Home is where health IT is

There are 77 million baby boomers in the United States who are quickly approaching retirement. By now it’s obvious that the traditional system of providing long-term care via networks of nursing homes will not be able to cope with such a large aging population. That realization is sparking a revolution in long-term health care — one that uses information technology and remote monitoring technologies to manage many of those who need long-term care at their own homes while reserving nursing home space for patients who most urgently need it.

Long-term care at home has not yet caught fire with policy-makers, however. Proponents say only a fraction of the problems they face are technological. Instead, most obstacles are policy matters, such as passing relevant legislation and creating Medicare incentives.

Nevertheless, some organizations have started to tackle the questions surrounding long-term care, and they’re finding answers.

PeaceHealth: Long-term care begins at home
For PeaceHealth, a Catholic health care organization in the Pacific Northwest, long-term care underlies its mission to provide medical care and healing tailored to individuals. In 1990 it set out to build a patient-centric health care system that included what its leaders believe is the linchpin of long-term care — a connection between hospital and home.

“We decided at the beginning that the most important commodity was having all of the necessary information that would be needed” in the home, said John Haughom, senior vice president of PeaceHealth’s Healthcare Improvement Division.

PeaceHealth views patients and their families as vital to long-term treatment and care. “It’s amazing what you can achieve if you can educate patients and give them just a little understanding of what they themselves can do to improve their health,” Haughom said.

Begun in 1890 by two Catholic nuns from New Jersey as a health service for a logging community in a remote part of Washington state, PeaceHealth now has six hospitals and numerous auxiliary centers in three states. A state-of-the-art fiber network connects the facilities.

The focus of PeaceHealth’s current IT efforts is building a Community Health Record that any provider can access even if he or she doesn’t do business with PeaceHealth. The system now includes information on about 1.5 million patients in Alaska, Washington and Oregon.

The Patient Connection, a password-protected Web portal, is the primary online tool that long-term care patients use to access the PeaceHealth system. Patients can set up appointments online and view the status of their accounts. They can also schedule consultations about medications and allergies, review lab tests and engage in “e-visits” with a doctor.

Shared care plan
For patients with chronic, complex illnesses, such as diabetes or congestive heart failure, long-term care is often difficult to plan and monitor. Because caring for individuals with such diseases normally requires a team of health care professionals, gaps in treatment can occur. They might arise when a doctor prescribes a new medication and fails to update the patient’s record. Or existing providers might not realize that a new professional has entered the picture, as often happens with chronic illnesses. Such gatekeeping issues are major problems in long-term care.

PeaceHealth’s Shared Care Plan is a major advance that attempts to address those problems by adding the patient to the long-term care team. Unlike the Community Health Record, which heavily relies on physicians’ input, the Shared Care Plan depends largely on patients’ access to their health records. It creates a health record that belongs to the patients that they can keep electronically or as paper records, Haughom said.

The health record contains a patient’s personal profile, treatment goals, health indicators, treatment steps, a comment section that the patient or health team members can add to, diagnoses and medications, and possible reactions because of allergies and intolerances. “We help patients populate it, but it’s essentially their record that they can use as they feel best fits their own circumstances,” Haughom said. “This way, the patients actually become a central part of the health care team.”

The PeaceHealth network has not yet linked to the Shared Care Plan, he said, but it will be at some point.

In addition to the Web-based tools and Shared Care Plan, Haughom said a third technology area could emerge — digital tools that would facilitate continuous online monitoring of patients at home.

Digital scales could detect weight increases that coincide with fluid retention among people with heart disease, for example. Developers could program machines to ask questions about symptoms such as shortness of breath. In sum, the dataset would paint a detailed and ongoing picture of patients’ health.

Likewise, digital machines could prompt diabetes patients to test their blood sugar levels at particular times and, allied with similar data from question-and-answer sessions, could provide a more complete picture of progress than intermittent doctor visits.

Those technologies are part of a vision for a long-term, continuous health care model that could take 10 years or more to develop. But in the end, it would not only improve health care for patients but also substantially cut costs for care-givers.

“Studies have shown that this kind of approach could cut the number of visits that people would have to make to their doctor’s office in half and reduce the cost of treatment of things like heart failure by around 30 percent a year,” Haughom said.

Ontario: Computing long-term care costs
In Ontario, Canada, long-term care is a separate component of health care that the province treats differently from care provided in hospitals, said Roger Girard, Ontario’s chief e-health strategist. “It’s about delivering health care to people’s homes, and it’s a very important part of the overall health system,” he said.

For years the Canadian system and its counterpart in the United States equated long-term care with the number of beds available at institutions that people went to because they had nowhere else to go, he said. But now the objective is to keep people at home in their communities as long as possible.

The decision for a person to go into a home care program traditionally has been based on the patient’s views and recommendations by doctors and relatives. But that isn’t necessarily a systematic way of assessing the situation, Girard said. Now, newer IT tools are in the works that can help assess long-term care using a standard framework.

One such tool is the Resident Assessment Instrument–Home Care, now in use at 42 Community Care Access Centres in Ontario. The centers evaluate a patient’s needs and eligibility for services to determine whether he or she can receive care at home or should be referred to a long-term care facility.

Other assessment tools rely on common databases that everyone from hospital to community workers can use to evaluate ways to meet patients’ long-term care needs.

“Because you have a much better way of measuring needs in a standardized fashion, you can effectively reallocate resources,” Girard said. “We now know we are not robbing Peter to pay Paul, and we end up with better long-term care for lower cost.”

The distance factor
The province already has experience with distance health care through an extensive telehealth network that serves remote towns and villages. More than 30,000 events take place annually over the network that otherwise would have required patients or doctors to travel long distances.

Girard said he believes that the province’s experience with remote health care will help it implement the home-based monitoring technology necessary to extend long-term care to patients’ homes.

That telehealth “experience helped us break the back of the technology that’s needed, and we’re now experimenting with ways to take this directly to the home,” he said. “There’s no question it will happen. It’s now just a question of how to make it happen.”