Safer, cheaper and healthier: it's time to look again at home care for older people

The COVID-19 pandemic has exposed the strengths and weaknesses of global healthcare systems. One area it has shone a light on is home care, both its benefits and its challenges. The industry delivers services such as doctor visits, nursing services such as wound care and naso-gastric tube change, chronic disease management, bathing, physiotherapy services, and non-clinical services as medication reminders, bathing and companionship.

The pandemic has up-ended institutional healthcare by limiting access to healthcare institutions as hospitals struggle to accommodate COVID-19 cases. Elective surgeries have been placed on hold, therapies have been interrupted and consultations curtailed. At the same time, the pandemic has exposed the vulnerability of nursing homes and skilled nursing facilities, which have seen rapid spread of the virus and have borne the brunt of COVID-19 deaths. In the US, 40% of deaths from this disease have been in nursing homes, while in Europe, 50% of deaths occurred in such facilities. In Canada, the figure has been as high as 80%. Staying at home has been the safest way for seniors to protect themselves during this pandemic, and to receive their needed medical services.

Even before the pandemic, home care has been a preferred care model for seniors. As people age, their biggest fear is loss of independence. In a 2007 study in the US, 26% of seniors said that their top fear was loss of independence. This was followed by 13% who identified moving out of the home and into nursing homes as their top fear. Death was the top concern of only 3% of respondents. The same survey showed that 89% of seniors believed it was very important to continue living at home.

Such feelings are understandable. Living at home ensures that seniors can continue to make decisions about their daily lives and are plugged into their social networks. Care is more easily personalised, and seniors enjoy a higher quality of life and greater personal happiness.

Home care has shown to be cheaper than institutional care, with improved patient outcomes. A 2019 research study that examined 17 million Medicare hospital admissions between 2010 and 2016, comparing home care and admission to a skilled nursing facility, found that home care was associated with average savings of $4,514 in the 60 days after hospitalization. With the use of technology aids such as personal emergency response systems and tele-monitoring, costs decrease further, as patient outcomes improve. In a 2016 study of the home health industry, home care providers were asked about the impact of the use of telehealth. The largest impact with telehealth reported by respondents was a 75% increase in overall quality of care, an 63% increase in patient satisfaction, and 63% lower unplanned hospitalizations.

In spite of its benefits, choosing home care can be challenging. At higher levels of frailty and with conditions that require more clinical care, home care may not be viable or safe. Home care also requires greater caregiver participation, most likely from family members. The burden typically falls disproportionately on female family members, who need to do more to coordinate and oversee care, and fill in care gaps. They face skill inadequacies, and experience greater stress and anxiety in their informal caregiving roles. In the EU, women represent 62% of all people providing informal long-term care to older people or people with disabilities in the EU. Women of pre-retirement age (50–64) are most likely to be providing such care. This engenders greater inequalities for these women as they retire.

Globally, the home care industry suffers from workforce shortages, as the demand for home care aides outstrips supply. Though the supply of trained personnel is a problem across healthcare, in the home care segment, the deficiency is compounded by low wages and a lack of respect for the profession. In many countries, including the US and Singapore, prices are set by government reimbursement rates. The lack of political will to raise these prices effectively caps wages for home care staff, and affects investment in staff training and benefits. Because they enter patient homes and work alone, home care staff are at higher risk for verbal and physical abuse, rendering the industry even less attractive. Unable to grow the domestic workforce, many countries rely on immigration and temporary foreign workers to fill these roles, but this brings its own problems.

Compared to institutional care, the global home care industry is only lightly regulated, and this raises questions about quality and standards. Technology adoption remains low, even though this has the potential to improve productivity and effectiveness.

Post-pandemic, governments should relook at home care as it provides a safer, more affordable and higher-quality option for ageing seniors. This means reviewing how countries organize and finance healthcare, to move more budget and resources into home care. We can make home care more affordable and accessible for families by ensuring that it can be financed by public and private healthcare insurance. Raising subsidy rates for home care will help raise the wages of home care worker.

To enable more families to choose home care, we need to provide more information assistance and community support to informal caregivers. We should channel more financial resources to supporting unpaid caregivers, such as subsidies for families on home care and tax credits for informal caregivers.

We need to better define standards and improve regulation of the home care industry. These will improve care quality, raise training standards and further professionalise the industry. Home care also needs to be better integrated with hospitals and other types of community care, so that seniors can enjoy seamless multidisciplinary care across the care continuum. Governments should promote the use of technology in home care, especially since the advent of 5G and cloud computing can enable telehealth and other innovative care models that could lower cost, improve care outcomes and increase staff productivity. Technology can also play an important role in care integration.

Many countries have started to embrace community care as a way to improve quality and lower healthcare costs. The Covid 19 pandemic has given an additional impetus to the movement away from institutionalised care. Now is the time to make the necessary policy decisions to embrace home care and radically change the way our healthcare systems work.