Home based and community health care

Sep 21, 2020

Home based care and community health teams require a diversity of funding models. Post COVID ,it is most unlikely that community health care will return to its pre-COVID state.

Firstly, anyone who has any choice in the matter is going to want to be cared for at home until absolutely impossible to do so.

Secondly, the success of virtual home care that has been implemented by the state government health services needs to be grown and developed as it has demonstrated an essential and vital alternative to growing hospitalisations.

Thirdly, funding for telehealth and virtual care needs to be distributed amongst all health care workers and cannot be the exclusive domain of GPs, as nurses and care workers, not GPs, have been the main workforce managing home based care.

It seems unnecessary to use a crystal ball to predict that, in the post COVID era, more people will seek to have home-based care for as long as possible, rather than moving into a nursing home, or indeed, rather than going to hospital. Furthermore, during COVID it has been ably demonstrated, through the use of virtual wards and telehealth, that it is possible to keep people (some of whom have actually been quite unwell) at home, monitored carefully by highly-skilled nursing and allied health staff, as well as by General Practitioners (GPs).

This care and monitoring has been achieved by a range of different media, but equally importantly by a range of different health professionals, the majority of whom have been funded through the various state and territory governments.

In public, state-based community health care in New South Wales (NSW), we have excellent multidisciplinary teams who provide a range of preventive, maintenance and rehabilitative services for the people of NSW. Due to the existence of our Primary Health Networks (PHNs), these services are linked in to the proximate Local Health District (LHD) and also to the GPs in the LHD who are providing services in the vicinity.

These services need to be linked and funded better to enable people to stay home when they are sick, but more importantly, to proactively manage their health and/or chronic disease when they are not sick. Such home based care will reduce the cost of health care significantly, particularly as the hotel costs relating to in hospital stay would be removed.

The evidence is already available that home-based care reduces the need for hospitals: Denmark has successfully introduced such a model and reduced its number of hospitals from 98 in 1999 to 32 in 2019. Similarly, Canterbury Health District in New Zealand has also successfully established integrated home-based primary health care.

So how could home-based care be funded? At present the majority of home based care not delivered by GPs is funded by the state and territory governments, and entails the use of highly skilled nursing and allied health staff who assess, plan, implement and evaluate the care delivered to their client groups. Examples include in-reach specialist care to nursing homes delivered by Clinical Nurse Consultants (CNCs) and Nurse Practitioners (NPs) and Occupational Therapy (OT) and physiotherapy programs being run for people, both in rehabilitation and maintenance, in local hospital and community health centre settings.

There is also the possibility of home-based physiotherapy and OT, and this is funded by some private health insurers. During the COVID 19 pandemic, these public services in particular have been shown to be capable of significant expansion, and have included the introduction of virtual wards, where nurses have monitored and advised patients on a regular basis in their homes, being able to intervene should deterioration occur, with the backup of hospital admission should that be required.

But specialist nurses such as NPs also need to be adequately funded to work in independent practice in the community, and this requires a major re-think of our funding system to ensure equity of access, as the current funding system for privately practising NPs makes it extremely difficult for them to survive. There are currently over 2000 NPs practising in Australia, but the majority work in hospitals in the public sector. We need far more to be working in the community in order to deliver the high level of specialist nursing care that is required.

With the exception of the appallingly funded and egregiously staffed private aged care services, the difficulty for moving to greater home-based care for our population is that the Federal government currently only funds GPs to provide telehealth. As recently as yesterday Australian Doctor reported that the mandatory requirement for bulk billing for telehealth will soon cease, which would mean that gap payments can be introduced and that these services may no longer be immediately accessible to all those who require them as basic MBS items.

This cannot be the answer to the question of how we make home-based care more widely available. We need new Federal funding for community based multidisciplinary teams (not necessarily led by GPs, but sensibly collaborating with them where appropriate). This funding needs to be allocated on a per capita, rather than a fee for service basis, as recommended by the now Deputy Chief Medical Officer, Dr Michael Kidd and colleagues as long ago as 2008.

Home based care and monitoring in the community, not only of the elderly, but for much acute care, is going to be the management of choice into the future and post COVID 19, as this is probably only the first of many novel viruses that we will confront in the future. Good public health is better served by home care. National and state government funding bodies all need to reset and rethink.

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