Why Home-Based Care Needs Home Modification

The spread of COVID-19 in institutional settings has caused millions of families to question the safety of these facilities. Assisted living, skilled nursing and other congregate housing models will likely never again occupy the image of safety they did before the pandemic. Amid this turmoil, homecare agencies and home medical equipment providers have an opportunity to increase their role in supporting the health and well-being of older adults. Is this the tipping point for aging in place and health care at home to be better recognized as a preferred solution? What will be different—and how can homecare seize the day to lead in creating a more robust, profitable and appreciated business?

What’s Needed for Aging in Place

Though homes are the preferred housing and care option—more than 80% of older consumers want to remain in their homes even when they need assistance—homecare has never had the significant attention it warrants. While fewer than 10% of older people ever live in senior housing or even residences that can be described as the “55+ lifestyle,” those with more resources often choose some form of congregate senior housing. The fact that some 40% of COVID-19 deaths have occurred inside nursing homes is refuting the notion that congregate senior housing is the safest place to be.

The ability to live in one’s home of choice through changes in health status without being forced to move is a clear alternative to senior housing. Aging in place and the homecare industry are closely aligned. Many people, even with long runs of good health and thorough planning, will still face a decline in their health. Whether the realties of health and care needs are minor or serious, homecare can be a significant factor in someone’s ability to age in place.

However, in order for seniors to age in place effectively, they must have a way to meet their needs. In addition to homecare, this means having transport services, food and meal delivery, adult day care (which was on the upswing with innovative programs and models before the pandemic and is bound to return), durable medical equipment, home and yard maintenance, security systems, technological monitoring and management, and more.

Four Factors for Change

Beyond the need for robust, coordinated home services, the path forward for the homecare industry will also be influenced by the following factors:

1. There are some dominant players and franchises, but the homecare industry is still fragmented among many operators, some of which are small and family-owned businesses, with old-style, analog operations in a single location. This fragmentation makes it difficult for the homecare industry to act as one voice when pushing for policy and public image changes.

2. The pandemic has seen a significant increase in the use of telehealth. Although it had long been on the fringes of innovative medical care with great promise, telehealth services remained largely nonreimbursable under Medicare until the pandemic struck. After the Centers for Medicare & Medicaid Services (CMS) relaxed the reimbursement rules for telehealth in March, the use of telehealth surged. By April, 43.5% of all Medicare primary care visits were being conducted through telehealth—up from just .1% in February. Medicare’s crisis-driven decision to reimburse for telehealth services is a trend that is bound to accelerate after the pandemic. Telehealth means more health care at home and that translates directly to more homecare.

3. In addition, CMS recently approved payment for structural modifications as a Medicare Advantage supplemental benefit, thereby sanctioning the funding of home upgrades. This change indicates that CMS is beginning to recognize the role and value social determinants of health can play in reducing costs.

4. Homecare has struggled through the difficulties and complexity of personal protective equipment, exposure management and quarantine requirements in the past few months. This experience will improve protocols and inform future practices, adding to the sophistication of the homecare industry.

Another Curve to Flatten

The overarching lesson learned during the pandemic is the concept of “flattening the curve,” or taking preventive measures to avoid overwhelming hospitals and the health care system. The same concept applies to the wave of aging baby boomers whose greater numbers and high health care costs will push the limits of our health care system. Flattening that curve demands greater attention to aging in place.

Two significant developments are necessary for aging in place to reach its potential:

Coordinated and comprehensive services

I wrote a white paper, “Aging in Place 2.0: Solutions to the Home Care Challenge,” published in 2010 by the Metlife Mature Market Institute, that describes a coordinated and comprehensive system for managing the services needed to age in place. This coordinated system of services is part of what attracted consumers to the promise of senior housing, because management hones care to residents’ ever-changing needs.

For this value to be recreated in the home, the service industries mentioned above must begin to see themselves as one industry, much like plumbers and roofers and electricians all see themselves as separate trades within the construction industry. Once homecare, food delivery, transport, health care, etc. all see that their best route to success comes from working together, aging in place can reach its promise.

Updated home environments

“By 2035, 17 million households will include a person for whom stairs, traditional bathrooms, and narrow doors pose challenges… Yet only 3.5% of U.S. housing offers [accessibility features].”

—Projections & Implications for Housing a Growing Population, Harvard Joint Center for Housing Studies, 2017

Typical home design features predate the physical conditions we now know are associated with aging. Updating home design can have a significant impact on health and long-term care costs. Grab bars, for example, can reduce the number and severity of falls that not only cause huge medical costs but also are a leading factor in upending lives, precipitating decline and forcing people to move from home. An updated home is easier to return to after a health incident or hospitalization, thereby increasing the use of homecare over more expensive residential rehab.

Though the idea of updating homes with grab bars, curbless showers, wider doors, better lighting and no-step entries is intuitively obvious and is of growing interest to the home remodeling industry, the benefits to other players is not as clear. With a well-designed environment, the homecare industry benefits by improved client and employee retention and reduced caregiver injuries. Benefits for other sectors are briefly described at homesrenewedcoalition.com.

Policy Matters

The new positioning of aging in place impacts two other stakeholders. One is the consumer, whose decision-making process will be forever altered by the pandemic experience. The second is the payer and provider industries. Due to economies of scale and the fairly well-recognized wisdom that home-based care can offer better clinical quality at lower cost than institutionalized care, the long-term care, Medicare Advantage and health care systems will also benefit from
a better defined, more robust aging-in-place system. They, too, will want a role in supporting the new positioning of aging in place.

As telehealth becomes the “new normal,” housing updates are a commonsense way to ensure an effective platform for delivering health care and other support services in the home and reducing health costs for individuals, families, the health care system and the country. In this sense, the most important infrastructure for the country to upgrade is the housing stock used by aging seniors. To achieve that goal, this issue needs to be more central to aging and infrastructure discussions and policy.

How can homecare seize this opportunity to lead in the reenvisioning of senior housing and care? The answer lies in repositioning homecare as part of a robust, comprehensive and coordinated aging-in-place industry. As part of a holistic approach, homecare joins together with other senior services that, together, are greater than the sum of their separate parts.

Reimagining the position of homecare as part of a newly comprehensive and systematic lifelong community industry is a good strategy. But realizing the
potential benefits to and increased influence of the now-siloed players requires recognition, awareness and a willingness to come together.

This broad coalition of business and community leaders working together is the strategy behind the organization I have founded, the HomesRenewed Coalition. The coalition is both the cross-sector trade group of the burgeoning aging-in-place industry and the public relations and advocacy arm of the new industry. To this end, the coalition is launching an advocacy campaign for tax incentives to update homes.

Timing is critical. Tax policy will be high on the agenda early in the next administration, no matter who is in the White House. On behalf of our growing constituency—the businesses, community-based organizations and consumers whose lives and livelihoods will be enhanced by the new aging-in-place industry—we are developing a bipartisan tax policy to secure a tax credit or incentive for home modifications in the new 2021 Congress.

HomesRenewed Coalition is the trade group of the new aging-in-place industry. Working together, our collective voice will be heard on Capitol Hill, Main Street and Wall Street. You can play a leadership role. I urge you to check out our website and join the bright future of housing and care for older Americans.