Like Jimmy Carter, more people want care at home. It takes a lot of coordination.

Former President Jimmy Carter, seen in this 2015 photo after being diagnosed with cancer, has entered home hospice care. (Photo: The Carter Center)

With Jimmy Carter choosing to enter home hospice care over the weekend, the former president reflects a growing trend among many Americans.

Whether it’s end-of-life care, avoiding a nursing home, or recovering after a long hospital stay, more Americans are deciding they want to go home. More hospitals are developing acute care programs at home. And CVS Health acquired Signify Health, which focuses on delivering care at home. in an $8 billion deal

Lissy Hu has seen that shift. Hu is the president of connected networks at WellSky, a healthcare technology company that works with hospitals, payers, health systems, home health and hospice agencies and community organizations to coordinate care.

WellSky has seen a 20% increase in referrals into the home over the past couple of years, Hu says. Since WellSky handles 40 million referrals annually, that means the company is seeing millions more referrals for care at home.

As more patients are opting for care at home, health systems, hospitals and primary care organizations are going to have to work together to ensure patients get what they need.

“When you're in a nursing home, you've got your home health there, you've got your doctor there, you've got your hospital bed there, your bedpan, everything's sort of all in one place,” Hu says. “But if that patient is going home, all of that needs to be coordinated.”

Hu spoke with Chief Healthcare Executive about the growing shift to care at the home, the hurdles and opportunities involved, and what health system leaders should be thinking about.

(See part of our interview with Lissy Hu in this video. The story continues below.)

‘Patients want to be home’

In a 2021 report on post-acute care trends, Trella Health documented the increase in patients seeking care at home. Between the second quarter of 2020 and the third quarter of 2021, home health instructions rose to 24.1% of inpatient discharges, an increase of 2.5 percentage points, the report stated.

From January 2019 through September 2021, hospitals saw a 10% increase in home referrals and an 18% drop in referrals to skilled nursing facilities, according to a report from CarePort powered by WellSky. (Hu is the founder of CarePort, a care coordination network which was acquired by WellSky in 2021).

Hu says the shift to home-based care has continued, and is more than a trend sparked by the emergence of COVID-19.

“I think there was a lot of question in the beginning of the pandemic, whether the shift to home-based care and seeing so many more engagements with home health, was going to just continue, was a pandemic phenomenon,” Hu says. “And at least what we're seeing in our data, is that, you know, just every year that numbers go up and up.”

The shift is being driven by patient preferences, and payers aiming to reduce costs.

“Home is a lower cost setting,” Hu says. “And so from a payer perspective, if the patient doesn't need to go to a facility, your preference from a value-based system would be to send them to the home.

“I think also patients want to be at home. They don't want to be in a nursing home, where they could be oftentimes far away from their family members,” Hu adds.

The trend is also being driven by technology, she says.

“We have integrations with home health, and other community providers to make sure that the services are actually being delivered,” Hu says. “And so people just have a lot more confidence that they can send a patient home, because there's better technology, better analytics.”

• Read more: Current Health CEO Christopher McCann says care is coming home

Lissy Hu, president of connected networks at WellSky

Making it work

With more patients going home, the task of care coordination is shifting to the ambulatory setting, Hu says.

“I think it's just a really interesting time in the ambulatory space where physicians are no longer just dealing with the hospital or other specialists,” Hu says. “They're really starting to engage with this, what I'm calling what we're calling the full continuum of care.”

Primary care providers are going to have to be part of the solution, and to ensure that post-acute services or home-based services don’t become “a black hole,” Hu says.

“I think, bringing the PCP into the mix, electronically through interoperability through analytics, I think it will be really important to make sure that we can continue to support patients in their home,” Hu says.

• Read more: Seniors are getting more help at home after hospitalization, but what are the costs?

Hu says interoperability, the exchange of patient data between providers, payers and home-based services, is going to be critical to ensure patients don’t fall through the cracks.

“I think being able to just provide primary care physicians visibility and being able to allow them to engage with home- and community-based services is really important,” she says.

Home health agencies and community-based services remain “very fragmented” components in healthcare delivery, Hu says. While a region may have a few hospitals, there could be dozens of home health agencies, hospice agencies or transportation companies.

WellSky works to connect primary care providers with these agencies to allow them to easily see how patients are faring and which patients need help, Hu says.

“We're able to alert the PCP when a patient hasn't been seen within 24 to 48 hours of discharge,” Hu says. “Those are the patients you need to pay attention to. If home health is already in place, and the patient's already being seen, you know that the patient's doing okay. Those are probably not the patients where you really need to focus on.”

Health systems need to ensure primary care providers can focus on patients who need more assistance at home, Hu says.

This is also important from the patient’s perspective, she adds. A patient who has been seen by a home health aide is likely to be irritated with a call from a primary care provider the following day, and may wonder why the physician doesn’t already have the information.

Shifting focus

Health systems have focused on connecting primary care physicians with other doctors, and to help ensure that doctors know if their patients are seeing specialists or going to the hospitals.

Now, Hu says, health systems must connect primary care to the wide range of organizations caring for patients at home.

“Going forward in the next five years, what we're going to see emerge is, how do we bring these primary care doctors closer to home- and community-based providers, because that's where a lot of the care is shifting,” she says.

“I think we're going to see a lot more dialogue on that, which is really connecting primary care doctors to the full continuum of care rather than just other doctors and other hospitals.”

Home health agencies and community providers are getting valuable insights on patients by seeing them at home.

These providers have “a really unique look into the patient's needs and what's going on in their home,” Hu says.

Now, Hu says, there must be more focus on getting that data “back to the doctor so that they can coordinate the care holistically, so that they have a full view, a comprehensive view of what's going on with their patient.”

Home health agencies and hospice agencies are continuing to struggle with the staffing issues across healthcare. Primary care organizations are also having a hard time holding onto workers. Hu says that only underscores the importance of using technology to allow providers to work more efficiently and care for their patients more effectively.

With more patients heading home from the hospital, health systems are going to have to be sure patients have what they need. Some hospitals can improve in helping patients transition to the home, a recent University of Michigan study found.

Hu says she’s encouraged by the progress some health systems are making in helping patients, including assessing needs for transportation and behavioral health.

“We're seeing so many more parts of the care continuum come to the table, because patients need these additional services when they're going home,” Hu says. “Because they're not just going into a facility where all those services are already in place.”