How Home-Based Elder Care Enabled by Digital Health Can Effectively Reduce Hospital Readmissions

Editor's Note: Author of this articleDavid Lee Scher, M.D., is an Associate Professor of Clinical Medicine at Penn State College of Medicine and an Electrophysiologist in the Heart Department at Lancaster General Health. He also serves as a Director of DLS Healthcare Consulting, LLC, a firm dedicated to assisting internet healthcare technology companies and their partners and clients. Dr. Scher has been a pioneer in adopting remote patient monitoring technologies and delivers lectures worldwide on the impact of these technologies on patients and health insurance systems. He is a member of HIMSS, the healthcare information and management systems society, and authors a blog titled “Digital Health Corner.” This article presents Dr. Scher’s insights into how home-based elderly care can effectively prevent hospital readmissions, compiled and translated by VCBeat as follows:

Exploring the topic of hospital readmissions is critically important—no one wants to be hospitalized again after recovering from a serious illness. However, the widespread attention this issue receives stems primarily from its financial implications. The cat-and-mouse game between healthcare providers and payers over reimbursement has been ongoing for decades, and these regulations are merely part of that dynamic. Yet, this is not the focus of this article. Today, patients and caregivers are more concerned with what support they can actually access after hospital discharge, and what strategies can help them maintain their health and avoid initial hospitalization.

For information on the coverage of home care in the United States, please refer to the document “Medical Insurance and Home Care”. Additionally, “European Home Care“The article also provides us with comparative information on the demand for and provision of family services across European countries in its overview.Home care is more important than readmission data because:It affects both initial and repeat hospital admissions.The focus on readmission rates has not been placed on why patients are admitted to the hospital, and the management of chronic diseases is also considered more important than their prevention (or at least the prevention of associated complications). Internet-based patient education tools may be more successful than oral communication and written materials. Internet-based tools in the form of apps have ideal interactivity, making it easy for patients to share data with caregivers, and include incentive mechanisms and social elements.It is suitable for all age groups, not just patients.It is well known that chronic diseases begin to lie dormant in childhood, and their occurrence and development are associated with unhealthy lifestyle behaviors. Today’s young people are “digital natives,” making internet-based tools likely the most effective—if not the only—means of engaging them.

Preventing chronic diseases among young people represents the largest and most valuable investment in healthcare. To address hospital readmissions among the insured population, one must not overlook the potential of population health management and internet-based tools for other demographic groups. Home-based elderly care should be applicable to all age groups. After all, as the term implies, “aging” is not a static state but a lifelong process.It has a greater impact on economic and healthcare outcomes.While the focus of readmission issues is undoubtedly on patients, limiting the timeframe for hospital admissions to 30 or 90 days fails to address the core of the problem. The author argues that greater efforts should be directed toward studying how to implement home-based elderly care more effectively. In this context, the importance of medication knowledge, medication reconciliation, and timely follow-up appointments is evident. Social workers have made every effort to address family health issues; however, their objectives are often confined to meeting regulatory requirements, which frequently do not take into account patients’ individualized needs or their personal financial circumstances.

For different patients, whether they can receive adequate care follows an "all-or-nothing principle," with the threshold depending solely on whether they are included in the Medicaid system.The market for internet healthcare technologies is larger.Patients who are not in the post-discharge recovery phase do not require intensive acute monitoring. Devices aimed at preventing complications of healthy or chronic conditions (as opposed to the actual management of chronic diseases) are not subject to FDA regulation. This will open up the market for lower-cost (and potentially more impactful) internet-based technologies.It has a greater impact on caregivers.According to a report by the AARP Public Policy Institute, the “caregiver support ratio” is projected to decline significantly in the coming years. From 2010 to 2030, the population aged 45 to 64 will increase by 1%, while the population aged 80 and older will surge by 79%. Consequently, the caregiver support ratio is expected to drop from the current approximately seven caregivers per high-risk individual (aged 80 and older) to four to one.Aging in place enables caregivers to fully leverage their roles. During patients’ post-discharge recovery period, Medicare covers part of the cost of home health services (although very few services are reimbursable amid ongoing legislative reductions).

In the future, internet-based tools, including mobile apps, will be able to provide information resources, logistical support for medical devices, scheduling of healthcare and emergency services, as well as assessment and nursing care by visiting nurses. Of course, current apps cannot yet offer all these services, but a growing number of applications—such as Balance: for Alzheimer's Caregivers, Care Zone, Elder 411, and CarePartners Mobile—are being adopted by caregivers, along with online platforms like tyze.com.Apps designed for caregivers have begun to attract significant media attention. To date, it has become clear that, in terms of long-term benefits, aging in place is more important for patients and their families than hospital readmission. Clearly, readmissions disrupt daily life, making aging in place a priority worthy of greater attention. Taxpayers and governments need to promote aging in place rather than frequent institutionalization, shifting resources and investment focus accordingly. This also aligns with the demands of the baby boomer generation, which is gradually aging.(For the latest updates on digital health entrepreneurship, please follow VCBeat’s WeChat official account: vcbeat. We also welcome your interaction on topics of interest, or you may contact us via WeChat to share your startup projects or related research insights.)