Hospitals are the frontline battlegrounds in the war on COVID-19. Doctors and nurses are saving lives at great cost to their mental and physical well-being. Never before has remote medical treatment been so relevant than now.
Thousands of lives have been lost due to poor healthcare and overexposure to the virus. India's health infrastructure remains tawdry, with basic facilities not available in the hinterland where Community Health Centres have a 76.1 percent shortage of doctors.
Professional home care has become the large-scale alternative to hospitalisation for both COVID-19 and non-COVID patients a sector that has grown exponentially over the last year. The India Home Healthcare Market Size and Share USD 6.2 billion in 2020, with a projected increase to USD 21.3 billion by 2027.
Gyan Mehta (name changed) from Bengaluru, all of 26 years of age, has Duchenne muscular dystrophy, a genetic disorder that leads to progressive muscle degeneration. He was admitted to ICU after a fall last year, which caused multiple fractures.
Unfortunately, the post-surgery complications put him on a ventilator, which led to more muscle weakness and ICU delirium. He needed long-term acute care at home, with skilled nursing and telemedical consultation. His family chose Cloudphysician, a medico-technical team dedicated to setting up home ICU facilities after hospital discharge.
Their services include identifying software, hardware, open-source technologies, pan-tilt zoom cameras, a reliable internet service, and a real-time video conferencing platform. They also provide specially trained critical care nurses and a physiotherapist for round-the-clock care.
ICU intensivists with experience in remote care offered guidance throughout the treatment, motivating Mehta and putting him on the path to recovery. In 50 days, he was able to make monthly outpatient visits to his doctor. In six months, he took a holiday abroad with his family when air services resumed.
Similarly, Vishakha Malhotra contracted the coronavirus in Delhi, which she suspects was the result of a visit to a mall. She went into home isolation; going to a hospital was risky, and the bed crunch accelerated the situation further.
A friend suggested a home care package from a top hospital, which included medical equipment, a vitals monitoring tool with built-in alert mechanism in case her situation deteriorated, daily monitoring by a nurse on call and video consultations with a doctor. Medicines were home-delivered. It took 15 days, but Vishakha recovered.
Why home care?
The patient is not disoriented since he or she is in familiar surroundings, like their own room, bed, their favourite cups and plates, music and TV. Home care includes a customised care plan that considers lifestyle needs with extra support.
Hospitalisation implies a loss of independence. Choosing the time to rise from bed, eat and sleep helps to retain confidence. Non-COVID patients can socialise and even have outings under supervision. Interaction with family and friends ensures mental health. It helps avoid hospitalisation during the pandemic.
For non-COVID patients, the home healthcare team from a hospital has nurses, physical therapists, occupational therapists, speech therapists, social workers and aides working under a doctor's care. Home care professionals help family members to avoid the burnout associated with caring for patients.
Specialised services from the home healthcare provider are an important factor in choosing it. On top of the list are nurse care, palliative care, elderly care and post-surgery care. In focus are expert packages that offer advanced services for tracheostomy care, paediatric nursing and counselling.
The Indian health industry is witnessing its biggest boost in medical home care, which involves teleconsultation, home lab testing and home delivery of pharmaceuticals. Home-based vaccinations, especially for paediatric purposes, are expected to grow in demand after the current age restrictions are removed.
Rise in Remote Treatment
A 2020 RedSeer Analysis report indicates the many reasons for the growth of this sector. India currently has nine beds per 10,000 patients far below the WHO-mandated standard of 40 beds per 10,000 patients and a single nurse for every 1,000 patients.
This has resulted in a severe lack of personalised attention for patients, whose needs are specific. The report highlights that going to a hospital invites a higher likelihood of catching infectious diseases, since 25 percent of patients in India have been found to be vulnerable to 'hospital-acquired infection'.
Intensive care averages between Rs 35,000 and Rs 50,000 a day. These factors make home-based care an attractive alternative to hospitalisation, except in critical cases. The growing demand for quality post-operative care, advancement in remotely operated technology, growing geriatric population, higher disposable income, and expanding chronic and lifestyle diseases are responsible for the meteoric growth of this sector in India.
Cloudphysician’s closely monitored protocol is a prime example of the feats being achieved by the Indian healthcare industry, to provide an economically viable solution for long-term acute care at home. According to Dr Ruchir Mehra, CEO and co-founder of DISHA by Remedo app, technology, startups and PPPs are driving novel solutions to the country's healthcare needs.
