Dear Nursing Homes: Here’s how to Stay Alive

Are nursing homes now considered old-fashioned? Has m-health and the variety it offers replaced this low-cost healthcare service provider? Healthcare Executive finds out.

1200Over the last few years, home healthcare providers have moved up the value chain, from home nursing services to an organized industry. Home healthcare providers are popping up in every metro today and if one disappears, another takes its place.  Care-24, a Mumbai based healthcare start-up recently raised $4 million in Series A funding, within three months of receiving seed funding. It’s not bad for a business built on palliative and maternity care. On several social networking sites, there are often discussions about the most efficient home healthcare service provider in the city. While one says Portea, another says Care-24 and the third says India Home Healthcare. However, there is actually, a low-cost equivalent of these start-ups, and it’s called “Nursing Homes”.

“Unlike hospitals, nursing homes were marketed to Indians as a low-cost model.”

Dr. Nikhil Datar, Serial Entrepreneur and Co-founder of two Nursing homes

Dr. Nikhil Datar is a serial entrepreneur and is the co-founder of two nursing homes in the city. He tells Healthcare Executive how the market is evolving. “The word nursing home in Western world means, a place where nursing care is given. Here, we use this word to describe miniature hospitals. Thus, in the current scenario we should use the word small healthcare facility instead of a nursing home. Currently, we call a corporate set-up a hospital, but if it’s started by doctor it is termed as nursing home. The advantages such as accessibility, cost, personalized service are still the USPs of small sector hospitals. Nursing Homes has its roots in post independent India. During 1960’s and 70’s, there were not many hospitals to cater to the Indian population. Most families had a family physician who took care of their healthcare requirements. These family physicians set up the first set of nursing homes in our cities. Later, they were replaced by specialists and super specialists,” says Dr. Datar

Unlike hospitals, nursing homes were marketed to Indians as a low-cost model. “Nursing homes seems to have become popular in 1970s. It took off among middle class due to availability of doctors, affordability as well as accessibility,” remembers the consultant with Cloud Nine Hospital in Mumbai.

Clearly, nursing home was an exciting modern model for middle class Indians. What is interesting is reasons why nursing homes took off in 60’s in Mumbai are similar to why home healthcare service providers doing well today.

There is a mistaken idea of nursing homes being a relic of Indian healthcare system.

Graph-1

In fact, Mudit Vijayvergia, co-founder, Curofy, a networking app for doctors, points out that there is definitely a positive sentiment about the Indian economy and it’s a good time to start a nursing home in the country.

“There are broadly three major reasons,” he says.  First, since the economy has grown, people who can afford a private nursing home have increased significantly. Hence, there is definitely an increase in the market size and would continue to grow as the economy grows. Second, even the people in the lower income groups would shift to low-end nursing homes, reason being the immense rush in the government set-up and a serious lack of doctors in the former. Doctors are paid very less in a government hospital and hence most of the doctors prefer joining a nursing home or a hospital. This leads to very low doctor-patient ratio in a government hospital. This would ultimately lead to patients moving to nursing homes. Third, as the financial products increase, doctors have more options now to finance their set-up; hence doctors can easily start their own nursing homes owing to the multiple financial options provided by banks.

” when more nursing homes would open up, competitive forces would push these private set-ups to ensure quality.”

Mudit Vijayvergia, co-founder, Curofy.

Quality Debate

In the early years of nursing homes, there were lot of criticism from hospital owners, who felt it was trying to degrade the quality of healthcare. Many were particularly disturbed by the fact that even complicated surgeries were conducted at these small facilities. And when they realised they couldn’t do much, they changed tags and called nursing homes very Indian.

“A doctor can only attend limited patients in a fixed set up and time. In a nursing home the quantity of patients the doctor would be treating is lesser compared to a government set-up and hence he would ensure quality. It’s always easy to maintain small set-ups, and hence I feel quality would be ensured. Moreover, when more nursing homes would open up, competitive forces would push these private set-ups to ensure quality.

