Is the future of care at home?
The centre of gravity of the health and care sector is shifting away from hospitals and nursing homes. Capacity and resource constraints combined with policy pushes for greater access in the community and advances in medtech mean that over the coming decades an increasing amount of care will be delivered in an outpatient setting and at home. But Joseph Musgrave, CEO of Home & Community Care Ireland, Ireland’s trade association for domiciliary care providers, warns us there is a major stumbling block: almost every country lacks a structured career pathway for carers.
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There are major benefits to reducing the time people spend in hospitals, for both patients and payors. The risk of getting a hospital acquired infection increases the longer patients are kept in hospital. And it’s far cheaper to have them recover at home supported by a nurse.
With elderly care, the advantages of keeping people at home or in an assisted living facility rather than a nursing home are even starker. “I recently met someone who, in their 40s, ended up in a nursing home for three years because of a brain haemorrhage, who said other residents were trying to escape,” Musgrave tells us.
“Contrast that with independent/assisted living, where you have your own front door, and you have enough clinical expertise on site (ideally a nurse and a team of care assistants).”
Some countries and regions have already made significant advances in shifting acute care away from the inpatient setting. In New York patients are given knee replacements and then sent back home the same day. Denmark does treatment for prostate cancer, for which there can be severe bladder retention issues, in the patient’s home.
“Long term, a lot more needs to be done at home,” Musgrave says.
In terms of having national systems in place for delivering long term care at home, Musgrave says Australia, Germany and Japan are the only countries that currently do it well – “almost everybody else is stumbling along”.
The biggest stumbling block, he says, is the lack of a structured career pathway for carers.
“In a hospital someone can start out as a junior nurse, and then following further qualifications and specialisation go into something like intensive care, all within the hospital structure. In the community it’s very different, because it’s difficult to project the types of problems someone is going to have at home. Should we train everyone to be able to do everything? Or train everyone to a minimum level? But then if one area has a higher need than that level and none of the carers are trained to deal with it, what do you do? There are certain things like cognitive decline (dementia) and mobility issues which most carers could be trained to deal with at a general level. But as soon as it gets more specific, that’s when it gets quite difficult (e.g. spine vs. hip issues – these are very different mobility issues).
“This question of how to build a career structure for carers is an international problem. Commissioning is the crucial part. We’re going to need far more clinical people in the community to sign off on the tasks carers are currently doing. We already have this in nursing homes but not in homecare.
“Germany’s solution is to have four social care bands. The fourth (highest) level is for those assessed as requiring care in an institution, whilst levels one, two and three carry different baskets of services you get access to in the community and home. Essentially, we need to agree on the basic minimum that a care assistant needs to be qualified to do (e.g. mobility and cognitive function). Then as you move up to level two and three, you need to have a commissioning model that supports nurses and doctors being intimately involved in the care plan.
“You also need to have a more flexible payment system. Most systems pay one flat rate for social care (in Ireland it’s €31 per hour regardless of the level of care needed). An interesting feature of the Australian system is the rate can vary depending on the distance travelled by the carer (the more rural you are the greater top up you get to go into a more rural area). We need to move to a more flexible way to pay for care, and that will facilitate introducing different levels of carer expertise.
“We have to change commissioning, it is the silver bullet. We have to have more levels of carer, and create a way to give carers a career structure. If we can do that it suddenly becomes seamless. Rather than having the health system orbit around the hospital, have it orbit around the community. We’re doing some of this in Ireland but it needs to get much more sophisticated.”
Musgrave highlights New York as having one of the most advanced systems in place: “New York has a 30-day nurse-led service, in which rehab at home and domiciliary care are all provided, by companies like Northwell Health, in the same package – that’s the commissioning I’ve been talking about. That’s the system of the future.
“This is where there are huge avenues for the private sector to innovate. VHI (one of Ireland’s three health insurers) is now offering cover for hospital at home. You go to hospital, and then get discharged at home. But it only covers short term post-acute care. So, we need to take that short term solution and adapt it into longer term care in the community.”
Musgrave also believes assisted living or retirement villages are a viable alternative to nursing homes in the long term. “But in order for more of these to get built we’ve got to stop being so NIMBY. But there’s some promise.
“I think the nursing homes of the future will be far smaller, and more expensive. But that’s not a bad thing because they will be only for the most complex cases, people who really need 24/7 care. Eventually with the right tech we may not need nursing homes at all; you might be able to replace them completely with independent living facilities with the right tech and staff.”
Musgrave says the fundamental question is whether we, as a society, care enough to address this issue. “Right now the answer seems to be ‘no’. We’re struggling to tread water, and meet the demands of the ageing population.”
We would welcome your thoughts on this story. Email your views to Martin De Benito Gellner or call 0207 183 3779.
