What ‘no place like home’ means to the health care industry

As much as some patients benefit from receiving care at home, it’s not right for everyone right now. About 3,000 of Penn’s cancer patients receive care or supportive services in their home, but that only accounts for about 20 percent of patients receiving cancer care from Penn Medicine.

“Patients who receive really complex chemotherapy can’t really do that at home,” said Sarah Johnson, MBA, chief operating officer of Penn Medicine At Home. “For many of our patients, we want them in a hospital suite with access to rapid response in case they need it.”

In order for a patient to receive cancer treatments at home, they must “have a low risk of adverse events, have tolerated the treatment, and are likely to continue to tolerate the treatment well,” said Justin Bekelman, MD, the radiation oncologist who led the development of Cancer Care at Home. Their cancer drug must also be easy to transport and then refrigerate at the right temperature at home, if necessary.

Medical providers also have to account for what is involved if an adverse event does happen. “Some of these side effects are things patients would experience in the clinic—the same at home. If a nurse can help with those in a home care setting, then there’s no reason we can’t administer it at home,” he added.

Safety is also a concern for clinicians, especially for those traveling to patients’ homes in areas with high crime rates. Home care staff wear a device with a button that, when pushed, immediately connects them to security. That person can listen in and call 911 if necessary. Staff are also trained on safety protocols and, if desired, can request that security personnel accompany them to home appointments.

“It’s exceedingly important that we do everything we can to make sure our staff is safe when going into people’s homes,” said Doyle.

Penn also faces the same staffing shortages that have hit health care systems across the country, and without enough staff, home care services can’t happen. “The last two years have been extremely hard and challenging on our entire team,” said Doyle, including on nurses, therapists, social workers, physicians and leaders.

“We recognize that the job is hard and it requires commitment and dedication, so we’re looking at ways that we can accelerate recruitment and improve retention—all those things that make an organization an employer of choice,” she said.

While retaining the home care work force is crucial, so is making sure that their work is adequately funded. Home care services often fall outside typical health insurance payment models, yet health systems providing this care must find ways to be reimbursed, and not burden patients. In some cases, Medicare patients are charged higher out-of-pocket costs for not coming into a facility, said Bekelman.

While the Centers for Medicare & Medicaid Services (CMS) is anticipating a major jump in at-home care spending, Medicare only covers home care after a stay in an acute-care hospital, but not as a preventative to avoid a hospital stay, and many private insurers have similar limitations. “Payment methodology for home services should be expanded to allow for services outside of what they accommodate now,” said Doyle. “I’m hopeful these models will start to shift for home services so we can get paid for many of the treatments we want to provide that aren’t provided for under current regulations.”

Despite the complexity of who is going to pay for these services, administering them in the home does reduce costs, especially for cancer and infusion therapies. When patients are cared for at home, they don’t require a facility charge because the facility is their own personal space.

Even without a COVID surge driving demand for hospital space, it’s still good business sense to sustain and expand capacity at the health system’s facilities. Hospital closures across the region have already increased demand for the remaining inpatient beds, and industry experts anticipate more closures in the years ahead. For Penn Medicine, additionally, home care can relieve bottlenecks in access to specialists. For example, the Plastic Surgery department developed the Connected Approach to Recovery home-care program that mastectomy patients Lauren and Robin Magaziner used, in part, to free up physicians’ time spent in follow-up appointments. At the time, demand was so high that fewer than half of new patients, many of whom were newly diagnosed with breast cancer, could get an appointment within two weeks.

In the years ahead, Penn Medicine’s expansion of acute care offerings for patients in their homes is likely to continue—more patients, with more conditions, and more types of medications.

Bekelman expects that the types of cancer drugs they can give at home will expand, especially as the FDA greenlights more at-home administration. Several monoclonal antibody and other targeted therapy cancer treatments approved by the FDA in the last two years, for example, can be administered at home.

Penn Medicine At Home is further making strategic investments in expanding home infusion therapy across the region, with the integration of Horizon Healthcare under the full ownership of Penn Medicine Lancaster General Health (LG Health) in January 2022. It was formerly jointly owned by LG Health with Penn State Health and Tower Health. Horizon provides home infusion and enteral nutrition services in over 40 counties throughout Central and Eastern Pennsylvania. The collaboration between Horizon and Penn Home Infusion teams is still in early stages, Doyle said, but it has exciting potential both in terms of sustaining a wide geographic reach for Penn Medicine patients to receive home infusion across the region, and in terms of building a deep bench of highly skilled home infusion staff.

Penn’s kidney care programs, which already include at-home care for many patients, are expanding and innovating, too. In March 2022, Penn Medicine formed a joint venture with Nashville-based Evergreen Nephrology. The program has contracted with CMS to provide value-based care for Medicare patients with advanced chronic kidney disease or who are on dialysis, with the goal of reducing the need for emergency department visits and hospitalizations. Penn Medicine is the first academic medical center to partner with Evergreen, and the payment model is intentionally designed to improve patient outcomes while reducing costs. It will provide in-home and other support services, encourage and facilitate use of home dialysis, include initiatives to delay the need for dialysis, and expedite access to kidney transplants.

That means more patients will stay out of the hospital and receive the care they need at home while waiting for a transplant.

Akilah Johnson, CPhT, for example, started receiving dialysis at home for the first time just as she was starting ninth grade. As a result of receiving her treatment at home, she didn’t have to take time off school for dialysis treatments, or travel to and from a dialysis center several times a week. Johnson was able to graduate high school on time, earn a college degree in biology, and start a career in the medical field as a pharmacy technician, all without her life revolving around treatments for her chronic illness every other day—and over those years, the technology has also improved to make her care even more convenient.

“I’ve seen the changes in home care,” Johnson said. “Back in 2020, there were not many people doing home dialysis. It’s grown exponentially.”

Editor’s note: This article originally appeared in the Fall/Winter 2022 issue of Penn Medicine magazine in a longer version. It has been edited into four separate parts, covering an overview of home care changes for patients, how the COVID-19 pandemic affected home care services, the business growth of home care in the health care industry (above), and the impact of providing care in patients’ real-world and community settings.