“A nursing home generally pays a nurse more than the government set-up. Now, as I see it, nurses who have completed BSc Nursing prefer to join a nursing home rather than government service. Hence getting more qualified manpower would ensure quality. As number of nursing homes will increase, the market forces would demand for more trained nurses, which will lead to opening up of various such institutes, hence my sense is that manpower issue will not be there,” explains the IIT Delhi alumnus.

Vijayvergia points out that digital healthcare wave will take a toll on primary nursing homes. But he predicts that more secondary and tertiary nursing homes would come up. “I agree with this that healthcare is not a commodity and people do look for brands. But honestly, that section is very less in India. We are missing out the mass here, there are lot of patients, who are not able to even access healthcare, forget about deciding where to go. Hence, once more nursing homes mushroom with economic growth, there is a huge chance of nursing homes being able to build their own brand. Still, lot of hospitals survive due to star doctors. Such doctors will exist and its’ just a matter of time when they start on their own,” notes the founder of Curofy, which aims to bring doctors across the nation on its mobile app, to help them communicate and collaborate with each other.

Remedy for a Nursing Home (5)The academic, Lawton Robert Burns has come up with a book on Indian healthcare system, which has a separate section on nursing homes. A regulation for nursing homes was important, as there were no definitive statistic about the number of nursing homes in the country. It was common across India for doctors to set up their own facilities. As per rules, there was no clear distinction between a hospital and a nursing home.

“There are laws in the country, but implementation is an issue. Quality will be driven from the side of patients and education will play a major part here. With the increase in education levels, people would determine this and will result in removal of bad apples from the system. M-health and home healthcare service providers would be able to disrupt nursing homes catering to primary care but one really needs such set up for secondary and tertiary care. Hence, what we will see in future is super specialized nursing homes. The key to survival would be maintaining quality at minimum expense,” says the healthcare entrepreneur.

“Nursing homes will have to reinvent themselves to survive”

Dr Kaustub Sardesai, Healthcare Consultant

Nursing homes did serve a purpose in a popularising quality care for masses, says Kaustub Sardesai, a healthcare consultant.  “The overall Indian healthcare market today is worth $ 100 billion and is expected to grow to $ 280 billion by 2020; a compound annual growth rate (CAGR) of 22.9 per cent. Healthcare delivery, which includes hospitals, nursing homes and diagnostics centers, and pharmaceuticals, constitutes 65 percent of the overall market.

“The health sector is growing, especially hospitals and nursing homes. There is a significant scope for enhancing healthcare services considering that healthcare spending as a percentage of Gross Domestic Product (GDP) is rising. Rural India, which accounts for over 70 percent of the population, is set to emerge as a potential sector. India requires 600,000 to 700,000 additional beds over the next five to six years, indicative of an investment opportunity of $ 25-30 billion. So I believe it is a perfect time to start a new venture in the sector,” explains Sardesai. It’s worth noting how setting up a nursing home is different from other healthcare facilities.

Sardesai says that average size of a nursing home is around 50 beds and operated by a single specialty doctor or family of doctors or two or three groups of doctors. “The emphasis of these facilities is on mother and child care, general medicine or general surgery. Also, the manpower working in these facilities is mostly midwives or Auxiliary Nurse Midwife (ANM) or unskilled paramedical staff and they are trained by the doctors on the job. Still, these facilities are developed by consultants and provided with personal care at low cost and are usually able to pull the patients.

However, nursing homes will have to reinvent themselves to survive, these facilities have to adapt to changes in the healthcare scenario and for same they need to invent in areas like change from one or two specialties to a multi specialty clinic.” The problem is that people no longer have the time to go to multiple nursing homes for different ailments.

“Nursing homes cannot work in isolation; they need to collaborate with other specialty nursing homes, laboratories and pharmacies. They also need to upgrade the quality of their services and must follow minimum standards required for quality care and as suggested by NABH,” adds Sardesai.

