even our procedural colleagues, interventionalists and electrophysiologists were thinking about a lot of these cases. This workbook allows us to create that awareness and start building a model and shifting the framework in this evolution. The adoption of home-based care may be limited by awareness and creativity. How do we meet patients where they are?
We still need some degree of infrastructure to allow for the safe usage of home-based care. What are the use cases? What kind of monitoring is needed? We need evidence and safety measures to demonstrate that home-based care is equivalent or perhaps superior to our traditional models. These may be barriers. How to measure success is for us to consider in a prospective manner.
Part of why we have not had a lot of adoption of home-based care pre-pandemic is that during the pandemic, there were certain allowances for payment models and incentives and reimbursements to allow for care at home. That is one of the main barriers to this. How can we build sustainable models that meet the requirements of our health payment systems as well as meeting what our patient and clinician needs are? That will be one of the biggest barriers to sustainable adoption.
We must also consider the cultural shift and how we manage our patients. All of us want to have hands on patients; however, we have become much more comfortable with managing our patients from afar, purely out of necessity, with the pandemic. What do our patients want? What is their comfort level with this?
This workbook was a collaborative effort and includes leaders from multiple disciplines. I hope for an interactive process for this and other workbooks. We must be at the forefront addressing this care evolution and providing tools and fuel for conversation to grow and address these changes together.
Reference:
- ACC. Home-based care workbook. Available at: https://www.acc.org/About-ACC/Innovation/Home-Based-Workbook. Published Sept. 26, 2023. Accessed Oct. 9, 2023.
For more information:
Nivee P. Amin, MD, MHS, FACC, can be reached at npa9001@med.cornell.edu.
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