Changes in technology, new government payment models, managed care, and consumer preferences all are shifting services for frail older adults and younger people with disabilities from facilities to home. These models will create new options for consumers and threaten to disrupt the business models of hospitals, traditional nursing homes, and other long-term care facilities.

These care models come with a range of names and designs, and they cover a wide spectrum of health care and social supports. While the type and level of care differs, they have a key feature in common: Instead of delivering care in a facility, providers bring their services to people in their own homes. Programs such as Hospital at Home are replacing inpatient hospital stays, SNF at home is substituting for skilled nursing facilities, and virtual assisted living or virtual retirement communities are an alternative to large campuses.

For now, these initiatives remain limited. While some began before covid-19, the pandemic has accelerated the trend.

Start with the highest level of care—Hospital at Home.  It works like this: A patient comes to a hospital emergency department with an acute medical problem. After an assessment, she may be returned home, where she receives what is effectively hospital care including nursing, medications, diagnostic tests, monitoring, and treatment–all at home. The program has been shown to be especially effective for patients with chronic conditions such as pneumonia, heart failure, or lung disease.

The concept was first designed more than 20 years ago at Johns Hopkins and the John A Hartford Foundation. In recent years, it has been adopted widely around the country, including at Cedars Sinai hospital in Los Angeles and several veterans medical centers. Large health systems such as Mayo Clinic and Intermountain Health have created similar programs.

Costs are lower than for hospital stays, outcomes are as good or better, and many patients are happier. In recent years, improvements in technology have enhanced the model by making sophisticated remote care even more accessible.

SNF at home is a much newer model.  The basic concept is the same, except that it is aimed at those receiving post-acute care after a hospitalization such as rehab following a hip replacement or stroke.

Instead of getting care in a skilled nursing facility, patients receive therapy, wound care, and personal assistance in their own homes. Home health agencies already provide much of this care, though at a less intensive level. And even before the pandemic, the concept was drawing interest from private investors, as well as managed care plans.

But with more than 70,000 residents of nursing homes and assisted living facilities dying of covid-19, and families unable to visit, consumers are looking for options to inpatient skilled care. So have managed care plans that currently cover more than one-third of Medicare beneficiaries. Thus, the door has opened wide for home health agencies to expand their services to SNF at home.

Still, these programs remain small for now. Home HealthCare News reports a senior official at one company pursuing the strategy, LHC Group, says he’s still counting SNF at home patients only in the dozens.

However, if this concept catches on, it will put new financial pressure on already-stressed nursing homes. Post-acute care is their most lucrative line of business and losing even a fraction of those revenues could be a big blow to many facilities.

Continuing care at home.  This model moves assisted living or continuing care retirement community (CCRC) services to people’s homes. It expands the traditional concept of home care to include a broader package of services.

Goodwin House, a continuing care community in Alexandria VA, created a subscription- based model long before the pandemic. For an upfront payment that scales up depending on a new participant’s age and level of care, as well as a modest monthly fee, members receive a wide range of services. Imagine a mash-up of long-term care insurance and expanded home-based assistance.

Like a physical CCRC, benefits for those who are relatively healthy are modest. They may include care coordination, a home safety assessment, access to social and wellness events, an emergency response system, and an annual medical checkup. For those with greater needs, benefits scale up to higher levels of personal care. About 170 older adults have enrolled in the Goodwin program.

These models still face challenges of their own. Payors, whether Medicare, Medicaid, or private insurance, have yet to catch up to the idea. Balancing flexibility against the potential for fraud will require some creative thinking. And because these models will require high-quality internet access for monitoring and communications, broadband services must be more widely available.

Still, all these concepts have one big thing in their favor: They hold the promise of moving more medical and long-term supports and services into homes—exactly where most people want them.