The next evolution of nursing delivery: Critical barriers to scaling home primary care
There is sufficient literature to prove that the chances of primary care in the United States are decreasing. The reasons are multiple factors. Some problems are the consequences of patient-related factors such as mobility and location, but are largely due to a shortage of physicians. In fact, a new report from the Human Resources and Services Administration (HRSA) predicts that by 2037, the shortage will be short of 87,150. The end result is that some of our most vulnerable patients do not have primary care, which ultimately leads to disease progression, adverse outcomes and increased costs. To address access issues, we need to find ways to provide care for patients more reliably and expand the skills of hard-working primary care physicians.
To cope with the rising costs, healthcare facilities are trying to transfer patients from higher environments such as ER or skilled nursing facilities to lower rated environments such as outpatient offices and even four walls of patient residence. However, none of this addresses the shortage of primary care physicians, meaning that care delivery organizations will need to scale by leveraging technologies such as remote patient monitoring and telemedicine, as well as team-based approaches to care.
First, as we move complex care from hospitals and brick-and-mortar clinics to homes to help those who work hard to attend doctors’ visits, I suspect we will also see a new professional rise: “Recreationist.” Similar to hospitalists who provide comprehensive care for patients during hospitals, “indoorists” will provide complex and high-quality care for patients at home. Just as the skills of the inhabitants are slightly different from those of the outpatient primary care physician, so is the “interiorists”. At-home care requires new features that go beyond the usual primary care, often requiring physicians to focus on health determinants (SDOHs), such as mobility, vulnerability, vulnerability, and other issues related to family limitations and limited families – all of which are provided in complex and vague environments.
To do this, doctors will need to truly perfect recording and physical examination skills, and rely less on things like complex imaging. In cases of distraction, they need to be satisfied with the delivery of care in sometimes unstable situations. They will need to be experts in observing and learning from the patient’s surroundings and influencing the outcomes.
Second, primary care providers will need to find ways to expand their skills. They need to rely on asynchronous care in the form of remote monitoring and telephone “touch points”. According to a multidisciplinary team including unskilled caregivers of patients, “recreationists” will need to be comfortable. An indoorist will need to serve patients at home at scale as a team leader and individual contributor.
While I hope these shifts help close the gap between patients who struggle with traditional visits during a physician shortage, we still have a long way to go in in-home care, a mainstream, scalable alternative to traditional care models. This is some of the key primary care barriers for healthcare executives in 2025, especially when we want to expand our home healthcare facilities.
Add tools to your doctor's bag
For more than a decade, the healthcare industry has recognized the role of SDOH in a person’s health and well-being. Home care offers unprecedented opportunities to bridge this gap. However, as an industry, we still have no standard way to collect and integrate SDOH data, let alone technology to support it.
The nursing team needs a lot of time and effort to identify and address social and environmental factors that affect the health outcomes of each patient we serve. In 2025, we will see providers working to implement more systematic processes to address these gaps. For example, mobile-friendly EHRs can be customized to support home workflows, such as coordinating community recommendations and tracking individual social determinants.
Solve the last mile home health care service
Many factors for healthcare providers to reach the patient’s doorstep: staffing, transportation, driving time, etc. Trained primary care providers are stuck in traffic or are expensive and inefficient in driving to rural areas during long drives. This will be a key area that technology will solve. All types of home primary care providers and organizations need to have the same advanced scheduling software as Amazon or Uber’s dynamic routing algorithms to ensure that well-trained doctors spend less time on the road and more time providing care. Providers also need to be satisfied with remote monitoring and low-tech touchpoints (such as phone check-in).
When the provider arrives, they may find other logistical barriers, such as the lack of WiFi or available durable medical equipment and services in nearby areas, including mobile labs and radiation services. While basic in-person care can still be provided without the internet, many logistical infrastructures need to be coordinated to provide the same level of care as a doctor’s office or emergency room.
Advocate value-based care
Health care at home will maintain a niche as long as the healthcare industry uses the financial model of paid services. Reimbursement of paid services simply does not reward preventive, team-based care, which focuses on keeping the sickest patients healthy and healthy at home and abroad.
Instead, we must advocate accelerated value-based care. Value-based models prioritize overall patient-centered care, preventive care, chronic disease management and cost efficiency – the benefits of all home healthcare. Value-based care provides agencies for primary care physicians who have the deepest insights on keeping patients healthy and at home – which may not be easily overwhelmed by CPT code.
Important work is being done through volunteer programs such as ACO Reach and Medicare Shared Savings Program (MSSP) to improve health benefits through value-based care. The CMS and healthcare industries need to continue to remove barriers to patients and providers entering these programs.
Paving the way forward
We are at a critical point. At-home primary health care service models are ready for rapid growth and transformation. But there is more work to be done before “indoorists” become household words.
It’s time to conduct payment models, training programs, trainees and service providers start using home healthcare as a medical professional and career avenue. A hundred years ago, most care was provided at home. Now, the old one is new. Let’s get together to find ways to provide extended access to complex primary care for patients who need it the most.
Photo: Boonchai Wedmakawand, Getty Images
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