The Remedo app connects patients to doctors by understanding their conditions and suggesting lifestyle changes, outside the fixed 10-15 minute consultation. Remedo acts as a digital extension of medical practice, helping doctors provide better care to patients outside the clinic.
Dr Dileep Raman, Intensivist, Pulmonologist, Sleep Specialist and Co-founder of Bengaluru-based Cloudphysician, highlights their proprietary software technology called RADAR, which provides analytical insights into patient health, disease state, treatment line, and medication effectiveness. It also helps with telerounds and allows seamless communication among all healthcare providers.
The ability to offer tele-ICU services is a step further in democratising healthcare in India and in increasing its reach. Awareness and the acceptance of technology-based medical advice, coupled with the penetration of smartphones and the internet, have triggered a shift in behaviour towards home care. The proliferation of devices on the market, from BP monitor to pulse oximeters, has helped people make better use of remote care.
The COVID-19 Equation
When 34-year-old Uma Maheswari in Chennai was diagnosed with mild COVID-19, she decided to return home after a few days at a COVID Care Centre. "I've two children and my husband works full time. I couldn’t afford to stay away from home for long," she says.
She immediately booked Apollo's home care plan. It cost her Rs 700 a day, and offered telecounselling and a home care kit. "I had top infectious disease specialists from the hospital checking on me via video conference," says Maheswari.
They suggested mental relaxation activities and physical exercises in addition to the ongoing treatment. "It was affordable and I got peace of mind since I could talk directly to the doctors." The pandemic has changed the healthcare landscape, breaking down as many barriers as it has imposed.
In Odisha, despite only 28 percent of the population accessing the internet, telemedicine services had an overwhelming response during last year’s lockdown. AIIMS Bhubaneswar and seven other medical colleges, in addition to the Centre’s medical setup at the district headquarters hospitals, collectively advised over 20 lakh patients virtually.
The first step to home care was taken by a majority of private super speciality hospitals, which have dedicated telemedicine departments to spearhead the transition into home-based healthcare.
Dr GV Rao, director of AIG Group of Hospitals in Telangana, claims they do 1,800-2,000 teleconsultations each month, with the number rising to over 5,000 consultations at the peak of the pandemic, pointing to the lockdown’s role in people accepting telemedicine more readily.
Home healthcare during the pandemic proved a boon for patients with non-communicable diseases, since they need a steady supply of medicines and periodic diagnosis. Andhra Pradesh reached out to such patients through a special toll-free number, 14410. A missed call would lead to a call back from an executive to note their details, medical history and primary symptoms.
This information would be forwarded to empanelled doctors who would contact the patient and provide counsel. Appropriate medicines would be prescribed and home-delivered.
Senior Gastroenterologist and Head of the Department of Bhubaneswar-based IMS and SUM Hospital, Prof Manoj Kumar Sahu, says, "Lifestyle diseases such as diabetes and hypertension, which are considered major comorbidities for COVID-19 patients, can be managed through teleconsultation. Quality care can be ensured without danger of exposure to the virus. Telemedicine will eventually boost the reach of high quality healthcare to peripheral areas, unlike before."
Dr Gaurav Thukral, EVP and COO of HCAH India, a dedicated home healthcare service launched by Dabur in 2012, states that the pandemic forced them to juggle responsibilities. From running COVID helplines for immediate query resolutions to remotely monitoring home isolation programmes, from large-scale testing to setting up isolation centres, from managing COVID patients at home to post-Covid recovery care programmes, Thukral’s pan-India team has done it all.
It’s All about the Team
Having a dedicated team in place is vital to the success of home healthcare services. Dr Harmeet Khurana is the Consultant Obstetrician and Gynaecologist at Neptune Hospital, Delhi. When the pandemic began, she and her team were given instructions through extensive webinars on the correct procedures for teleconsultation.
However, Dr Khurana believes that these cannot replace physical consultations. "At medical school, we were taught that doctors must follow strict procedures before pronouncing treatment. We must check the patient's history and perform examinations before treating them. Apart from the first step, the rest simply can’t be performed on video and WhatsApp. Online consultation for documenting the medical history and follow-up checks can reduce patient time and risk, but physical examination is imperative for a holistic diagnosis," she says.
