Home care or domiciliary care is supportive care provided in the home. Care may be provided by licensed healthcare professionals who provide medical care needs or by professional caregivers who provide daily care to help ensure that the activities of daily living are met.
It is the delivery of a range of personal care and support services to individuals in their own homes. The word “domiciliary” is taken from the Latin “domus” meaning home. The care delivered can range from a 15 minute check to ensure that the individual has taken prescribed medication, for example, through to 24 hour, live-in care.
Funding for domiciliary care is of two types : self funded or state funded.
State funding includes commissioning bodies either paying the homecare provider or providing Direct Payments to the Patients enabling them to pay for the care of their choice. Domiciliary care agencies provide care to children, young people, adults and older people with a variety of care and support needs. Many homecare providers specialize in the delivery of services to one of these age groups or to groups with care needs dictated by a specific disability or illness, e.g. learning disability, mental health diagnosis. Domiciliary care agencies work in partnership with other health & social care professionals, so an individual may receive personal and medical care at home through the co-ordinated services of, for example, care workers, district nurses and occupational therapists.
Homecare is also delivered by individuals’ families and friends on an unpaid and informal basis, although the range of care delivered and the time involved is often extensive.
While domiciliary care generally refers to care delivered in the home, care workers employed by domiciliary care agencies may also undertake duties outside a patient’s home. These duties may include providing an escort for a patient attending a hospital appointment or social event or shopping on behalf of, or with, a patient.
Homecare should promote and develop the independence of patients by encouraging individuals to do as much as possible for themselves and take part in social activities. There is a greater move towards personalization, which gives greater choice and control to the patient regarding their care delivery, rather than the prescriptive method of homecare where specific duties are undertaken by care workers at specific times.
Procedure and Regulations
Domiciliary care agencies are required to follow stringent procedures when recruiting care staff and must provide appropriate training to ensure that staff can deliver care safely and effectively.
Domiciliary care agencies in most countries are inspected, monitored and regulated by national regulatory bodies:
Domiciliary care agencies also undertake their own quality assurance checks using methods such as staff supervision and appraisal, spot checks, training assessments, client satisfaction questionnaires, complaints and compliments, client forums, staff surveys, team meetings and feedback from other Health & Social Care professionals.
Domiciliary care in India is gaining traction and is poised for transformation. Once an unorganized and fragmented sector, it is fast catching the attention of entrepreneurs and investors and becoming an organized, technology-led industry with standards and protocols.
Life expectancy is estimated to increase significantly in India. Domiciliary care is becoming mandatory. Patients who are suffering from chronic illnesses like heart failure, respiratory failure and Alzheimer’s do not really need hospitalization. With advanced medical gadgets, most of the patient monitoring, which was earlier possible only in hospitals, can now be offered with remarkable ease at home.
India has the second largest geriatric population in the world. According to a United Nations Population Fund report, the number of people age 60 and over in India will increase from 100 million in 2011 to 300 million by 2050; this means one in five Indians will be above the age of 60. Of the 300 million over-60s, 200 million are likely to be suffering from chronic ailments. Already, non-communicable diseases including cardiovascular diseases, diabetes, chronic obstructive pulmonary disease and cancer cause around 50% of all deaths in India.
With life expectancy increasing significantly in India, domiciliary care is becoming mandatory.
The concept of old-age homes or assisted living is socially largely unacceptable in India and therefore better domiciliary care facilities are becoming an imperative. It is estimated that for an average individual, 70% of domiciliary care needs can be met in the home environment. This can result in better health outcomes and lower medical costs for the patients.
The growth of home-based care as a part of the expanding spectrum of health care services in India is quite evident. This ranges from government-run primary domiciliary care centers and private family physicians to large hospital chains, specialized boutiques, luxury services and telemedicine. As a country moves up the economic ladder, different pockets of the population demand different services.
As a result of advances in communication and medical technology, a lot of interventions that could earlier take place only in hospital settings are now becoming possible in the home environment. Alongside, there is now a sizable population in India that needs and is willing to pay for these services. This makes it a viable business proposition for entrepreneurs and their investors. As this market grows, there is an increasing realization that profit streams can be huge and long-term, and lead to large returns on capital invested.
A recent paper by consulting firm Pacific Bridge Medical notes that the global home domiciliary care market, which includes devices, products and services, was worth almost $215 billion in 2013 and is projected to grow at 8% per annum until 2020. Pacific Bridge Medical pegs the Indian home domiciliary care market at around $2.3 billion and growing at more than 18%. According to venture capital fund Accel Partners, the home domiciliary care market in India, currently estimated to be a $2 billion to $4 billion-a-year opportunity, is driven by an aging population, the increasing prevalence of chronic diseases and the need for better quality post-operative and primary care.
