The healthcare system should increasingly look towards home-based care, especially for the aging, to offset costs and increase patient outcomes. The impact of the COVID-19 pandemic on nursing homes was particularly devastating and had a disproportionate effect on the more than 1 million residents in the nation’s nursing homes. The first wave of COVID-19 killed 60,000 residents of nursing homes and other long-term care facilities in less than six months. In horrible ways, the pandemic revealed the U.S. was largely willing to abandon outcomes for children, by closing schools, and the elderly, by leaving them to die alone without person-centered care and without treatment.  

Given that, it is unsurprising that 88% of Americans would prefer to age and die at home. There is also substantial evidence in other developed countries which proves it is cost-effective and has a positive impact on patient outcomes.

Here in the U.S., certain states have acknowledged the cost-savings and care-quality benefits of home-based care. For example, the Arizona Long-Term Care System (ALTCS). This program focuses on home and community-based services (HCBS) and tries to keep people out of nursing homes. 

By doing this, Arizona has managed to spend 16% less on Medicaid for long-term care (LTC) and has slowed down how fast these costs are going up. A major contributing factor to the success of  ALTCS is the coordination of care. In other states, HCBS programs are not as successful because Medicaid does not pay extra for the work it takes to make sure everything in a patient’s care works together smoothly. Arizona got around this problem by paying for Medicaid in a lump sum per patient, not per service. That way, healthcare providers get a set amount of money each month for each person in the program, which makes things simpler.

The federal government has tried out similar programs that pay healthcare providers in lump sums for home-based care. One program, called the Program of All-Inclusive Care for the Elderly (PACE), is for people who need the level of care you get in a nursing home but can still live at home. This program covers a wide range of medical and social services. People in PACE generally have shorter hospital stays, live longer, and feel better about their health and life, and it costs less than traditional Medicare or Medicaid services.

However, PACE failed to expand as rapidly as it should have because of issues like not enough money for nonprofit providers to set up PACE sites, not enough for-profit providers, older adults not wanting to change doctors to join PACE, not enough people knowing about it, not enough state support, and the cost for people who don’t qualify for Medicaid.

The University of Missouri’s Sinclair School of Nursing created its own program called Aging in Place (AIP), which uses nurses to coordinate care for people getting both Medicaid HCBS and Medicare home health services. What’s special about AIP is that the same team of healthcare workers provides both Medicaid and Medicare services. People in AIP did better health-wise than those in nursing homes, and the program saved an average of $1,784 per person in Medicare and Medicaid costs. If just 10% of Americans needing long-term care joined AIP or a similar program, it could save almost $9 billion.

These studies show that when care is well-coordinated and integrated, especially in home or community settings, it’s better for everyone. Patients get continuous care without having to move around, providers get paid in a way that’s simpler and sometimes for the extra work of coordinating care, and it’s more fiscally responsible.