Home-Based Medical Care During COVID-19 and Beyond

Abstract and Introduction

Abstract

Ms. H is a 78-year-old woman with a history of congestive heart failure, chronic obstructive pulmonary disease, and recent stroke who was discharged 1 month ago from a subacute rehabilitation facility. She moved in with her son because she now requires a walker and cannot return to her third-floor apartment. One evening, Ms. H develops a low-grade fever and mild shortness of breath intermittently relieved by her albuterol inhaler. Her son is worried, but knows that his mom does not want to return to the hospital.

Introduction

Introduction: Home-based Medical Care

The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented strains on our healthcare system. Emergency rooms, hospitals, and nursing facilities around the nation have been particularly affected. Given capacity limitations during the initial crisis and continuing into another season of increasing infection rates, there is tremendous pressure to keep high-risk patients out of acute care settings and discharge those who are admitted to appropriate post-acute care. At the same time, disease outbreaks and visitor restrictions at skilled nursing facilities (SNFs) create barriers to placement, both at an individual and public health level. In this context, care at home became and continues to be an increasingly critical option, particularly for older, comorbid patients who represent a large proportion of those affected. Patients discharged from an acute care setting to their homes, as well as those in the community diagnosed with both COVID and non-COVID illness, require robust systems for monitoring and support with an interdisciplinary team of providers.

Home-based medical care (HBMC) is a powerful modality to address these challenges. Importantly, HBMC already functions across the continuum of care, providing primary, hospital-level, post-acute, and palliative care to multimorbid and functionally impaired older adults throughout the United States.^[1–4] Additionally, HBMC providers work closely with other home care services and often utilize technology for remote monitoring and virtual care. Many of these programs have been shown to reduce healthcare costs through lower rates of hospitalization, emergency room visits, and institutionalization while improving quality of life and patient satisfaction.^[1,5–8]

The HBMC model, quietly evolving over the last two decades, has rapidly transformed in response to COVID-19 with many health systems expanding established home-based care programs to further meet the needs of vulnerable populations. The potential contributions of HBMC during this challenging time include (1) to continue tending to the chronic but substantial health needs of medically complex patients, thus reducing the need for emergent care in overburdened hospital systems; (2) to provide hospital-level care for both COVID and non-COVID illness ("hospital at home"); (3) to provide post-acute level care as an alternative to SNFs; and (4) to provide palliative care to help clarify patient goals and manage symptoms of acute and chronic illness. With additional resources, HBMC has the potential to not only decompress the healthcare system, but also provide high-quality, patient-centered care during this time of crisis and beyond.