The Affordable Care Act added a section to the Social Security Act known which established the Hospital Readmissions Reduction Program. Under the new fines as described in an article by Kaiser Health News, three-quarters of eligible hospitals will be fined in the program’s third year. Fines totaling $428M will be levied from payments of Medicare patients, not limited to those who were readmitted. I first wrote about the role of role of digital health tools in reducing readmissions in 2011 prior to the program going into effect. Digital tools have been since been developed for providers and offered by entities including the Agency for Healthcare Research and Quality . Technology is being touted as a savior for readmission penalty reduction. But as I have stated many times, technology offers tools which only become solutions in the context of processes involving humans and aimed at solving specific problems. The topic of hospital readmissions is important because no one wants to rebound back into a hospital after a serious illness but popular primarily because of its financial implications. These regulations are part of the historical Medicare-provider cat and mouse reimbursement game that has been taking place for decades. But I digress. Patients and caregivers today are more concerned about what support THEY have when discharged from a hospital as well as that which can help them avoid an initial hospitalization.

Information regarding coverage home care in the USA is available at Medicare and Home Care. An interesting comprehensive overview Home Care Across Europe furnishes information comparing needs and services among nations. Home care is more important than Readmission data because:

1. It can affect initial as well as repeat hospitalizations. The focus of readmission rates misses the point of what got the patient in the hospital in the first place. The management of a chronic disease is regarded as more important than its prevention (or at least the prevention of its presenting complications). Digital patient education tools might succeed where verbal encounters and/or written materials haven’t. Digital tools in the form of apps are ideally interactive, can easily be shared with caregivers, contain incentives and have a social component.
2. It applies to people of all ages, not just patients. As we now know too well, chronic diseases are beginning in childhood, linked to unhealthy lifestyle behaviors. Young people are all digitally ‘connected’. Therefore digital tools are likely the best (and possibly the only) way to engage them. Addressing chronic disease prevention in young people is the biggest and best investment in healthcare. Addressing the readmission problem, primarily in the Medicare population misses the boat with regards to population health management and the potential for digital tools in other groups. Aging at home should be applied to ALL ages (after all aging, by definition, is a lifelong process).
3. The implications for the economy and healthcare outcomes are greater. Thinking of hospital readmissions certainly has the patient as a focus, but limiting the readmission time to 30 or 90 days is really not addressing the core problem which is how to institute processes at home which lead to better outcomes. The importance of medication literacy and reconciliation and prompt follow-up appointments are self-evident. Social workers do their best to assure adequate home health concerns are addressed, but they are limited in purpose to meeting regulatory requirements which many times have nothing to do with the patient’s individual needs or ability to meet them financially. The threshold for furnishing adequate care is many times dictated in an all or nothing fashion based on whether the patient is on Medicaid or not.
4. The market for digital health technologies is greater. People who are not recovering from a recent hospitalization require less acute monitoring. Devices which are directed towards wellness or the prevention of complications of chronic diseases (as opposed to actually managing the chronic disease) have been declared not necessary for regulation by the FDA. This opens the market for less costly (and potentially more impactful) mobile technologies.
5. The impact on caregivers is greater. According to a report by the AARP Policy Insititute, the ‘caregiver support ratio’ will dramatically plunge. Between 2010 and 2030, the population between 45 and 64 years old will increase by 1% while those over 80 will increase by 79%. The ratio is expected to drop from 7 potential caregivers for every high risk person (over 80 years old) to 4 to 1. Aging at home is where the rubber meets the road for caregivers. While the patient is recovering from a recent hospitalization, Medicare pays for some home health services (though woefully little with legislation which continues to decrease services). Digital tools including apps will one day deliver informational resources, logistical help with medical equipment, health aid scheduling and visiting nurse assessment and care. While apps today don’t cover much of this, there is a growing group of apps geared to caregivers. Some examples are: Balance: for Alzheimer’s caregivers, Care Zone, Elder 411, and CarePartners Mobile. Online web-based tools include: http://tyze.com/. Apps for caregivers have begun to attract general media attention. Aging at home is by far a bigger issue for patients and families than readmissions because of the longer-term benefits to all involved. Sure, readmissions disrupt life but aging at home is what we think about more and deserves more attention. Payers including the government need to make aging at home, not an institution, the focus of resources and investment. It’s what Baby Boomers who are becoming seniors of the present and future will demand.