Her sentiments are echoed by Dr Lingaiah Amidayala, director of Medical Services, Yashoda Hospitals Group, Hyderabad. He notes that patients are more likely to be satisfied when they are admitted to hospital or get a physical OPD check.
It takes time to establish complete trust in telemedicine. However, hospitals are keen to enter this space after witnessing the change in medical consumer patterns. Home healthcare is likely to be incorporated in steps, beginning with follow-up checks, or post-operative care where patients are also willing to accept online consultation.
With remote technology acting as the new pivot, healthcare systems are turning to the field of robotics to assist human healthcare personnel. The Meenakshi Mission Hospital in Chennai, for instance, has introduced 16 mobile Teladoc Health Robots to operate CT and MRI scan machines.
They collect and process data from other diagnostic equipment to be presented to doctors who can make precise clinical decisions based on the inputs. Last year, the Tamil Nadu State Health Department introduced ‘robotic nurses’ in key government hospitals for in-patient care, though these are yet to be used.
Telerobotic surgeries are on the upswing, with a Global Market Insights report putting their market value at USD 5.5 billion in 2018. With 5G poised to go worldwide soon, telerobotic surgery using robotic arms could become the norm. Danish Ahmed, CEO of the Hospals app that facilitates teleconsultations of foreigners with Indian doctors, claims that such tech will spur growth in Indian medical tourism, and surgeries being conducted online under the supervision of their favoured physicians from India could be a reality.
The Government Position
An important consequence of the pandemic is that the government of India realised the need for a policy to regulate the telemedicine sector to prevent possible profiteering and misuse. The Telemedicine Guidelines of India, 2020, were introduced to regularise teleconsultation services across the country and to specifically address their skyrocketing prices.
These cover all modes of communication such as text, audio, video and others, between service providers and users. Medications are grouped and listed corresponding to specific types of consultation, and restricted drugs are notified.
The Ministry of Health and Family Welfare has launched the national teleconsultation service eSanjeevani that provides healthcare services at home through safe and structured video-based clinical consultations.
These services are operated by state governments. The Kerala health department’s facility has served over one lakh people who would otherwise have been compelled to visit government hospitals for outpatient care. Dr NM Arun, internal medicine specialist and public health expert based in Palakkad, lauds the platform’s immense popularity and efficacy.
"A lot of patients continue to use the facility even after the lockdown restrictions were over. It is especially useful for follow-up appointments," he says. Patients send reports of their blood sugar, blood pressure, oxygen levels and photos of X-rays and ECGs to their medical professionals. Private labs send digital reports to the doctors concerned.
Health department officials in Tamil Nadu assert that eSanjeevani has helped 6,42,708 people, especially in the rural belt. Odisha government’s online preparedness has expanded the reach of telemedical assistance far and wide.
It has set up a dedicated healthcare helpline in association with a Delhi-based firm to provide a platform for people seeking medical advice from home. A team of over 300 physicians are on call round the clock. The Delhi government’s Corona Telemedicine helpline had invited doctors as volunteers who would offer counsel free of cost.
Spurred by the success of state telemedicine helplines, several private hospitals around the country have developed their own mobile telemedicine apps to prevent losing business. A report released by popular tele-appointment app, Practo, shows a 500 percent spike in online medical consultations during the lockdown.
There was a 200 percent increase in psychiatric consultations, of which 62 percent were aged between 21 and 30. Overall 50 million Indians accessed healthcare through telemedicine during the lockdown, of which 80 percent were first-time users. The report, which concentrated on the three-month lockdown in 2020, concluded that more than 50 percent of all e-consultations were Covid-related.
Getting the People's vote
When 82-year-old Prakash Singh (name changed) in Delhi had a severe stroke and needed constant care, his family decided to nurse him at home. It was 2019, well before the pandemic struck, and home-based care of an elderly patient seemed more cost-effective and humane than letting him languish in a hospital.
They called in a team of nurses and took the home care package offered by Apollo Hospital. Singh died in May 2020, but the family had no complaints about the quality of the medical care. Many such patients are turning to non-medical specialists for succour.
Sabrina Singh, an end-of-life doula, virtually guides her patients who are on the brink of death. Doulas are non-medical professionals who give physical and emotional support to patients.
