We frequently hear that the U.S. healthcare system is broken. Our costs of care are skyrocketing and health outcomes are poor. Healthcare debt remains a major problem for families with chronic illnesses. If there is any benefit to the COVID-19 pandemic, it is the shift from hospital-based care to the home- based care model. This shift from a hospital-centric model is the beginning of a shift from centralized medicine (hospital centered) to decentralized medicine (patient-centered).
Decentralized medicine or patient centered medicine is a medical care model that brings healthcare to the patients where they reside. Decentralized medicine takes the focus of care out of the hospital and to patients in their home environments. Decentralized medicine encompasses the continuum of care including home nursing, home based physical rehabilitation, telemedicine, palliative care, and hospice care. All these services enhance patient autonomy and promote wellness and healthcare financial stewardship. Theses services utilize a team approach to patient care management. As such, collaboration and communication is key across the continuum of care.
The whole continuum of care consists of wellness, physician, hospital, home, palliative and hospice-based care. Decentralized medicine focuses on home based programs to keep patients in their homes.
Home-based care: Image from: Serena, Thomas & Yaakov, Raphael & DeLegge, Mark & Mayhugh, Tim & Moore, Sarah. (2018). Nutrition in patients with chronic non-healing ulcers: a paradigm shift in wound care. Chronic Wound Care Management and Research. Volume 5. 5-9. 10.2147/CWCMR.S155114.
Wellness care and preventive medicine are becoming a focal point of mainstream medicine. True effective patent health care is patient wellness and preventive health. This includes healthy diet, exercise, healthy relationships and mental health. Lack of care from a wellness perspective leads to utilization and engagement in the medical arena.
Primary care providers are the main gatekeepers for patients across the healthcare continuum. They serve the role to prevent illness, screen for acute illness and management of chronic disease. Primary care physicians help establish plans for prevention of hospitalization, recognize the need for home health or skilled nursing services. Telemedicine has become a key tool for primary care during the pandemic. Primary care physicians have the benefit of establishing trust relationships with patients and their families. As we shift to a decentralized healthcare model, primary care providers will be a driving force.
EMERGENCY CARE/ HOSPITAL CARE
Utilization of emergency and hospital care are high cost for patients and insurance providers. A stay in the hospital can cost tens of thousands of dollars per day. It is not uncommon for patients to remain in the hospital for days as suitable placement is found for patients such as skilled nursing facilities. As the decentralized model of care is implemented fully, hospitals will be reserved for the sickest patients who require surgery and or intensive care.
Skilled nursing facilities remain a key component in the continuum of care. Patients are not well enough or able to care for themselves independently, but not sick enough to require hospitalization. Post-acute stays can be very effective for those patient who require physician rehabilitation. Typically, for the patients who are able, the goal is to return home.
HOME BASED CARE WITH CHRONIC DISEASE SYMPTOM MANAGEMENT:
The American Hospital Association partnered with the Center to Advance Palliative Care and asked hospital leaders to reexamine their approach to palliative care, identify patients needing additional support and build a care plan centered on the whole patient, both clinical and emotional needs. In 2018, Congress passed the Creating High-Quality Results Necessary to Improve Chronic Care Act (CHRONIC) to expand home based palliative care.
Palliative care is specialized medical care that focuses on relieving the symptoms and stress of any serious illness, ideally alongside curative treatment. Palliative care will play a key role in the decentralized medicine care model. Because it focuses on the highest need and highest cost patient segment, palliative care is an essential strategy for population health management.
Hospice care is a compassionate model of care of those with end-stage disease processes. Hospice care provides symptom relief for patients as the disease progresses while usually allowing patients the dignity to remain in their own homes surrounded by family.
SUPPORTING A DECENTRALIZED MODEL OF CARE:
The decentralized healthcare care shifts the focus of the continuum of care from the hospitals and institutions to the patient-centric, home-based model of care. Telemedicine, home health care, primary care and palliative care will play key roles in keeping patients at home. The logistics of proving patients with the supplies they need when they need it will become a paramount focus for decentralized healthcare. Delivery of medications and supplies while having skilled nursing available for care will be focal points for growth. As a hospitalist physician who has worked with post-acute care, palliative and hospice care, I am encouraged by the momentum we see in this patient centered model. It truly seems as if healthcare is moving “Back to the future” to a home-based model of health care.