As the pandemic persists and the healthcare landscape shifts accordingly, it’s critical that our senior care sector reexamines the patient journey from hospital to home. Focusing on older adults’ needs after hospitalization can significantly improve health outcomes, quality of life and ensure a successful transition of care.
The COVID-19 pandemic created unprecedented disruption to care transitions and the response by many providers and staff of post-acute care services has been to embrace technology and quickly adapt to meet the needs of older adults to set them up to receive timely, effective care in the best setting possible. Remote clinical team meetings, physician virtual video visits, telehealth rounding and remote family “facetime” visits were all implemented, with many of these practices likely to continue post-pandemic.
Innovation and technology will be key in continuing to improve home care delivery and the transitions from hospital to home. Holistic care models will be critical in meeting the long-term needs of older adults. In the past, a siloed approach to post-acute care has led to higher readmissions rates after a care transition. More holistic models that incorporate non-clinical patient navigators or community health workers to address the non-medical factors (such as housing and food security, transportation, and more) will be critical to drive a successful acute care model in the home. We must consider a patient’s whole health and the causes behind hospitalization to prevent readmission. Many of the remote-technology practices that recently arose in inpatient post-acute settings can also be used in home settings to support holistic care of seniors. It is time for our sector to collaboratively examine key learnings, successes and failures to implement the best care scenarios for older adults in the right settings.
With COVID-19’s continued impact and new variants such as omicron on the rise, providing more comprehensive in-home post-acute care for seniors is more important than ever. Older adults in care transition populations present distinct needs, chronic conditions and, in many cases, complex social and behavioral health needs. Previous studies show that older adults who struggle to recover after hospitalization are at significantly greater risk of rehospitalization or placement in a long-term care facility. We need to prioritize a patient’s post-acute experience as a unique journey, optimizing each step of the way from the hospital to home. By personalizing and properly assessing function and mobility, and social determinants of health, providers can better care for each individual patient and transition them toward their most ideal environment. All these factors lead to the same goal; returning patients to independent living in their home.
The pandemic has exposed many flaws in our sector and we have a better view of social determinants of health and the weight they carry in senior care. According to recent data, Medicare alone spends $26 billion annually on hospital readmissions, of which $17 billion is spent on avoidable readmissions from factors at play such as social determinants of health. From transportation challenges and food insecurity, we must break down barriers to care in each patient’s journey to consider outcomes and measure success in their progression. We need to also consider the patient’s journey at every level of the sector — from on-the-ground care to frontline service providers to C-suites — to make the necessary gains to benefit the entire demographic.
The highly infectious nature of COVID-19 also has shifted popular opinions about hospitalizations, and older adults and their loved ones recognize the health benefits of staying well and receiving care outside of facilities. By supporting each patient with optimal care at each stage in their journey, they will be prepared to go home safely and, many will be able to stay at home without a need for rehospitalization. The pandemic has invited us to look at the home as a setting of care where seniors can receive comprehensive care. We need to continue to develop and implement more holistic capabilities to support patients in their homes. There has never been a more ideal moment for this evolution to occur, both in terms of market readiness and technological advancements.
As we reassess healthcare shifts and trends, our sector moving forward needs to pursue patient-centered, innovative care models to implement technologies such as remote patient monitoring, virtual rehabilitation platforms allowing at-home access, and other quality-assurance tools that will enhance patient care. When we pair these technological advances with the right caregivers who help older adults navigate their care journeys, we find an optimal balance using all available resources. Keeping older adults healthy in their homes requires a combination of human care and technology, addressing the whole patient and their needs.
Years down the road as we reflect on the pandemic, we should be able to say that we used its hard-won lessons to engineer better care for seniors. Without question, the senior sector collaboratively has the knowledge, the tools, and the ready audience it needs to accomplish this goal.
Jon Shaw is the senior vice president of solutions at naviHealth, an industry leader in post-acute care management and transitions. The company partners with health plans, health systems and post-acute care providers to manage the entire continuum of post-acute care.
