One of my first jobs out of college was as a case manager for a local mental health wraparound service. My job basically entailed managing a caseload of individuals, mostly kids, checking in with them to see how they were doing, and helping coordinate their multitude of services when needed. With only a small background in mental health at the time, I really didn’t know too much about what I was doing. Most days I found myself going around town, visiting schools, juvenile detention centers, and meeting with both the client as well as the other professionals working with them on whatever the identified issue was. And while this was a wonderful experience where I learned a lot, it was actually the home visits that stand out to me the most.
I remember one of my fist home visits. It was in a part of town I was unfamiliar with, and my instructions had been to make sure I parked close to the address, lock my car, and go straight inside. I did as told, and found myself in a small, two bedroom apartment with the client and another social worker who was helping on the case. My goal in showing up at the home was to “check in” and find out why the client, an older adult in this case, wasn’t taking their medication. In our case review there had been some concern about the medication getting stolen, but no one really knew the whole story. We quickly learned the whole story but I’ll get to that in a second.
There’s something powerful about being in another person’s home. Before Zoom virtually brought us into homes all over the country, most of us didn’t know what our coworkers homes looked like. When you are sitting on the person’s couch, seeing what they value, smelling the remnants of whatever they cooked last meal, and gently petting the household animal, it does help you understand the person a bit better. To this day, even in our still mostly virtual world, I take the time to observe people’s backgrounds as I feel it gives me a better understanding of the person and what they value.
While sitting on the couch of my home visit, I asked the home owner the typical questions: “How are you? How’s it going with your medication?” Once comfortable in their favorite chair, the client opened up in ways I had never seen in any of our previous meetings together, which had mainly been in an office. They seemed to light up at small things that brought them joy - then, on more than one occasion, made sure to show me little pictures around their house they were proud of. Family. Friends. Old memories. On almost every occasion where I did a home visit, it was like I was working with a different person. In their home environment they were more open to sharing and more relaxed than I had ever seen them before. The home became a sacred place where a different level of engagement could occur.
I have written previously about the importance of housing. We need a place to live, a place to feel safe in order to take care of other facets of our health. In this piece, I want to stay with the theme of home and talk about the numerous ways we can better bring care to where people are - their homes.
During the pandemic many of us learned creative ways to get the things we wanted while still being at home. From your favorite restaurant now offering takeout to virtual visits with your medical team, a lot of the things we used to have to go to receive in person found ways to come to us. Turns out that a lot of people like it when we make it easier for them to get what they need, including mental health related services. But let’s not forget that even with lockdown restrictions lifted, there still are people who can’t leave their home and solely dependent on care to come to them.
According to one source, over 4 million people are completely or mostly homebound. These are people who rely almost exclusively on in home services. Without some benefit that allows for food, medical care, and even clean clothes, there are millions in this country who would languish. We should do all we can to provide ongoing support for these individuals! However, this got me thinking, what if we could have a more home based options for those who were not homebound? What if we could create a better option for home based services?
Home visits for care used to be a standard practice. Its an age old archetype of a family doctor with black leather case in hand coming to visit the family at their home. Over 50 years ago, 40 percent of all primary care patient visits occurred in the home. Today? Just a mere fraction of that though some innovative companies have tried to increase the amount of home based primary care visits. One Medicare study found that house calls did indeed save money though fewer patients could be seen throughout the day. There are several reasons we don’t see more home based primary care, including lack of public awareness, funding, regulatory barriers, workforce shortages, and a lack of infrastructure to support it.
What would happen if we went back to some of how it was before? What if we built how we approach care around where people actually wanted care to happen? Sure, not everyone may want services in their home, but many people could be interested in having them. There’s something safe about our homes that allows us to let our guard down, to be more open and honest as we are relaxed and feel in control. We may be willing to share more because of this safe environment. I think this is a space we need to spend some more time thinking about.
Here are three things that I kept coming back to:
We don’t often give people a choice as to where care happens. A variety of factors, including our health insurance, where we live, the resources we have, and our access to transportation limit who we can see, where, and when. If you did a small survey with your friends and asked them where they would most like to receive care or even just get some help, most people are going to pick someplace other than a clinic. In fact, one survey found that 70 percent of people reported being more comfortable receiving care in the home as it helps decrease anxiety and increase communication and 85 percent, from the same survey, said those who received care at home would recommend home based care for their family and friends. Giving people more of a choice may likely mean that more people choose home.
Our structures don’t always promote healing and a patient first focus. Similar to the comment above, it feels that there’s a reminder brewing under the surface of how the structures of our health care system don’t necessarily put our needs first. And perhaps even greater, how some of our structures, facilities or otherwise, make it more frustrating than anything to get help. I know it’s a bit silly to knock a building because of how it looks, but honestly, there are so many clinics throughout the country that don’t fill you with a sense of hope. Add to this that many of these buildings were never designed to be about the patient, but more about the care team. Homes don’t have the same feel to them as a clinic - a big benefit that in and of itself can be therapeutic.
It helps shift the power in health care just a bit. When a provider is on the patient’s home court, there is an inherent advantage to the patient, and that’s a good thing. We all know that there is a massive power differential between providers and patients, and anything we can do to help bridge the gap between this hierarchy is likely to benefit the patient. Shifting power allows for their to be a more shared agenda on what gets done. It’s hard to imagine a scenario where care is delivered in a home where the patient wasn’t more involved in what happened; in fact, they get to control the environment, which changes the entire dynamic.
Back to my story about the client who kept missing on their medications. I asked about the meds to which they promptly stood up, walked over to their television, moved it away from the wall, and showed me a small hole behind the television where they stored their medication. It was quite an elaborate set up to which I had to ask why they had to hide their medication so carefully.
“Because he will steal it,” they said.
“Who will?” I asked.
“My nephew, of course.”
Until I was able to see, first hand, what this person had to do to hide their medication so they could take it and not have it stolen, I don’t think I could have ever appreciated the challenging dynamic they faced everyday just trying to do the basic things to keep themselves healthy. The home provided me context. It also highlighted entirely new problems for us to address together. I can’t imagine this coming out in a clinic setting in such a powerful way. And while this is just one story about the home, I have countless others that equally show how much you can learn by being in someone else’s home.
The future of health care must be more focused on us and what we want. Home based care is yet another solution from our past that we should revisit for our future. Bringing health care services, including mental health, to our home can provide us with a greater convenience and comfort, allowing us to receive quality care in a familiar and supportive environment. What’s not to like about that?
Yes yes yes
Ben can you do a follow up essay on health care companies working to provide more equitable in home health care for all people?