Potentially half of hospital care activities could be provided at home

18 October 2016 Consultancy.uk

Nearly half of care activities provided in a hospital setting could, with the space of the coming ten years, potentially be provided at home. Technology serves as the key driver, and will see hospitals transform into IT companies, medical technology companies transition into consumer technology firms and all people become patients. If managed well, the transformation of hospital healthcare could lead to significant financial benefits for society and improve patients’ quality of life.

Across industries, technology is redefining the playing field of entire markets and revamping the shelf life of business models and delivery modes. The healthcare sector – with a total annual expenditure of $6.5 trillion globally (according to the WHO), making it one of the globe’s chief sectors in terms of spending – has some time now been earmarked as one of the segments that will be most disrupted by the mind blowing possibilities new technologies can offer. However, across the board, much debate exists on the scale of change that is likely to materialise.

The inpatient care revolution

An areas within healthcare that is set to see the winds of change storm through its frontiers is that of inpatient care – health support provided to patients within the premises of a hospital, often combined with an (or many) overnight stay(s). According to a study by Gupta Strategists, a healthcare management consultancy based in the Netherlands, approximately 46% of all activities that are performed in-hospital today could in the future be done at home. In other words, patients can receive the same, or even better care they need in their home situation. The researchers base their bold statement on an in-depth examination of all care activities that are performed in hospitals. They find that with the current state of technology, many activities can be provided at home. Gupta analyses how this transition will impact the care delivery system, with ten years taken as a time span for their analysis. 

Hospital care that could be provided at home within 10 years

In coming to their estimate, the consultants assessed, for each of the ~160 Diagnosis-Related Groups (DRGs) delivered at hospitals, the share of those that could potentially be performed safely at home. They hereby looked at the prospect of already existing technologies, and mapped out how advancements in technology could influence the inpatient versus outpatient equation. Within this framework, specific assumptions were worked out across seven major categories of hospital care. An overview of main considerations:

Outpatient visits can be done by video call when no physical tests need to be performed and no difficult message needs to be told. This already happens on a very small scale, for example, for dermatology and diabetes patients. The more extreme scenario that doctors visit patients at home has been excluded from the analysis.

Imaging diagnostics consists of ultrasounds, X-rays, MRIs and CT scans. Given the nature of current technology, ultrasounds could be done at home, but X-rays, MRIs and CT scans still require large machines and must be done in specially designed rooms. 

Surgical interventions should still be done almost exclusively in the hospital building, except for certain low risk interventions, such as inserting a contraceptive device, skin interventions and cataract surgery. 

Diagnostic activities can be done from home when the activities themselves are not dangerous. Some diagnostic activities are already primarily performed at home, such as sleep studies, where the patient can apply the required patches by following video instructions. Other activities are more complex logistically to arrange at home but can nonetheless still be done there, for example, pulmonary function tests.

Potentially half of hospital care activities could be provided at home

Other therapeutic interventions consist of a large, diffuse set of activities, where many are part of the surgical pathway and can therefore not be separated from surgical intervention. However, some specific therapeutic interventions, such as haemodialysis, light therapy and chemotherapy, are already performed at home to a small extent and can be performed at home on a much larger scale.

Nursing days can take place at home when the main purpose is to monitor the patient, for example, when a patient stays overnight in the hospital to perform a sleep study or is largely recovered from a surgery but the doctor needs to monitor the status of the patient frequently. Also, patients that are stable but still need to recover can, in many cases, do so at home. An example of this is patients with bone fractures. However, patients that are hospitalised for severe conditions, such as older people with pneumonia for example, should probably remain in the hospital.

Day admissions are mostly related to surgical or therapeutic interventions. Only when these interventions can be performed at home completely are day admissions in the hospital no longer needed for these patients.

The analysis found that especially nursing days, therapeutic activities, day admissions and diagnostic activities could be moved away from a hospital setting to patients’ homes. For example: dialysis could be performed almost entirely at home, and patients with diabetes don’t have to visit the hospital for regular check-up consultations or for blood tests, since this can easily be done using video calls and postal services. In particular the shift of nursing days to homes would have a massive impact on the volume of home care – even though the number of nursing days has already decreased significantly over the past 20 years, the impact is, from a financial point of view, described as “immense” on the back of the relatively high costs of delivery. 

Percentage of care that could be provided at home per ICD10-chapter

A similar assessment was performed for the type of disease (grouped by ICD10 chapters). The breakdown shows that diseases of the respiratory system, genitourinary system, circulatory system, nervous system, and digestive system in particular are treated more in the hospital now than they could be in 5 or 10 years’ time, all thanks to evolving technology.

