As people age, the subject of caring for loved ones enters the conversation. Most find this discussion escalating while events are already in motion.

Ashish V. Shah experienced this firsthand with his aging father. And after his dad's death, he learned how pockets of information among care teams were not shared in a meaningful way that might have delayed the fateful event.

Shah realized there was no easy mechanism for care teams from different providers to share information that could help patients age in place, so he set out to create one. Now he is CEO of Dina, which makes an AI-powered platform for care-at-home models.

Seven out of 10 people require assisted living care in their lifetimes. Studies show that most elderly people would prefer to stay at home and age rather than be moved to an assisted living facility.

Healthcare IT News sat down with Shah to discuss health IT's role in aging in place.

Q. Please describe the experience you had with caring for your aging father, and what you learned about information not being shared in a meaningful way.

A. Anyone who has cared for an aging parent knows it can be a challenging experience. Shortly after my previous company, Medicity, was acquired by Aetna, my father suddenly passed away. Unfortunately, this is something that you hear a lot in healthcare ventures – there's often a personal connection.

In my case, I'm trying to solve a problem that our family experienced. My dad was a senior citizen. He was being seen by in-home caregivers and in and out of senior centers.

After he passed unexpectedly, we spent time with those folks who saw a meaningful decline coming, and yet that information wasn't being shared with the formal healthcare team, definitely not his insurance company, and not with his family in a way that we could intervene to try to change his care trajectory. They were an untapped resource with a critical and objective perspective.

At Medicity, we were serving 1,300 hospitals, facilitating lots of data exchange across hospitals, primary care and labs, but nothing we were doing was ever going to touch the home and community. And as I dug into it more and more, I found that my story, unfortunately, is not unique. It's going to be one that grows in nature.

So, both out of professional and personal need, we looked for an opportunity to organize the home and community-based care ecosystem and make it easier for health systems, ACOs and health plans to extend their reach and visibility into the home, in an effort to help people maximize their healthy days at home. We launched Dina in 2015, and we've been very focused and committed to bringing the vision to life.

As an industry, we have two problems to solve. One is when you are a really engaged family caregiver. How do we make life easier for that person? The second is, how do we give less-engaged family members the visibility into what's happening with a loved one?

For us at Dina, that means how do we activate and coordinate the very best in-home care, and how do we unlock visibility into how that care is progressing to the people who are typically not part of that process, such as insurance companies, physicians, health systems, etc.

Q. What are some of the reasons it is important for care teams from different providers to share information when it comes to trying to help patients age in place?

A. Healthcare is hard. But if you look at a hospital, it's the place with the best resources for clinical care in our country, for example, the staff, providers, equipment and technology.

Now if you think about that model being unbundled, and you're now delivering care at home and in the community, in order to match that experience and make it a smart one you have to have great visibility and the ability to track everything. How do you understand what's happening now?

Coming out of COVID, it's also become clear that people want to have control of their overall healthcare experience, and a lot of that centers in and around their homes. And, unfortunately, when people end up in a hospital, returning home is often easier said than done.

Most home-based providers and family caregivers lack the technology to share how the patient is progressing with the extended care team. In addition, there is a growing number of people with chronic conditions who don't need episodic care, but need to stay connected to their providers to manage their health at home.

In a hospital, you hit the nurse call button if you're not feeling well or something isn't right. You have to replicate that remotely and share the information among caregivers.

Lastly, all the people who typically interact with a patient bedside have to be empowered to share information dynamically to coordinate care. Care happens because all those resources are there. What does it mean to match those resources in your home?

All those care team members won't be at your home at the same time. They'll come at different points and in different shifts, so sharing that information becomes critical.

Q. What kinds of healthcare information technology can help this situation?

A. There have been great advancements in virtual care, remote patient monitoring and patient engagement. But the type of technology that will need the most investment now is that which brings it all together – for example, the right sort of infrastructure for the coordinators, be they at the hospital or in an insurance company, to be able to monitor what is happening outside of the hospital and activate physical and virtual services.

That care might include personal care, companion care, house calls, meal delivery, home modification or durable medical equipment. It's a very broad and fragmented market. So, the technology to bring it all together with a single push of a button is crucial.

Moving forward, care is going to be delivered in three ways: in high-quality facilities, online with telehealth capabilities and in your living room. I believe that in the next five to 10 years, every home will need to be configured to operate as a formalized care setting (for example, primary care clinic or hospital), and providers – especially those who are part of value-based contracts – need to be ready to deliver care in this setting.

There's no one-size-fits-all solution for establishing care-at-home models. It takes alignment with payers and hospital finance and contracting teams, and you need to understand your target patient populations.

During the past year, more people opened their doors to healthcare at home, and these models are here to stay. We've seen that when the home is the focal point, care is more affordable, more convenient – and a more comfortable experience.

Q. What role do remote patient monitoring and engagement technologies play?

A. Remote patient monitoring tools act as an early warning system and create visibility between care visits. They increase the touches or connection between the health system and the individual.

If you're a traditional healthcare provider organization or a health plan, setting up the infrastructure to activate, track and manage care outside of the traditional four walls of a hospital is critical. We refer to this as "care traffic control" to remotely monitor and engage patients – and generate home-based insights to help identify functional, behavioral and social determinants of health needs.

While most providers do perform some level of tracking, monitoring and trending, one-way visibility is not enough. For example, text-based patient check-ins can be used to get feedback in real time and manage by exception, thus helping people stay home safely.

This helps drive down unnecessary hospital and ER visits. For seniors, it can slow the progression to long-term nursing home care. That is something that we're going to need to do more of, especially as 10,000 people turn 65 years old every day.

Healthcare organizations across the country are struggling with staff shortages and burnout. To navigate the shift to home-based care, they need to find ways to extend their reach into the home without further overburdening staff. Technology is one way to overcome that challenge.

Q. What experiences have you and your company had with remote patient monitoring when it comes to aging in place?

A. Studies show that most people feel safer receiving care in the confines of their own home and report greater satisfaction with the care they receive when they are in familiar and comfortable surroundings.

Right now, we don't have enough nurses, doctors and home health workers, so technology has to foster greater efficiencies and interactions.

By activating remote patient engagement tools, we can connect different points of care and different providers of care, and align them with the same goals, all while keeping the patient at the center. And this has positively influenced outcomes and kept more patients safe and well cared for in their homes.

It's not just passively collecting data, but remotely engaging in just-in-time conversations with someone – for example, asking how they're feeling, how their diabetes is progressing, or whatever the case may be.

They're not being directed to visit a portal, but rather engage in a dynamic conversation. And through those conversations we can determine if they need to be escalated to the appropriate care team member who can determine next steps.

Dina's technology uses triggers from predictive modeling and patients to help determine in real time who may need intervention or support with social determinant issues. Care teams are critical to guide and intervene when signals indicate that an escalation is needed. Using technology to "manage by exception" ensures no one falls through the cracks.

It's maintaining a connection and pulling back these insights around social, behavioral and functional health, and then acting on them in real time. I think it's a progressive model of care, and we're passionate about helping more people access care on their terms, in their homes, and maximize their healthy days at home.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.