Apart from guiding them to put their affairs in order, doulas also comfort patients to face fears associated with death. Their calm presence enables the patient’s loved ones to find peace during the turbulent period.
These healthcare personnel have come to be much in demand around the country, as witnessed through the rise of numerous geriatric-specific home care centres. Sivaramakrishnan, a 69-year-old retired bank manager in Chennai, turned to Alserv's team for home-based care during the pandemic. He was not ill but needed assistance for general medical upkeep.
He describes the dedication of Alserv's team akin to the care he would expect from his own children. For outright physical injuries such as knee sprains, doctors profess to diagnose their severity by checking limb movements on video. Coimbatore-based iCliniq has a network of over 3,500 doctors; in the last year, it had an average of 3,500 to 4,000 calls daily from Indian and overseas patients.
The influx of new medical devices is behind the transition in treatment approach. Manav Bhushan, CTO and Co-founder, Fourth Frontier, manufacturers of a wearable device that measures ECG continuously, observes that COVID-19 has pushed people to be more aware of their general health.
He says, "Research shows that Covid has a long-term impact on cardiac health. This finding has popularised tools and devices that can be used at home, especially to monitor heart rate. All kinds of continuous glucose monitors and wearable devices that provide detailed information are getting a good response."
Most prominent players of home-based care/phygital care models assure that healthcare at home is a supplement to traditional healthcare, and not its replacement. They only reduce the burden on the medical industry. Since the care management takes place under the supervision of doctors attached to hospitals, both services must work in tandem for maximum benefit.
Dr Thukral points out that despite the inherent difficulties, a majority of COVID-positive patients are receiving care at home. "The goal is to keep hospitals from being overburdened unnecessarily. Hospitals are under tremendous pressure right now, facing severe manpower and infrastructure stress. Home-based healthcare is the future and the answer to lessening the burden on our healthcare system. Increasing the use of home health services during COVID-19 allows discharged patients to continue getting care at home, freeing up much-needed hospital beds for critically ill patients," he says.
What are the factors to be considered while choosing home healthcare? Credibility matters. Many private home care facilities have mushroomed without proper oversight. Consult friends and neighbours for recommendations, and caution. Check testimonials, client referrals and collaborations with respected hospitals.
Be clear about the services that are needed. A good home healthcare professional will develop a suitable care plan only after assessing the needs of the patient. Select a service that will meet all the patient’s needs. Their professionals must tailor evidence-based care with specific improvement goals in mind.
Home healthcare services must be cost-effective.
Eliminate the superficial aspects. Other significant aspects of home care are convenience and treatment accessibility. Medical expenditure no longer has to break the bank since it promises a reduction of nearly 60-70 percent in hospital bills. Further, with increased internet access and improved technology, high-quality healthcare services are becoming available in rural areas. Home is where the chart is.
Medical equipment aiding healthcare at home
Frontier X: A wearable device that provides high-quality ECG continuously, allowing the wearer to spot any abnormality immediately. Can identify arrhythmia, ST Depression indicating ischemia, prolonged QT intervals and other medical parameters from ECG. Worn on chest, so the quality of ECG is far better than those of hand-held devices. Became a high-in-demand healthcare product during Covid for people to monitor their cardiac health at home. The ability to live-stream the ECG remotely to any location to their doctors for consultations, works in its favour. Can be purchased online.
Blood Glucose Monitor :A device used to check blood sugar levels. This works by analysing a small amount of blood, usually from a fingertip.
Nebuliser: It turns liquid medicine into a fine mist that a person can inhale through a face mask or mouthpiece. Taking medicine this way allows it to go straight into the lungs and the respiratory system where it is most needed.
Omnytraq: A ring-like device that monitors every single heartbeat continuously for in-depth proprietary data analysis for heart health and long-term health trends. Only available on doctor’s prescription.
Oxygen Concentrators: A device that takes in air and separates the oxygen, delivering it to a person through a nasal cannula. Air consists of 79 percent nitrogen and 21 percent oxygen, and a concentrator that works by plugging into a source of electricity delivers air with up to 95 percent oxygen.
Blood Pressure Monitor: A device that consists of an inflatable cuff that’s wrapped around the arm, roughly level with the heart, and a monitoring device that measures the cuff’s pressure. The monitor measures two pressures: systolic and diastolic.
