Moving Cancer Care into the Home with The Huntsman at Home™ Program (Part 2)
In June, we visited with Dr. Kathi Mooney from the Huntsman Cancer Institute in Utah to learn about her research surrounding the Institute’s Huntsman at Home cancer care program. We followed up with Dr. Mooney to understand her vision for the future of home-based care and what policies must be advanced for further adoption.
What is your vision for future adoption of at home care for cancer patients?
I believe that home-based cancer care offers a new pathway for patient-centered cancer care. We need to study what aspects of cancer care can be safely delivered at home. Thus far, we know that many acute episodes from treatment-related side effects and, early discharge to complete hospitalization at home after procedures for disease progression can be safely treated at home.
The Penn Center for Cancer Innovation spurred the development of Penn Medicine’s Cancer Care at Home program to evaluate chemotherapy infusions at home and is now safely providing home chemotherapy to nearly 3,000 patients with cancer a year.
"[Home-based Care] adds the third leg to a 3-legged stool of cancer care- hospital, clinic, and home." - Dr. Kathi Mooney
This is only the beginning of rethinking how and where cancer care is given. It is a transformative innovation that not only requires study but significant workflow infrastructure, regulatory, and payment policy development in order to sustain it. We know that patients and their families are enthusiastic about care in the home, it maintains and improves their quality of life, it protects immunosuppressed patients from viral and nosocomial exposures, it decreases travel burden and it improves our ability to prevent or earlier detect and treat cancer-related events that now require emergency department use and often rehospitalization, as a result, it decreases health care costs. It also frees-up hospital beds so patients requiring diagnostic procedures, surgical interventions or other hospital-based procedures can receive them in a timely way.
How can greater adoption occur in rural settings – specifically in lower income settings?
I think we first need to study models of home-based care in rural communities. As we understand what works best in rural communities, we can promote broader adoption. It is important that home-based care not be reserved for patients lucky enough to live near a cancer treatment facility. We perpetuate an access disparity when we do not address care needs for those at geographical distance from cancer treatment centers. While challenging to adapt, both advances in technology and local partnerships can make geographic outreach and care possible.
Home based models of care in lower income settings- whether urban or rural- helps providers understand the social determinants of health that are adding to the burden of a patient’s disease, their ability to participate in their care and the treatment decisions they make. When we only see patients in the hospital or clinic settings, we miss the full context of the patient’s experience in dealing with illness. By providing home-based care, we are more effective in identifying and bringing in resources that help to address these factors that add burden and impact outcomes. It also opens our eyes to advocate for better coordination of care and services to address social determinants of health in a meaningful way.
How will the increased adoption of at home services impact brick and mortar operations like the Huntsman Cancer Institute?
It is important that we plan for growth in cancer services. Huntsman Cancer Institute has increased patient volume and a very large service footprint and Huntsman Cancer Hospital operates at capacity. Even though we are improving cancer survival, we have to recognize that the number of people in our country being diagnosed with cancer is increasing due to the growth and aging of our population. Rather than just adding more hospital beds and expanding emergency departments, we also need to better utilize the bricks and mortar space we have. One of those ways is to rethink hospital bed utilization, using home-based services to prevent and avoid hospitalization and to limit the length of appropriate hospitalizations by transferring patients’ home to complete acute based care. This will allow cancer programs such as Huntsman Cancer Institute to serve more patients and better utilize care delivery sites.
Huntsman at Home™ Clinical Team (2018)
What obstacles exist today that might prevent greater adoption of at home services?
The primary obstacles to home-based care relate to it being an entirely new site for acute level services and as such, current health care infrastructure, regulations and payment models do not facilitate care in the home.
We have to recognize that to sustain a transformative innovation requires building out existing infrastructure, removing restrictive regulations, adding enabling regulations and developing payment models that cover costs and promote model uptake.
