As a new generation ages into Medicare — some with complex chronic conditions, others with a penchant for an active lifestyle and many expected to live into theirs 80s and 90s — home healthcare models are changing.
Barbara McCann, who oversees clinical operations as chief industry officer of the franchise network Interim HealthCare, has been working in home healthcare since the 1970s. As a boomer herself, McCann sees home care currently in transition as it is serving two generations.
Government Health IT Associate Editor Anthony Brino spoke with McCann bout changing patient expectations, the long-term care crisis and whether Medicare should embrace telehealth.
Q: Amid this “grey tsunami” of aging populations in the U.S. and Europe, there are these notions of retirement 2.0 or aging 2.0 — it’s going to be different for those now aging into their 60s. Have you heard those terms?
A: I haven’t, but it makes sense to me. I’m one of those boomers; it’s going to be a different world for us and for our parents.
We’re going to live longer, significantly. Our parents may be in their eighties. It’s not unexpected that we’ll be in our nineties and older. In the years I’ve been with Interim HealthCare and in home care — I’ve been in home care since the mid-70s — the number of people over 100 has been amazing to me. We just had recently a 100-year-old who had brought over his 76-year-old daughter, and then his 50-year-old grandson. That had never happened before.
If you look around, you’ll see what at least appear to be baby boomers exercising, so for us I think the issue of knees, hips and replacements will probably come up even earlier than in the current generation. If you look at your grandparents or your parents, they often looked at that in their late 70s or into their 80s. We’re going to deal with that earlier, if nothing else because we expect greater function and we may be working longer.
Also, chronic disease: When I began in home care, people died from cancer, people died from heart attacks. Now they live for decades after. While that’s part of the wonder of American medicine, it also means that chronic diseases may develop as a result of some of the medication. There will be more, if you will, partner chronic diseases. If you’re living into almost 90 with heart failure, you’re at risk for diabetes, you’re at risk for ulcers on your leg, because your circulation isn’t as good. So a much more diverse knowledge is required of practitioners, and I think a different understanding of the next generation coming and their expectations for function and participation in life.
Q: Has Interim changed how it approaches care in response to changing expectations?
A: We’ve certainly embraced telemonitoring; telemonitoring is different than telehealth. What it does is acknowledge that someone has a chronic disease, and for them to stay at home safely, they need to begin to understand their own symptoms and call a doctor and not put it off so they don’t wind up in the emergency room or in the hospital. Telemonitoring for our patients lets them learn to report their symptoms, often daily, and then pass that on to the doctor. We’re really focusing on helping them learn to self-manage their disease, and it’s because of the multiple diseases that often occur. Few people over 75 have only one chronic disease.
The other change is we have refocused all of our patient education material, about six years ago, to not just respond immediately to a heart attack or your joint replacement, but rather to stand back and say, ‘What will it take for you to live with this situation? For heart failure, diabetes, COPD, it’s an emphasis on best managing what’s happening to you day-to-day. Our physical and occupational therapy expanded: let’s learn new exercises, to use alternative muscles to make it easier for you to stand without becoming short of breath, how to do different breathing, how to conserve energy, so if you know you’ve got your grandson’s birthday on Sunday, then on Saturday you need to rest.
Q: CMS is considering expanding Medicare coverage for primary care telehealth visits in designated rural areas. Do you think more tele-consults could be covered, not just in rural regions?
A: If our goal is to search for efficiency in healthcare, we need to find the best solution at the lowest cost. Medicare patients may not always need someone present but they do need support and they need to learn how to manage their diseases. They often need to just get confirmation: Am I taking the right medication? I’m not feeling well today, is this ok? Is this abnormal for me to have these symptoms? Over time, a tele-monitoring device is the lowest cost option for doing this well. But right now, it’s not considered a reimbursable way of contact with a beneficiary.
As we move more and more into the digital age, tele-monitoring and using digital technology makes more and more sense. I think we could see over time this become the easiest, lowest cost way to stay in touch.