Oximeter: A clip-on device that you place on your finger, a toe or even on your ear lobe, which measures your oxygen saturation level, or the oxygen levels, in your blood. The non-invasive and painless test can rapidly detect even small changes in how efficiently oxygen is being carried to the extremities furthest from the heart, including the legs and the arms.
Top Home Healthcare providers
Services: Setting up ICU, cancer care, nursing care and physiotherapy along with 70 percent of all clinical procedures at home. Pan-India
Services: Orthopaedic, heart, neuro and lung rehab, mother and baby care, and eldercare. Medical supervision with care, including nurse and physician visits. Pan-India
India Home Health Care (partner of BAYADA Home Health Care, US)
Services: Orthopaedic, cancer, post-surgical, critical, palliative, geriatric, tracheostomy and ventilator care. Pan-India
Portea Heal At Home
Services: Nursing care for basics like injection and infusion, medical dressing, vaccinations, eldercare, mother and baby care, post-operative support and health and lifestyle management. Pan-India
Services: Smart-ICU solution, which increases the number of ICU beds that an intensivist can reach in a timely, and cost-effective manner. Pan-India, through its remote technology, RADAR
Services: Attendants, nursing care, eldercare, physiotherapy and rehabilitation. Delhi, Mumbai and Bengaluru
Healers at Home
ervices: Nursing care, home doctor visits, physiotherapy, eldercare, mother and child care, X-ray at home, sample collection, medicines and on-call dressing visits. Delhi-NCR
Services: ICU care, doctor consultations, caregivers, physiotherapy, sleep studies, speech and language therapy, respiratory care, stroke rehabilitation, dental care and lab tests. Bengaluru, Hyderabad, Chennai and Mumbai
Services: Attendants, nurses, physiotherapy, eldercare, baby care, cancer care and provision of medical equipment and administration of injections. Delhi-NCR and Dehradun
Services: Contactless, continuous remote patient monitoring. AI algorithms track the patient’s vitals trends and generate an Early Warning Score enabling early detection of health deterioration. Pan-India, through its proprietary remote technology
The Remote Advantage
Increase in outreach
More efficient output
Follow-ups in chronic cases and for elderly patients
Reduced healthcare cost
Shortened length of in-clinic stay
Less clinician burnout
Lower mortality rates
More clinical contribution
Rules So Far
Here are the government regulations related to the telemedicine sector
The Telemedicine Practice Guidelines, 2020, regulate remote consulting over audio/video and text-based platforms
The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has initiated work on digital health standards for accreditation of telehealth providers
Discussions are on how to operationalise the telehealth model of Aarogya Setu and fund remote care for Ayushman Bharat
What to look for when choosing home healthcare services
Dr Gaurav Thukral - EVP & COO, HealthCare atHome India
Whether the home healthcare provider has a team of trained, experienced, background-verified and clinically trained staff equipped to handle medical emergencies that can be trusted
The decision-maker - family member /patient/caregiver - should search for someone who suits their needs best. The home care partner should be trustworthy, credible, and experienced. Ask the following questions to check it is not a sham
Are the home care partner and their team rightfully qualified and trained?
Are they quality-driven in terms of safety, time efficiency, etc?
Can they handle medical emergencies?
Do they have medical backups in place?
Dr Dileep Raman Intensivist, Pulmonologist, Sleep Specialist and Co-founder, Cloudphysician
People must consider the appropriate expertise and the qualifications of the caregivers. They must be evaluated and vetted by trustworthy entities to ensure that the caregivers are adequately trained and skilled at what they do.
Jagadish Ramamoorthy, Co-founder & Director, Alserv
The healthcare service provider must have hired only trained staff from verified institutes. Each member of staff must go through a background check before being deployed.
Archana Sharma, founder, Samvedna Senior Care & Dr Jayashree Dasgupta co-Founder
The team must be a mix of experienced and young professionals, including doctors, clinical psychologists, social workers, nurses and caregivers. For eldercare services, the staff should have been hired from reputed institutes specialising in geriatric care and elderly issues. The staff must also go through a specialised in-house training in geriatric care
(With inputs from Manju Latha Kalanidhi, Unnikrishnan S, Hemant Kumar Rout, Binita Jaiswal, Omjasvin MD, Donita Jose & Guru Srikanth)