Abstract
C
Nevertheless, inpatient settings remain an expensive place for rescue—scooping up a patient and his or her family and putting them in a bed in a building with highly skilled staff working as a team to address the problems. For people with chronic progressive illnesses, the most patient-centered approach is to bring the care to where the patient lives rather than bringing the patient to where the staff live. Going back to our roots, St. Christopher's Hospice began sending support teams into homes to work alongside general practitioners and district nurses to help patients at home soon after it opened. In the United States, the Medicare Hospice Benefit ensured funding for teams that do nothing but care for people in their homes. Innovating to ensure broad access to care at home is where I think the major new frontier for our field, and for healthcare, is to be found.
In this issue, Pinderhughes and colleagues report that patients in their home-based palliative care program demonstrated clear cost differences ($9,843 vs. $27,530) compared with a matched control group. The main costs avoided are unnecessary hospitalization. Intriguingly, in another report in this issue, Washington and colleagues report the relationships among symptom management burden and coping responses. They point out that “escape-avoidance” coping is common unless other alternatives are developed. These two reports, together, illustrate an underappreciated phenomenon that drives much of the readmission merry-go-round. The sick repetitively go to the emergency department (ED) to be hospitalized because it is a great emotional coping strategy. Endless data mining to look for biological reasons for readmission (e.g., medication adherence in congestive heart failure [CHF] and chronic obstructive pulmonary disease [COPD]) misses the bigger psychological drivers of fear and the coping strategy of “let's escape to the hospital.” This is the fundamental reason why ED and hospitalization use with home hospice programs is so low—the team comes to the home and responds with a real person and real visits at night and on weekends. Pinderhughes points out that when the care is funded on a global basis (such as in Medicare Advantage) rather than fee-for-service and the care is in the home, money is saved that the institution can keep. I think this has enormous implications for healthcare design and redesign worldwide.
I see at least one major barrier: physicians, and other healthcare professionals, are not trained to practice in the home. Since the middle ages, the major training venue for healthcare has been the inpatient hospital. The history is clear—it was for the convenience of the healthcare staff. It is much easier to go room-to-room rather than house-to-house. Now, 1000 years later, we still have that pattern. In fact, we can globalize Washington's data to describe healthcare professional responses to sick people at home—bring them to the ED! I note that you cannot telephone a doctor's office anywhere in the United States without getting the recording, “If this is a life threatening emergency, put down the phone and call 911.” We can view this as an “escape-avoidance” coping mechanism on the part of our health system.
Since the science indicates the best place for this care is in the home, and the economics and clinical outcome data favor the home, the education science needs to follow with ways to prepare people to practice in that environment. Although palliative medicine is one field, it is practiced very differently in the home as compared with an inpatient or ambulatory outpatient setting. At a minimum, our fellowship programs need to offer physicians routinely practicing in homes as role models for our new fellows, as well as residents and medical students. They also need experience practicing with telehealth, the next innovation in home care.
I think these studies illustrate the powerful role that implementation science needs to play in advancing our ability to improve the quality of life and relieve the suffering of people with serious illness and their families. Those of us who are clinicians want to know how to achieve the results of research innovations where we live and work. By necessity, that research cannot be done in academic medical centers. Academic medical centers are “different” and the way they organize care cannot be duplicated in the community. Research needs to be done in settings that can be reproduced anywhere. The reports of successful reproduction need to be published and disseminated for the field to reach its full potential. Journal of Palliative Medicine is eager to see the reports of such studies, such as Pinderhughes et al., to lead us all forward.