The Future of At Home Care Delivery


With consumer interest in virtual care booming, someone's home is often a sacred space that reveals contextual health details.

Niyum Gandhi  and  Dan Shellenbarger

10 min read

Editor’s Note: The following article is part of an ongoing series offering our strategic advice and expertise on what healthcare industry stakeholders should do in response to the rapidly evolving novel coronavirus (COVID-19) pandemic. As COVID-19 presses onward, below we explore how care delivery is now happening not from within the four walls of a clinic or emergency room, but from wherever people happen to be. This interview was conducted last March.

Amidst COVID-19, the home is now becoming a primary hub for healthcare. A world where patients no longer step foot in a physician’s office is becoming a reality. But what will patients’ “homes” – defined broadly from a five-bedroom house to an apartment with five roommates and all in-between – look like in time as brick and mortar care delivery perhaps becomes a thing of the past?

To learn more, Dan Shellenbarger, Partner in Oliver Wyman’s Health & Life Sciences Practice, spoke with Niyum Gandhi, Chief Population Health Officer and soon-to-be Chief Financial Officer at Mount Sinai Health System. Here’s what they had to say.

Dan: Last February, you spoke at the Wharton Health Care Business conference about how “home care” should be redefined as “location-agnostic care.” What does care at home really look like? 

Niyum: Historically, the hub for healthcare was the hospital. This was a “build it and they come” sort of thing. So much of what needed to be done in healthcare required heavy resources. The most cost-effective way to bring care to patients was to centralize it all and have patients come to you.

There’s now a shifting set of consumer preferences around how people want to consume healthcare. There is, therefore, an imperative for us to push more care out to the place that’s most convenient for patients. That is sometimes the home, which may be location-agnostic. But it could be on the iPhone. Patients may be calling from home, but they may also be calling from work or from somewhere else.

There’s some uniqueness to the home. It’s where you sleep. It’s where so many contextual factors about you come together.

Dan: When you think about the proliferation of technology and the ability to do more and in more places, how are the lines of home healthcare blurring?

Niyum: There’s some uniqueness to the home. It’s where you sleep. It’s where so many contextual factors about you come together. The problem is, we’re increasingly not recognizing or acting on the fact that social influencers of health have a big impact on what happens to you.

When a patient with congestive heart failure is trying to cut salt out of her diet, you can open the fridge [while talking to her on a video app] and see a jar of pickle juice.

Along these lines, when Mount Sinai does our Hospital-at-Home episodes, for example, medication reconciliation is easy because everything’s there in the home. We’re reconciled before the acute care episode ends. You can’t do this in any setting except for where the person’s “home” is – whether the person perceives their home as a house, an apartment, somewhere under a bridge, or in a homeless shelter. But whatever someone calls their home is somewhat sacred.

Dan: What are some roadblocks to greater telehealth and virtual care progress?

Niyum: There’s enough creativity in the industry now that we can figure out reimbursement models. But doing so takes longer than it ought to because it’s against the grain. Home health doesn’t need to look the same everywhere. It doesn’t need to be about needing global capitation to deliver care in the home. Certainly for home-based primary care, yes, you want a true longitudinal risk arrangement. But otherwise, you just need a construct that allows for payment. Often, a fee-for-service style construct can work.

When ambulatory surgery centers started to take off, for example, most surgeries were done inpatient, and then later they started happening outpatient. And then people said they needed a new location of service to do this same service. The way you construct a value-based reimbursement model here is you pay less for it. So for whoever is providing the service, revenue goes down, but margin maybe goes up because it’s lower cost.

Dan: Thinking about your backyard at Mount Sinai, with 17 million people or so in the broader metropolitan area, it’s a highly diverse population. What cultural ramifications do you run into with home care? For example, what if someone’s family members aren’t receptive to someone coming into their home? What are some ramifications of examples like that?

Niyum Gandhi: Well, if you’re in New York City public housing, there are only certain things we can do in the home versus if you’re in a home in Westchester County. We normally don’t think about care delivery from that standpoint, though. We have very clear definitions of what can be done, including the level of facility at a regulatory level. The gradient between a fifth-floor 350-square foot walkup with one bedroom where four people live versus a big home in the suburbs means there are certain things we can and can’t do.

We also find receptivity from the family is interesting. The most frequent complaint we get is, “There were too many people knocking on the door over a few days.” We respond, “Think about it. If you were in the hospital, how many times would somebody come into your room? That’s how many times somebody’s going to come into your home.” Maybe a nurse leaves and then the infusion nurse shows up. Then they leave, and the physical therapist shows up. Then they leave, and the person doing portable imaging shows up. That may be considered a lot of people, but that’s exactly what would happen in the hospital.

Dan: How do you anticipate the workforce evolving to keep up with home care demand?

Niyum: Well, we’ve been talking about certification, training, nurse residency programs, and the like for home hospitalization nurses with our partner for Hospital-at-Home. We’re thinking about things like maybe having a special kind of fellowship component for hospitalists at home, like additional training on how to do hospital-level medicine in the home as part of the residency and fellowship training.

I think we’re going to start to see new roles emerging, like community health workers. There are now certification programs for them that relate specifically to health coaching in the home.

There’s a workforce implication there that could be really interesting where we’re not just tapping into that receptivity but tapping into the underlying demand. And then meeting that with a formal way to develop, train, and expand a workforce who leverage the fact that they are in the home.