It will still take a professional to make a judgment, so couldn’t we look at a broader scope at an effective way to intervene with chronically ill patients? You’re only going to avoid emergency rooms if people can get feedback and tele-monitoring accomplishes that.
Q: Aside from telehealth, what do you think about using personal tech products like iPads in senior healthcare?
A: Certainly not all of our 80- and 90-year-olds are totally responsive to that. But they are responsive to hitting a button and letting people know they need help. And they do respond to devices reminding them about medication. But the baby boomers — late 60s, early 70s — they love tablets. I was just watching one of our patients the other day, who’s really only just 65. At lunch he pulled out his iPhone that his grandson had taught him how to use and he was calculating carbs on the menu, because he’s pre-diabetic and he doesn’t want to start taking medication.
If you look at the baby boomers, we all know how to use computers; we’re pretty independent. I think apps are going to offer an incredible boon in helping us understand how to be healthy and when to get ahold of the doctor earlier.
Q: There’s certainly a need for residential and long-term nursing care facilities, but several surveys have found that a lot of seniors want to “age in place,” living in their homes if they can — and long-term care is of course very expensive. Do you see home health assistance as sort of a more affordable alternative?
A: I do, but with an important caveat. Boomers my age need to understand and be aware sooner of changes in their parents. A lot of people write off symptoms to aging, and it may not be. It may be a new prescription that’s made them fall; I went through that with my own dad, and came to find out the medication hadn’t been tested on people over 75.
Also, we need to understand social isolation. They might need help just with grocery shopping and housekeeping. Most people that age don’t bathe everyday, but maybe you need bars in the shower and a raised toilet seat. The number of people that fall in the bathroom is just terrible. Then there’s helping people with rehabilitation therapy. When they leave the hospital, they’ve lost a lot of muscle mass. They have to regain their strength.
How I like to think about it — and I’m a medical social worker by training — is the stuff that keeps us out of the nursing home is our ability to get to the bathroom and back, get out of bed, out of chairs, without falling, and being able to at least receive meals and eat. Just those things alone can improve people’s conditions and keep them at home much much longer than ever before.
Q: Given the Affordable Care Act’s focus on reducing hospital readmissions and what some have called a long-term care crisis that’s really putting pressure on Medicaid, do you think Medicare could be covering more home care, even perhaps with some cost-sharing?
A: They’ve pretty much stepped away from that for decades. But I think what’s helpful for all of us — consumers and caregivers — was the long-term care council that’s part of the fiscal cliff deal. There’s millions of seniors not in need of acute care, just experiencing destabilization or slight decline, and that’s a national problem that I don’t think we have a solution for. There’s probably a multitude of solutions, but there’s not to my knowledge a national strategy to look at the long-term needs of people they age.
Q: The long-term care commission is set to release suggestions in the fall. If you had a spot on there, what would you suggest?
A: Are there services that can be available in a community of older people at a reasonable cost to help them do daily functions — acknowledging that at a certain point, that’s where the aging is going to be? We need more coordination, which includes a primary care physician. I like the parts of the Affordable Care Act that have the concept of having a physician and a team that’s responsible for a lifetime care plan, so that as you age you get regular checkups; if you’re not doing well, somebody comes to the home and evaluates you on a regular basis and anticipates needs. With ongoing access to wellness, prevention and functional status, we may keep people in the community a little while longer, with not as high a cost as waiting for them to get to a point where they’re in a hospital and we’re not able to do anything else.
The other recommendation I would bring up is to have the discussions about alternatives as disease progresses, and what their wishes are — instead of what the latest intervention is. Do we give folks that kind of conversation? When someone gets out of the hospital, who’s 85, someone could actually sit with her and the family and say, ‘We’re going to be able to bring your function back to a walker; right now, I’m not sure if you’re going to be able to walk without that, and you aren’t going to be walking 4 to 5 miles again like you were 15 years ago.’ It’s conversation about what you can do in your life and what your goals are.
