Family caregivers play a key role in homecare. The number of people involved is staggering: in 2013, 40 million family caregivers in the U.S. provided 37 billion hours of care.
Crucially, the number of adults living with chronic conditions is expected to significantly increase as medical treatments and applied technology enables more people with disabilities to age at home. Unfortunately, the number of family caregivers will not grow in proportion to the care needed.
Instead, the trend is in the other direction, as adult children move further away from their hometowns, families become smaller and those same smaller families either have working parents or are single-parent households. This family caregiver gap contradicts a fundamental assumption of Bundled Payment Plans that aging at home, which is preferred by most older adults, is also cost-effective. Lack of family caregivers may render aging at home impossible for many.
Public health professionals have recognized functional independence of an aging population as a national goal. This aligns with CMS’s six-step assessment scale for post-acute care functional measures, designed to capture the degree to which care recipients are either: 1. functioning independently without the need for equipment or caregiver assistance, 2. reliant on varying combinations of assistive equipment/caregiver assistance, or 3. are fully dependent on caregivers. The goal is to measure changes in care recipients’ abilities to manage their care or mobility over time and across post-acute care settings.
Technology is helping reconcile the mismatch between falling numbers of family caregivers. “Catalyzing Technology to Support Family Caregivers” suggests five categories of products that can make family caregiving easier:
- Online communities to educate caregivers, connect with one another and provide information
- Tools to help choose the right homecare agency or recruit, hire and pay direct care workers
- Apps to support internal family communications and collaboration
- Help with day-to-day tasks
- Remote Patient Monitoring (RPM) to check on older adults at home
HME that enables older adults to complete their activities of daily living, often with help from caregivers, reflects the standard applied by Medicare, Medicaid and commercial insurers for reimbursement—that is, the cheapest alternative. As older adults have traditionally been reluctant to pay out of pocket, HME manufacturers have had little incentive to improve the functionality of the equipment; rather the leading basic product design is a $150 mass-produced black manual wheelchair.
RPM and HME
Researchers have begun to evaluate the value of embedding RPM technology within common ADL assistive devices. Carnegie Mellon faculty is testing the ability of sensors embedded in a walker to predict the onset of dizziness and fatigue and, if indicated, tell the user to sit down or the caregiver to intervene. Early Sense monitors heart/respiration rates and motion patterns via an electronic device under the mattress to detect significant changes in those indicators while a person rests or sleeps. This allows physicians to detect changes in health status and intervene before the patient crashes. Such passive data capture and transmission renders RPM invisible to the older adult; allows caregivers awareness without being physically present; gives clinicians access to biometrics and predictive analytics; and avoids the need for emergency care.
Time to Reset?
Such innovations not only reduce the total cost of care, they create an opportunity to update HME design to promote cost-efficient self-care while simultaneously eliminating or reducing the risk for strained backs, shoulders and legs caused by the currently under-designed assistive devices. Hospitals and nursing homes know that the musculoskeletal injury rate of hospital and nursing home workers is six times the rate of the general workforce. This level of facility-based injury is being addressed via investments in sophisticated patient handling equipment and training programs. A similar vigilance should be applied to the home setting.
It will not be simple to transform HME. Hospitals undervalue it, seeing the equipment as commodities with low medical value. The lack of professional networks or access to capital for new manufacturing makes bringing a better product to market difficult for those with the vision to attempt a start-up that would lead to innovation. Wary existing HME companies won’t take on a new, affordable product due to high manufacturing costs.
Government, insurers and health systems, however, can overcome these obstacles. Post-acute care’s unique challenges require partnerships among different stakeholders: homecare agencies, HME companies, rehab clinicians and long-term care advocacy groups. They should sponsor competitions and pitch opportunities for older adults and caregivers to suggest equipment design improvements, judged by their capacity to promote self-care/mobility goals, reduce caregiving burden and capture biometrics important for clinical care and predictive analytics. Interested companies would be awarded cash prizes to cover prototype development. Simultaneously, targeted provisions in Bundled Payment Plans can indicate the potential for large, system-wide orders needed to entice HME companies to bring new products to market. Alternatively, the health care system can continues as is, waiting for the family caregiver gap to make it impossible for many older adults to age at home.