Scope for Entrepreneurs and Startups
Some of the biggest players in the sector here in India have service offerings that include geriatric care, post-operative care, palliative care, primary care and physiotherapy along with collection of lab samples, home delivery of medicines, and medical equipment for hire. These companies require teams including doctors, physiotherapists, nurses, care givers and office staff. Some have even introduced programs for NRIs. Under this, non-resident Indians (NRIs) can sign up for customized domiciliary care services for their relatives in India and get regular updates from the companies.
Specialty home domiciliary care will be a key element of patient-centric care in the coming years. Services for specialties such as pulmonology, cardiology, metabolic diseases, neurological health, orthopedics, geriatrics, rehabilitation and post-operative surgical site management are still at a very nascent stage.
Foreign investors have funneled in millions of dollars as investments to young firms in the domiciliary care domain. These firms, in consequence, are ever on the lookout to expand their businesses to new cities.
Some large hospital chains like the Manipal Group and Max Healthcare have also started providing this service either on their own or through partnerships with standalone providers. Most service providers have a dual revenue stream comprising annual or monthly subscription fees and a per-interaction fee.
The role of technology
Unlike in developed countries, domiciliary care in India is not covered by most health insurance policies. Organized players will bring in credibility, standards and accountability, which have been lacking in this area in India. This could encourage insurance companies to cover domiciliary care giving a further boost to this sector. Organized firms are also expected to bring scale, which will result in cost benefits.
Domiciliary care is not a high margin business and in order to be profitable, it has to be at scale; strong execution capabilities are also critical. This is possible only with the effective use of technology across every aspect — be it scheduling of appointments and other logistics to manage remote workers, having standardized care protocols, capturing and analyzing patient data, and continuous monitoring for error-free and personalized treatment.
A lot of research is also being focused on evaluating wearable medical devices that can be offered as part of their service or work with manufacturers to define care protocol standards. These devices can record patient data in real time and can trigger alerts in the system for quick and pre-emptive actions.
The home domiciliary care delivery system is an important but underdeveloped component of the larger health care delivery system in India. Similar systems in many countries, such as in Sweden, play a critical role in reducing costs of care, and in decongesting hospital systems by helping patients leave earlier. A side benefit is that with better home management of chronic care, the patient is able to come to the hospital at an early stage of the disease and receive less intensive and sometimes even less invasive care. Home health supports the hospital systems by reducing the average length of stay and enabling quicker turnover of patients.
Delivering domiciliary care at home has its own challenges. Service providers need to ensure that there is consistency in quality and continuum of care for the patients. The obvious advantages are that the service can come to the patient, rather than vice versa. This makes a difference to patients’ quality of life given the range of side effects from treatments like anti-cancer therapy, for instance. But it also requires strong management, medical oversight, and high-quality nurses supported by a quality controlled pharmacy. We need clear, evidence-based treatment protocols that cover the range of protocols delivered by the team.
One of the biggest obstacles to scaling is the lack of skilled manpower. The Indian educational system currently does not have a structured training program for domiciliary care. Unless there is vocational training for para-medical services, a strong domiciliary care system will remain a distant reality.
The ability to handle last-mile logistics and remote domiciliary care workers is critical for effective domiciliary care delivery. Specialized players are more equipped to offer this service than hospitals because the core competencies and business models are very different. For hospitals, the singular metric of profitability is average revenue per operating bed, which depends on the average length of stay of a patient. Typically, hospitals make the maximum money per patient in the first 48 hour to 72 hours of admission. It is a high margins model. Domiciliary care is a different business model. It is a volume game.
The big players are not usually focused on domiciliary care because the revenue model is very different. It requires a different mindset and a different business model. It is specialist groups providing these services as the large hospitals are under great pressure to deliver their own services without taking on any further duties.
But one singular advantage that the big hospitals have is access to extensive trained and skilled manpower coupled with well-built infrastructure for training and monitoring. In the Western countries, standalone domiciliary care providers are becoming very popular. But for a standalone home health –care provider to deliver this service in India will be difficult and expensive. To begin with, hospitals in India might tie up with standalone home health providers. But this relationship will continue only until this service becomes a significant part of the hospital’s offering.
In conclusion, it’s the business models that coexist with the current domiciliary care systems and networks in India that will be the key to success in this market. Companies that try to work outside of the domiciliary care referral networks that exist today quickly fade away. Creating the definitive business model that takes all the aforementioned aspects into account, in the context of the Indian scenario, will hold the key to the success of companies/organizations in domiciliary care.