No place like home

Robin and Lauren Magaziner got the bad news at just about the same time. After a relative learned that her breast cancer was tied to having a BRCA1 gene mutation, the New Hope, PA mother/daughter pair also underwent genetic testing, and found that they, too, carried the harmful mutation.

Along with other elevated cancer risks, a BRCA1 mutation brings a 55 to 72 percent chance of developing breast cancer over an individual’s lifetime, according to the National Cancer Institute. The Magaziners came to the same conclusion: Rather than having what Lauren called a “ticking time bomb” in their bodies, they both underwent double mastectomy with DIEP flap breast reconstruction, which uses abdominal tissue in place of implants.

Lauren, an author of middle-grade fiction, went first, in March 2022 and mother Robin, a retired school teacher, six weeks later. Each accompanied the other to appointments prior to surgery, providing shoulders to lean on at every step of their shared journey.

Afterwards, instead of repeatedly driving from their remote Bucks County home to their surgeon’s office in West Philadelphia, they both also received regular visits from Erin McCarthy, RN, NP, registered nurse case manager with Penn Medicine At Home. McCarthy did everything from adjusting medication to checking and eventually removing their surgical drains. One time, when Robin developed an open wound, McCarthy used telemedicine to contact her surgeon so they could, as a team, examine and address the problem.

“Erin reached one of my doctors right away, and I was able to get medicine quicker because of her,” said Robin. “She was able to get the care I needed before it got worse.”

Having care at home saved the Magaziners time and stress after major surgery. “I loved that I was able to do this right from the house, because otherwise we’d have to drive 40 minutes and then wait in a doctor’s office,” said Lauren.

“Longer in traffic!” Robin interjected.

Plus, “during recovery, I didn’t feel comfortable being in the car because the seat belt pulls on your chest and stomach,” Lauren said.

“The vibrations from the car can make it painful,” Robin added.

Not long ago, experiences like theirs were either hard to imagine, or were available most often in small pilot programs of innovative care models. In the past few years, though, turbocharged by the COVID-19 pandemic, an explosive growth in home care has been underway. Penn Medicine is working to forge the most efficient and effective paths through that change.

The expansion of home care

Penn Medicine provided nearly 730,000 home care visits for patients like Lauren and Robin Magaziner in the 2021 fiscal year.

The push towards offering patients more clinical care inside their homes and outside of medical offices had begun before the COVID-19 pandemic. But COVID prompted even more expansion of services offered.

“It made us re-think who needed to be in the hospital,” said Joan Doyle, MSN, RN, MBA, CEO of Penn Medicine At Home. “Patients, especially those who are chronically ill and/or are immunocompromised, re-evaluated whether they really wanted to go to a clinical care setting at all. There was an increased openness from providers and patients to see if this could work.”

It did work—and it’s sticking around. The Centers for Medicare and Medicaid Services (CMS) expects home care expenditures to reach $201 billion by 2028, a 73 percent increase from 2020. This growth has been enabled by both patients’ and providers’ desire to do at-home care, plus COVID-driven investments and advances in technologies for telehealth and remote patient monitoring.

Not only has the shift to care at home been better for patients, but it also keeps hospital beds open for very sick patients at a time when many acute care hospitals are closing, and cuts down on health care costs. A 2018 study published in the American Journal of Medicine, for example, found that home health care saved $15,233 per patient for the first year after discharge from the hospital, across specialties.

For a patient receiving a complex medication infusion at home, such as a cancer therapy, a broader array of home care is also available to meet their needs, like physical and occupational therapy, said Sarah Johnson, MBA, chief operating officer for Penn Medicine at Home. It helps practitioners get “eyes on a patient in their home and maybe see if there are stressors we can address,” she said. “You can find out about something you didn’t know before because their cancer team only interacted with them in at the doctor’s office.”

The benefits of receiving care at home can be broader than one might expect from a simple change of venue from a medical office. Treatment at home can also ease some of the added burdens that aren’t side effects from medications. It’s what Justin Bekelman, MD, a professor of Radiation Oncology, Medicine, and Medical Ethics and Health Policy and director of the Penn Center for Cancer Care Innovation, calls “time toxicity,” which is “the amount of time it takes just to be on the receiving end of all these medicines that can be truly life-saving and life extending.” Requiring patients to come to clinical settings also increases out-of-pocket costs for travel, parking, time away from work and, in some cases, arranging and paying for childcare.

Cancer Care at Home, a program Bekelman led which was planned to launch as a small pilot in early 2020 but rapidly scaled up during the COVID-19 pandemic, has already been shown to cut down on trips patients need to make for clinical services and time spent in the hospital. Patients with breast and prostate cancer were saved 12 outpatient visits per year—for injections they would typically need to receive every few months, for up to 10 years for breast cancer patients. Patients with aggressive lymphoma spent 25 fewer days admitted to the hospital when they were able to receive a combined-drug therapy infusion at home.

Breast reconstruction patients at Penn like Lauren and Robin Magaziner need 58 percent fewer clinic visits in just the first 30 days after discharge, according to a study Penn researchers published in NEJM Catalyst.

Technology for remote monitoring, safer home medication infusions, and more

Safe and effective home care at Penn Medicine has also had a big boost from combining advances in technology including clinical equipment and telehealth—and parlaying them into permanent modes of treatment in combination with in-person care at home.

Advanced infusion pumps make it possible to provide controlled medication at home as safely as in the hospital, even when administered by patients themselves.

A growing number of Penn Medicine At Home patients receive equipment that monitors their vital signs and symptoms to augment their scheduled in-home visits and telemedicine visits with a nurse from a virtual case management team. Nearly 700 telehealth devices have been deployed to patients’ homes. Penn Medicine Home Health has provided telehealth monitoring for more than 11,000 unique patients since the start of the pandemic, totaling more than 100,000 virtual visits.

Heart failure patients can have their weight and blood pressure taken at home and reported back to their care team virtually. Home palliative care patients are also treated through remote monitoring and then virtual visits. Post-surgical patients like the Magaziners are prompted to send text messages to update their care team about surgical drain output so their drains can be removed, at home, at the right time.

For Akilah Johnson, CPhT, who works as a pharmacy technician at HUP and has had kidney disease since her early teens, dialysis today is something she can do while she sleeps thanks to Penn Home Dialysis, a home care program that operates separately from Penn Medicine At Home. The small machine she uses for peritoneal dialysis is digitally connected to her care team. “They have a better picture of what your dialysis cycles look like at night and make adjustments so treatments are better geared toward what you need,” she said.

The ongoing improvements to remote monitoring technologies have helped to expand home care to help sicker patients than was possible in the past; they enable care teams to stay connected and know when a patient needs further intervention at home or truly needs to come to the hospital.