As the healthcare system has evolved, home-based care has increasingly become a model that has produced remarkable patient outcomes across a broad range of cases, from the most complex chronic conditions to postoperative recovery to palliative care. In fact, clinical care in home settings frequently translates into increased patient comfort, personalized care plans, and fewer hospital readmissions. To illustrate this, in this article, we examine several success stories that highlight the power of clinical care that’s flourishing in the home.
Case Study 1: Managing Chronic Heart Failure with Home-Based Care
Patient Profile:
- Name: John Smith
- Age: 68
- Condition: Chronic Heart Failure (CHF)
Five years ago, John was diagnosed with chronic heart failure. Since then, medication and lifestyle have kept him out of the hospital, except for three admissions to the cardiac ward in the past year, when he developed complications and his symptoms worsened.
Intervention: John’s care team decided that he would be better able to manage his condition if they moved him to a home-based care model, including:
- Home Health Monitoring: John had a remote monitoring device that measured his blood pressure, heart rate, weight, and other vital signs, transmitting this information daily to his care team.
- Individualised Care Plan: A home nursing care provider saw John once a week to make medication adjustments, monitor his symptoms, and educate him about how to care for his condition.
- He agreed to undergo regular telemedicine appointments with his cardiologist for feedback and adjustments to his presumptive treatment plan.
Outcomes:
- Decreased Hospitalizations: John experienced only one hospital stay in the past year, compared to multiple hospitalizations or even extended stays before receiving home care.
- Improved Quality of Life: John reports better symptom control and a significantly improved quality of life. He now engages in more physical activity and shows a greater willingness to expand his social circles.
- Improved Patient Engagement: John felt more engaged in his care plan and felt better able to manage his condition, thanks to the encouragement and support of his home care team.
Case Study 2: Post-Surgical Recovery and Rehabilitation at Home
Patient Profile:
- Name: Mary Johnson
- Age: 72
- Condition: Hip Replacement Surgery
Procedure: I have recently undergone a hip replacement as I was suffering from very bad arthritis. It has been difficult for me to recover from the surgery as I can’t go for walks in the hospital, and I am in a great deal of pain.
Intervention: Mary’s care team decided that rehabilitation would be best performed at home:
- Home physical therapy: The physical therapist visited Mary twice a week at her home to guide her through exercises that improved her mobility and function, as well as increased motor control, strength, joint and muscle range of motion, endurance, and balance. The therapist provided education on body mechanics and joint protection.
- Pain Management: A home care nurse continuously checked and adapted Mary’s pain meds administration. Also through the use of the home care agency, her physician could be contacted to make decisions about her comfort and her pain.
- Nutritional Support: A dietitian helped Mary plan nutritionally complete meals for healing and recovery, making sure they fit within her family’s budget and her preferences.
Outcomes:
- Faster Discharge: Mary was able to return home in days to weeks, versus the several months in an inpatient rehab hospital that’s typical for this type of impairment.Faster Recovery: Mary was ambulatory within days of receiving the treatment and was earlier and more independent in walking with a cane compared with the usual.
- Improved Comfort: Feeling able to recover at home can make for a more positive recovery experience for the patient.
- Better Outcomes: Her return to daily life was seamless with home-based rehab. Mary was able to return to her normal activities much sooner than anticipated.
Case Study 3: Palliative Care for Terminal Illness
Patient Profile:
- Name: Robert Lee
- Age: 80
- Condition: Terminal Cancer
At the time, 79-year-old Robert was diagnosed with terminal cancer that no longer responded to aggressive treatment. He chose to receive palliative care at home, focusing on therapeutic goals aimed at comfort and quality of life, while avoiding interventions with uncertain outcomes or potential harm.
Intervention: Robert’s palliative care plan included:
- Pain and Symptom Management: A palliative care team of a nurse and a physician made regular visits to manage his pain and other symptoms related to his disease. Medications were adjusted according to his tolerability, as well as providing emotional support.
- Caregiver Counselling: Family support for the care team with counseling services was provided for Robert’s family to assist with managing the emotional stress of providing care at the end of his life. The care team also helped the family provide care and support for Robert’s needs.
- Person-Centered Care: Robert followed a care plan tailored to his personal preferences and needs. It included meaningful and enjoyable activities, such as spending time outdoors with family, listening to music, and reminiscing about his life.
Outcomes:
- Improved quality of life: ‘I was able to get better pain control and was more comfortable in the final couple of months of my life,’ Robert reported.
- Family Care: The involvement of his family in his care gave him a chance to experience a more personalized, familial, and honoring living experience that was as conducive to Robert as it was to his family.
- Dignified End-of-Life: Robert chose to receive care at home, allowing him to spend his final days in a meaningful environment surrounded by his loved ones..
Case Study 4: Managing Diabetes with Home-Based Care
Patient Profile:
- Name: Susan Miller
- Age: 65
- Condition: Type 2 Diabetes
After switching to a ketogenic diet, she reported improved blood sugar control and reduced blood fat levels both of which are linked to a lower risk of heart disease and stroke. ‘Susan had had type 2 diabetes for years and hadn’t been able to achieve better blood sugar levels because of poor glycemic control, which is how I would describe that term,’ says Phinney. Pólicková’s diabetes stabilized faster at lower doses, suggesting that the ketogenic diet was responsive in her body. ‘She had no hypoglycemia, she had less insulin,’ says Feinman.
Intervention: Susan’s care team implemented a home-based diabetes management program that included:
- CGM: The Case Manager gave Susan a continuous glucose monitor device, which produced a wireless read-out of her blood sugar at any given moment, enabling her to take relevant next steps, such as altering her diet and/or medication.
- Home Health Visits: A diabetes educator came to Susan’s home every few weeks to review her glucose data, provide education on diabetes management, and change her treatment plan, as needed.
- Counselling (Dietary): A nutritionist helped Susan create a meal plan of foods she could still enjoy and that wouldn’t send her blood sugar soaring. It was also designed to fit into her busy lifestyle.
Outcomes:
- Better Glycaemic Control: Susan achieved improved blood sugar management, which significantly reduced the frequency of both hyperglycaemic and hypoglycaemic episodes.
- Enhanced Self-Management: Susan felt more capable of self-managing her diabetes by using this CGM data and dietary recommendations.
- Increased Quality of Life: Because of the all-encompassing approach used by home-based care, Susan now has an increased ability to take part in her daily life.
These case studies show how home-based clinical care can contribute to the success of home care by delivering individualized, patient-centered care in the home to the benefit of improved health outcomes, a quality of life consistent with medical goals, and a better patient and family experience. Whether in the context of chronic condition management, surgery recovery post-acute care, or palliation, home-based care provides a flexible and efficient way to meet the many differing needs of patients. Around the world, there are developing models of care tied to primary care that demonstrate a new way of healthcare delivery – high-touch, high-tech, and high-value care to improve the patient and family (or staff or informal caregiver) experience while still achieving or even exceeding health outcomes.
