Where is LTC headed? From hospital to home

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Patrick Pilch
Patrick Pilch

Where is post-acute care headed? If provider investment plans in elder care are any indication, post-acute care services will move from hospital to home — and tech will help them do it.

Healthcare providers have historically medicalized old age. They have shied away from productively uncomfortable conversations with patients about how they measure quality of life and what their care goals are.

But that's starting to change, helped along by Medicare's move to reimburse providers for having these types of conversations, the growth of mobile technologies, expansion of telehealth coverage and the shift to value-based care. The biggest driver, though, is senior consumers — which as of 2029 will make up more than 20% of the U.S. population. They're demanding elder care focus on quality of life versus number of days left, and they're pushing to receive care at home instead of in a facility.

In response, providers are planning to move away from traditional models like skilled nursing facilities (SNFs) and long-term acute-care centers and towards those that promote care outside the institutional setting, BDO's Candid Conversations on Elder Care reveals.

My colleague David Friend, M.D., M.B.A., chief transformation officer of The BDO Center for Healthcare Excellence & Innovation, has been at the forefront of the elder care evolution. In his 40 years in the industry — both as a physician and a business transformation adviser — he's witnessed the rise of digital health firsthand. Here's his take on my questions about how technology is driving changes in elder care and where long-term care providers fit in the mix.

Explain the changes you've seen within the healthcare space and technology's role in them.

I've been in healthcare since 1979 when I started medical school. In nearly 40 years in the industry, the amount of money we spend on care has skyrocketed. When I started, the U.S. healthcare system was very much hospital-centric, and we were spending 9% of GDP on healthcare. The Internet did not exist, and everything was being recorded on paper. Just about 29% of medical school students were women. We barely understood DNA.

Now, we're spending about 18% of GDP on healthcare. Everything is done through electronic health records, or if it's not, it's moving that way. The number of women in medical school is greater than men (nearly 51%). You can go have genomic testing done now, and genomic advancements are quickening. Mobile technologies are coming into their own, and the healthcare supply chain is consolidating as players fight for data. Hospitals are disappearing, as the advancement of treatment modalities moves much of care to non-hospital settings. Today, we're trying to curb healthcare costs and improve care outcomes — which will ultimately improve consumers' quality of life. Elder care is the most important piece of that puzzle. 

Five percent of Americans account for almost half of U.S. healthcare spending, and many of them are chronically ill seniors. Technologies that empower home health—at-home cameras, mobile assistants, virtual reality, telemedicine capabilities, transportation coordination apps and wearables included—will help improve elder care outcomes and reduce costs.

What trends are you seeing in elder care?

By 2029, as the fastest-growing age demographic in the U.S., seniors are projected to make up more than 20 percent of the total population. By 2050, those aged 85 and above will grow at a faster rate than the working age population. So elder care finds itself in a race against time.

Elder care providers are tasked with curbing overall healthcare costs and improving care outcomes, and they're using technology to do both. A shift in consumer attitudes towards elder care is also happening: Seniors are tired of care that focuses mostly on increasing the number of days left without maximizing the quality of that time.

We worked with NEJM Catalyst to ask healthcare executives, clinical leaders and clinicians about the outlook for elder care investment and innovation as they work to overcome these challenges. By 2020, to meet the needs of the growing aging population, they plan to invest most in home health (44%), palliative care (44%) and geriatric caretakers (39%). Their investments will focus less on skilled nursing facilities (12 %) and Long-Term Acute-Care Facilities (7%), which tells us that senior care, like the broader industry, is moving outside the four walls of the hospital.

How do provider investment plans in elder care vary by region?

The most noticeable regional variations around investments to improve elder care concern home health. While 52 percent of healthcare organizations in the Northeast said home health was one of the top two segments of care they'd invest in by 2020 to prepare for the growth of the aging population, just 35 percent of providers in the West said the same.

But we don't think providers in the West are less interested in home health models. It's just that their counterparts in the Northeast are playing catchup.

In the Northeast, you have states that tend to spend more on healthcare and hospital care because of the region's larger portion of elderly residents and high-profile hospitals. And then in the West, you have health systems like Kaiser and others which have for years provided a strong model of how a holistic, well-coordinated health system can keep patients healthy and out of the hospital.

The West's tech-centric economy is another likely reason providers there have been ahead of the game in adopting home health models. They have more direct access to the innovative technologies that make them successful.

What kinds of investments are needed in these growing areas of elder care?

The biggest investments needed are related to people. Elder care is less attractive to many in the medical profession because of negative connotations around aging and its often lower-paying specialties. Add to that the stiff competition from other specialties in an industry already dealing with a huge talent shortage, and you can see how healthcare organizations need to bolster talent resources in senior care.

To start, organizations must invest in new ways of staffing, including advanced and technology-enabled processes to forecast patient levels, and to recruit, oversee and train clinical staff. There's also value in innovating around the role nurses play in holistic care. Care costs and outcomes improve by giving nurses room to play a more direct role in patient care, especially when it comes to elder care.

Paint a picture of the life of a senior citizen in 10 years from now. Specifically, do you believe that emerging technology will be embraced by seniors or will they continue to by and large stay away from it?

I do believe seniors will embrace emerging technologies—especially as healthcare providers themselves learn to do so. As providers learn to embrace technologies, they'll be better equipped to educate seniors on their potential to improve quality of life. As generations that have grown up with technology age, this trend will quicken.

In today's world, when seniors lose their driver's license, that's often when things start to go downhill. They can be confined to their homes and isolated from social circles. Running errands for vital things like groceries and medications — or making it to doctor's appointments — becomes difficult. Their health deteriorates, and they're eventually forced into some sort of supervised home.

Now let's say you're a senior 10 years from now. You'll use your mobile app to summon your driverless car to take you to do your grocery shopping, or take you to your doctor's appointment, or take you to visit a friend. Or, you'll press a button to have your personalized (and medically recommended) groceries in your Amazon cart delivered to your doorstep, and your driverless car can skip the grocery store and take you straight to your friend's. You'll be wearing an advanced watch that will monitor your vital signs and call for emergency help when you need it. An Amazon drone will deliver your medications, and Alexa will remind you when to take each one. You'll use VR technologies to visit your family or friends who live far away. Your independence, familial and social ties will remain largely intact, and quality of life will be much better. Technologies like the driverless car, connected mobile devices and VR have the potential to revolutionize the entire healthcare industry, but especially elder care.

Our study shows that some of these technologies will have impact on the quality and safety of elder care in the near term. Eighty-nine percent of healthcare organizations say wearables or connected devices will improve elder care safety and quality by 2020, with artificial intelligence (71%), mobile phone apps (77%), robotics (52%) and virtual reality (38%) following.

Where do you see an opportunity for tech entities to contribute to the elder care marketplace? What aspects of senior care do you think they'll end up disrupting?

If you look at the vision we talked about for senior care 10 years from now, tech companies — those that already exist and those whose names we don't yet know — are going to bring a lot of that to life. There are opportunities to disrupt every aspect of senior care: transportation, drug delivery, drug compliance, preventive and reactive health monitoring, and end-of-life care. Underlining this potential, healthcare organizations see the greatest opportunity for tech disruptors to improve elder care in home-based care (63%), care coordination (58%) and drug pricing (24%).

The focus of senior care — and broader care — should really be about maximizing the patient's quality of life. Tech companies will empower providers to focus more on quality, making it possible for more people to age more comfortably, and more humanely, in their own homes.

Patrick Pilch is a managing director and national leader at the BDO Center for Healthcare Excellence & Innovation. David Friend is the a managing director and chief transformation officer at BDO Center.


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