Table-1

Regulations for Nursing Homes

The laws in India that regulate all types of “clinical establishments” including “nursing homes” as well as bigger hospitals and diagnostic centers are still evolving through Clinical Establishment Acts in various states.  The central Clinical Establishment Act, 2010 (CEA) has defined a Nursing Home (NH) as “Any premises used or intended to be used for reception of persons suffering from any sickness, injury or infirmity and providing of treatment and nursing for them and include a maternity home”.  So, legally speaking, there is no distinction between a NH and a typical hospital in India as both are required to have medical treatment as well as nursing facilities.  Ironically, the CEA has distinguished the NHs and hospitals into four different levels (Level 1-4) based not on the type of services or nursing care they provide but rather on the number of beds any particular institution may have with the larger teaching hospitals with hundreds of beds as Level 4 while any clinical establishment having up to 30 beds as Level 1. On top of this inequitable technical distinction from the affluent large private hospitals, many local authorities including municipal corporations have imposed their own rules and guidelines to control the smaller nursing homes posing even more burdens to their existence in our society,

Graph-3“There can be little dispute that most NHs in India are primarily involved with providing long-term supportive or simple palliative care for the chronically ailing individuals many of whom are unable to afford the high cost of medical care in private hospitals.  It is unfortunate that the present laws in India do not consider the obvious fact that smaller nursing homes providing nursing care for the local population including senior citizens at a nominal cost should not be regulated in the same way as the large pricy hospitals that are reaping huge profit from the vulnerable patients who have little choice but to rush to the big hospitals for treatment of serious illnesses,” says Dr Kunal Saha, President of People for Better Treatment (PBT).

“Indian health ministry needs to come up with separate but realistic plans to regulate the highly profitable large private hospitals and small NHs that are generally owned by less affluent individual doctors or doctor-couples.”

Dr Kunal Saha, President of People for Better Treatment (PBT)

As in most Western countries, “Nursing Homes” in India should also be better defined under a separate class of medical facilities that are designed primarily to offer basic nursing care, under proper medical supervision, at a low cost but without the rigorous regulatory obligations that are generally associated for the bigger full-fledged treating hospitals. Stringent rules are still absolutely essential in a country like India for protection of the defenceless patients who are treated in expensive private hospitals by doctors who are frequently motivated to bring bigger profit for the hospital.  But application of the same strict regulations for smaller NHs cannot be deemed as fair for the owners as well as ordinary patients in India.

“Indian health ministry needs to come up with separate but realistic plans to regulate the highly profitable large private hospitals and small NHs that are generally owned by less affluent individual doctors or doctor-couples. However, it would also be important to assure that government keeps a close watch on these small NHs owned by single doctors or doctor-couples so that they are not able to abuse these relaxed regulations by exploiting the hapless patients because the way the healthcare delivery system stands in India today, there are hardly any checks and balances for the delinquent doctors who can be disciplined only by their peers in the Medical Council of India (MCI) or state medical councils (SMCs).  Unfortunately, it is a common knowledge today that medical councils in India primarily function to shield their errant medical colleagues without caring for the innocent patients,” says Saha.

BURNING #1 QUESTION

Are nursing homes at the verge of extinction?

Over the years, many nursing homes have started to rely on the part-time services of specialists and general physicians. Today one might even hear stories from consultants about how patients prefer ophthalmology nursing homes run by eminent doctors to a single specialty chain in a Mumbai suburb.

“It’s a great opportunity to co-exist if we purely look at solving the healthcare staffing shortage, up-skilling staff and better continuity of care for patients.”

Dr Satish Jeevannavar, CEO of Activ Doctors Online

It is no surprise then, when Dr Satish Jeevannavar, CEO of Activ Doctors Online tells us that the onslaught from home health service providers or corporate hospitals is akin to whether Kirana stores survive the onslaught of chain of department stores or grocery home delivery business. “Guess, the customers (patients) will decide that in the years to come. There is no easy answer. However I personally feel it’s a great opportunity to co-exist if we purely look at solving the healthcare staffing shortage, up-skilling staff and better continuity of care for patients.”

He explains that nursing homes in all likelihood will find it very tough to keep going in metros and tier 1 cities. “However – guess, it’s still a long way to go for the corporate hospitals and home health to penetrate majority of the Indian population – which is in tier 2 and 3. It’s also important to note that home health is in its nascent stage (business models) and hence the need to study the fundamentals of the model.