The Covid-19 pandemic has resulted in some temporary national changes to regulation and reimbursement that aide home-based care- notably broader payment for telehealth services and the CMS waiver that allows Medicare coverage of hospital at home services at the same DRG rate as inpatient care. However, because these provisions are only temporary, it is unknown if any components will be made permanent or retained with modifications. This uncertainty delays uptake and sustainability.
Are there specific policies (regulatory or legislative) you would recommend to further advance the adoption of home care models?
There are many and we discover new ones every day. Current barriers include infrastructure, regulations, and payment models.
In terms of infrastructure, most health care systems do not have infrastructure to incorporate home-based services. Most existing home health agencies do not have compatible electronic health records systems that can be integrated with the health system’s hospital and clinic-based system. Each are set up with different communication capabilities, documentation style, order transmission, particularly transmission of pharmacy orders. It is expensive and time consuming to address interoperability and as a result there are disincentives to health care systems to add home-based services.
In addition, workflow processes within a hospital are not always compatible with workflow for the home. For example, order sets and pharmacy procedures to prepare antibiotics for home infusion versus traditional hospital infusion are often different. Infusion pumps for home infusion are often different than what is available in the hospital and requires different packaging and administration. In addition, current regulations and reimbursement may favor inpatient infusion or even prevent payment for antibiotic infusion at home. There are often co-pays for the patient for outpatient services not found if the patient is hospitalized, thus disincentivizing home services, even if the patient prefers the home.
Currently, home-based services require a great deal of ‘work arounds’ to follow current regulations and many patients do not qualify because of insurance restrictions. If home-based care is going to become the 3rd leg of the cancer care stool, then infrastructure, regulation and payment models must adapt to be inclusive of these new home-based care models.
What technological advancements are coming that might further improve at home care?
Technology is a bright spot with many companies developing or have available technology that improves care at home. Telehealth connecting patient and provider is an area, due to the Covid-19 pandemic, which has had, at least temporarily, wide adoption and study. I think based on this experience, evolving telehealth platforms will become easier to utilize in the home by patient and their families. Improvements should also come with technical aspects of remote physical exam quality and capacity. Remote ePRO systems (patient reported data) are widely available and serve a growing role to monitor patients during subacute care to prevent acute episode escalations.
In addition, passive remote wearables and sensors will become more sophisticated and reliable allowing detailed monitoring and early identification of physiologic and behavioral changes that herald signs of deterioration or an impending acute episode. Eventually this will come together with virtual care centers monitoring patients remotely coupled with the deployment of in-person care.
An important barrier to overcome is availability of stable and good quality internet connections at home. As national efforts take force to improve infrastructure including internet, home-based services will benefit. For now, inclusion of internet hot sporting and temporary service as a part of home-based care will address some of the access inequities. This is important so as not to perpetuate care disparities in new models of care delivery. Secure real time communications systems for patient data streams to the care team is also important and efficient HIPPA compliant communication platforms among the on-ground and remote care team members is essential. In addition, point of care labs and imaging is primed to improve.
How will greater adoption of home care services impact the healthcare workforce?
Right now, there are significant issues with the healthcare workforce in terms of numbers and resiliency from the demands placed by the Covid-19 pandemic. The development of home-based care will provide more options for health care workers in terms of career choices. There will be choices around virtual care positions as well as in-home positions.
Many healthcare providers enjoy working with families at home and being in communities rather than health care facilities, while others prefer the immediate access to colleagues in a facility and providing care in the traditional brick and mortar setting. People self-elect their work setting. For those new to home-based care, training is needed to understand approaches to home-based care which is different from a hospital or clinic; for those grounded in home-based care, training is needed to add acute level assessment and cancer care skills not currently found in traditional home health. For those in the virtual care settings, comfort with technology and its effective utilization are needed.
We have found with Huntsman at Home that initially there was some turnover as our staff experienced the in-home setting versus the hospital or clinic settings that they came from. We now have a very stable healthcare workforce and have developed an orientation program that is sensitive to the adjustment from brick-and-mortar delivery to home-based delivery.