Healthcare at home

The shift to home-based healthcare is made possible by technological advancements / innovation and the convergence of a range of current methods, find the authors. Through the integration of drugs and devices with diagnostics, disease management programmes, and clinical decision support – enabled by technology – hospitals will be able to shift clinical offerings from mass generalisation to mass customisation, paving the way for new therapies that may radically improve patient outcomes and can be provided at home. 

Connected health, known as cHealth, is another large driver highlighted by Gupta Strategists. cHealth is digital and technology-enabled integrated care delivery that allows for remote communication, diagnosis, treatment, and monitoring. By improving the digital connectivity between providers and patients, individuals can access the care they need, anytime and anywhere, and vice versa, doctors can monitor or provide healthcare remotely. Key cHealth examples cited that support the adoption of outpatient care are mobile health apps (mHealth), telehealth and wearable devices. “The rise of these technologies increasingly enables performing procedures or treatments of several DRGs at home”, state the researchers. 

The study further heralds the potential of wearables as a ‘game changer’. Through leveraging the power of biosensors, which can, for instance, be placed in a watch, a patch on the skin, implanted under the skin, or even swallowed like a pill, the applications can monitor a range of internal and external factors related to healthcare, such as motion, light, pressure, temperature, moisture, gas, chemicals and biomarkers. Feeding sensor information back into healthcare processes can, according to the authors, provide a wealth of intelligence, that in turn can be used to facilitate decision making and ultimately healthcare delivery.

The shift is further accelerated by the increasing availability of (digital) data, building largely on the benefits of two main factors. Using data, doctors can conduct an improved risk assessment on whether a patient can safely go home after a surgical intervention or during treatment, down the line lowering the threshold for care at home. The threshold can subsequently be lowered furthermore through better monitoring at home. When doctors are certain that they will be alerted in a timely manner when the safety of a patient is endangered, the decision to send the patient home becomes easier. And by closely monitoring patients, caregivers can intervene when needed, thereby minimise the risks of complications.

New responsibilities when care is shifted from the hospital to the home

Besides the medical side to treatments, the authors speculate that the delivery of healthcare in the comfort of patients’ own homes will in general also bolster client satisfaction. “Most patients prefer treatment at home to hospitalisation whenever possible: treatment at home is less cumbersome for patients, prevents hospital infections and saves valuable time.”

No place like home?

The transformation in the inpatient care segment will however at the same time bring rise to major changes to the structure and organisation of healthcare. The move will require stakeholders to take on new roles: individuals will be able to collect medical data on themselves and monitor their own health and nurses will take on a different, more supporting role in patient management. In the report, the authors use the ecosystem of an airplane as an analogy, placing patients in the pilot seat, and nurses in the role of co-pilot.

“Many patients will need assistance in piloting their own healthcare. Nurses will be the first in line to provide this help. As patients’ co-pilots, nurses will be expected to jump in and take control in certain situations. This will be a new role for nurses and a break from the hands-on proactiveness that tends to define the work of nurses today”, write the consultants. 

Doctors will as a result of the changes have to shift their perspective to larger groups of patients, in the analogy placing them in them in the role of an air traffic controller. “Doctors as air traffic controllers will be necessary to ensure each individual patient is headed in the right direction. This will be a very demanding job, as the amount of information that these air traffic controllers will need to process and the speed at which they will need to do so is much higher than in the one-on-one situations they are used to.”

Drastic changes in stakeholders’ roles and responsibilities

At a more macro-level, hospital management will increasingly become reliant on technologies and systems, sparking a transition towards becoming IT companies, while technology companies serving the medical sector will gradually become consumer technology firms, aimed at developing devices that are easy to use and as intuitive as possible so that patients can use them without intensive training. 

Reflecting on the transition set to unfold, the authors state: “As the development towards less care in institutions and more care at patients’ homes progresses, the impact on the care landscape will be enormous. All stakeholders are impacted and need to change their way of working.”

Several considerations will in addition have to be worked out in order to lay the fundaments for a transition, such as safety considerations, operational changes to value chains, trade-offs between cost and practicality and a range of regulatory and human capital challenges. The researchers conclude by highlighting that their estimate of 46% is a ballpark figure, and one that reflects the potential given (safe) technology that will become widely available in the coming ten years. “However, it does not mean that all types of this care will be moved to the home, since doing so might not be cost effective or might only be safe or feasible for a certain group of patients. Some shifts may in practice turn out too expensive, large or cumbersome. For example, although standard consultations can be done at home, patients with complications will still need to visit the hospital.”

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