For decades, fiscal pressures on hospitals have come from all sides. Persistent downward limitations on pricing brought on by payers, the movement toward more accountable, value-based care, and budgetary restrictions from state and federal government programs.
These influences are exacerbated further with the current and emerging demographic trends taking place in the U.S., namely the aging population, increased severity of illnesses, and a rise in chronic conditions.
Constrained by top-line price, as well as assets and capital investment, hospital operators are being forced to be creative when it comes to maximizing the value of services provided within the hospital. Often this means defining which services they will and, importantly, will not provide on their campuses.
As health system administrators rethink the strategies surrounding the services they provide, how do they make sure they are using their physical assets most effectively?
Technology and advances in care delivery are driving the movement to more ‘in-home’ provision of services that were formerly provided in an institutional setting. The pandemic escalated this with the rapid increase of telemedicine, but not all services are convenient, safe, and cost-effective to offer in a patient’s home. Consider dialysis. It is often provided outside of the hospital setting, but it requires space and specialized equipment.
Now consider rehabilitation services, specifically, physical therapy, which can be provided human-to-human without the need for extensive facility infrastructure, expensive devices or heavy machinery. In fact, 87% of physical therapy can be conducted with minimal equipment and only 13% of outpatient therapy cases require special equipment or facility-based care1.
For providers, offering physical therapy at home is an ideal way to test and experiment with ‘in-home’ service opportunities. It is easy to start, low risk, presents an opportunity to further engage patients, and expands care access and geographic coverage. For health systems, it helps to keep patients integrated within the system, and ensures that they adhere to their care program, as well as providing an opportunity to repurpose facilities to accommodate other services best provided on-site.
Precedents to the Model
If you are a hospital in an accountable care or value-based environment, then you care deeply about what happens with patients once they leave your premises. Adherence to their prescribed physical therapy regimen is an essential element of high-quality care, regardless of where it is completed. Completing outpatient physical therapy at home is a proven way to achieve greater adherence and, therefore, have fewer complications and readmissions, and a higher likelihood of a satisfied and recovering patient. It is in the interest of the patient, the payer, and the provider.
If this model of moving low-acuity services outside the hospital sounds familiar, it is because the industry has seen it before. For example, high-cost, inconvenient diagnostic imaging leaving the hospital, leading to an entire industry of free-standing diagnostic imaging centers.
Ambulatory surgery centers are another example. In both cases, it was not merely a cost difference; patients began to demand these alternate sites for reasons of convenience. Now, with physical therapy at home, there is also a quality and adherence component, as well as an opportunity to serve patients within the system.
Obstacles to Adoption: Hospitals Must Rethink Offerings and Facilities
There remain several high-level processes and cultural hurdles hindering adoption of physical therapy at home.
Acute care hospitals are fond of trying to be all things to all people––providing every conceivable type of service on their campuses. And yet, if they face the kinds of demands and pressures outlined earlier, they need to rethink how they are using their facilities and their staff capabilities.
Over the past 20 years, that has meant a persistent trend toward offering higher acuity, more complex, and more procedure-oriented healthcare inside the hospital.
Meanwhile, the less complex, less procedure-oriented services have moved off campus and for a very good reason: because the on-campus environment is the most expensive and complicated setting.
So, there are economic and quality incentives, and a patient satisfaction incentive to follow this trend. The cultural barrier, typically, is that hospitals (because they are serving a community) want to be known as a place you can go for every type of health service. That is no longer realistic, especially for geographically-constrained providers in urban areas. But even in rural regions, the investment required for some services can not be justified. So, we must first deconstruct the hospital as a collection of services as opposed to a physical building.
Once we think of the hospital in terms of services, then we can start being creative about where those services should be provided, and in what proportion they should be emphasized in business planning.
Take Luna, for example. Since it was founded in 2018, the company has experienced massive growth (6,183%) and is now the nation’s fastest growing physical therapy clinic.
Luna’s physical therapy at home model is shaking up healthcare and has treated over 25,000 patients to date, operating across 45 markets in 25 states. This success has, in part, been driven by partnerships with over 50 health systems and orthopaedic groups, including Emory Health, Intermountain Healthcare and UCLA Health.
In this video, Intermountain Healthcare’s COO, Barb Jahn, and VP of Strategy and Development, John Casey, discuss how partnering with Luna fits into their in-home care strategy. https://www.youtube.com/watch?v=-4RtLfPBTFI
Heightened Patient Engagement
How should providers best prepare for this merging of remote options being built out from every direction? Are there key considerations as they develop their strategies?
Providers should be mindful of building and maintaining a connection with their patients through healthy times. This will increase the likelihood that patients turn to them first when they have a need for healthcare services.
At the opposite extreme, envision a hospital system that only engages with its patients when they arrive, often by ambulance, in their emergency rooms. This is a low-value, low-satisfaction approach which is going to be marginalized by payers because it is also very high-cost.
The systems that will be most successful are those that have a high level of engagement and retain the patients within their networks for all their care. Why would the patient go anywhere else if they are satisfied, and if the care is integrated, lower-cost, covered by insurance, and high quality?
Hospitals and health systems need to reconsider the concept of patient engagement. Rather than trying to provide every imaginable service under its roof, the hospital needs to focus more on the essentials of engagement: emailing, calling, and making sure the patient’s primary care provider is responsive.
Patients are consumers. Consumers today want convenience, and physical therapy at home is convenient.
In the end, healthcare is an industry that, for reasons ranging from safety to resource constraints, is often slow to embrace change. But the physical therapy at home movement is already underway and gaining momentum. For forward-thinking organizations looking for an ideal entry point, outpatient physical therapy provided in the home setting is a natural way forward.
Payers should be very much in favor of physical therapy at home, because it drives better outcomes2, happier patients/members, greater adherence, and lower costs. It also frees the space that was devoted to outpatient rehab in the hospital for more operating rooms, or more beds for high-acuity units––anything that is at capacity within the facility and can only be provided in the inpatient setting.
Physical therapy at home provides hospitals with a good place from which to advance this transition while expanding market reach and redefining their role in the overall wellness of the communities they serve.
Editor’s Note: Palak Shah is a co-founder and Head of Clinical Services at Luna, the leading in-home physical therapy platform. Palak is a passionate healthcare leader with orthopedic specialist board certification and physical therapist for 15+ years. Starting out as an outpatient physical therapist, Palak obtained Orthopedic specialization from the American Board of Physical Therapy Specialists in 2014. She spent the next 4 years at Stanford Hospital as a senior physical therapist treating complex musculoskeletal conditions and co-lectured at the Stanford PT residency program. Palak leads clinical vision and strategy with focus on operational excellence and patient experience. She excels in data & technology driven approach for scalable clinical products and program design that improve accessibility to quality healthcare.
1 Scripps Health outpatient case volume analysis, 2020
2 Industry averages reported by Evaluation of Legacy Patient Reported Outcome Measures as Performance Measures in Rehabilitation, CERortho, July 11, 2019.