While, India already struggles with healthcare manpower shortage – one question to ask is “Would you want a GP or nurse to be in a clinic/hospital and consult about 15-20 patients at 1/3rd cost viz a viz see 3-4 rich/affordable patients in 4 hours considering commute (like in Bangalore traffic?). Are you solving healthcare accessibility or you are creating more resource crunch within the existing system?” asks, the CXO.

He also adds that the industry is moving away from multi specialty towards single specialty. “If you look at the traditional nursing homes, it’s mainly managed by doctor couples or generations of doctors (Obstetrics, Gynaecology, Paediatrics, Medicine, Anaesthetists) – catering to maternity, paediatric, OPD and basic emergency services. In metros – the onslaught of corporate hospitals, home health providers, lack of support from insurance, star doctors and the fact that the small nursing homes are more vulnerable to violence by patients/attendees (as they cannot afford security, PR etc etc) makes the future very bleak for nursing homes,” he adds.

BURNING #2 QUESTION

Is collaboration the key for survival of a nursing home?

Of course, the other truth is a modern hospital is not only about care. There are all these other reasons to go to them like a cafeteria, better ambience and even better facilities for patients relatives.

“A person walks in to large hospital as he is ready to shell out more money for better care and services. However, there is a great opportunity for large corporate hospitals to collaborate with local nursing homes – it will result in standardized care, professional up-gradation of knowledge for doctors from nursing homes and stronger processes in place resulting in better quality and continuity of care for patients. For e.g. a patient travelling hundreds of kilometres from tier 2, 3 to metros to get any major procedure done can do the follow up care at local nursing homes if the collaboration exists. Also, with the advantage of having access to healthcare staff and nursing homes in tier 2, 3 (and even infrastructure) at comparatively lesser cost with rising disposable income – the larger corporate hospitals have a better chance to optimize the financials with collaboration viz a viz spreading thin and trying to set up outreach clinics/hospitals on their own without having the local knowledge,” says Jeevannavar.

However, he warns that collaboration in healthcare is a very tricky affair (not comparable with other industries) – due to multiple reasons: liability issues, lack of trust and transparency in financials, plus the ego-conflicts between the star doctors.

Graph-2Differential Pricing

However, what many find strange is the fact most professional academic bodies, government committees find representation only from the CEO’s, promoters of corporate hospital chains and the grievance redressal mechanism for smaller nursing homes is almost non-existent.

“It is a vicious cycle for nursing homes – routine procedures like appendectomy which would cost about approximately `30,000 to `50,000 in a smaller nursing home would easily cost about `1 to `1.5 lakh in a large corporate hospital chain and both private and public insurance would reimburse the bill easily in corporate hospital chain but not in a smaller nursing homes,” says Jeevannavar.

Perhaps, there is a possible disruption potential available to bring the unorganized smaller nursing homes under a single umbrella, with focus on better quality, process – maybe on an aggregation model like in the hotel, taxi space and optimize the bed occupancy. However, it is easier said than done – especially, as the life of patients is at stake unlike in the hotel/taxi space.

BURNING #3 QUESTION

Is it possible to increase quality without increasing cost?

“If the second-generation is not from a medical background a NH is either shut down or acquired/leased by single or group of doctors”

Dr Abhishek Pawar, Principal Consultant, Hosmac

Guess, one way to address the cost versus quality issue is – linking the insurance reimbursement via co-pay model to the quality/process standards maintained by the hospital/nursing homes and not the bed strength alone.

If the patients are willing to pay the additional premium for the ambience and coffee shop at corporate hospitals what is the harm in nominal hike due to the higher quality standards available closer to your home.

In most parts of India, nursing homes often relies on referral kick-backs and networking skills of hospitals. According to Dr Abhishek Pawar, principal consultant, Hosmac, nursing homes cannot compete with the bigger players in tertiary care due to lack of process-driven practices.

“They are in a league of their own but have the potential to compete with super specialty hospitals in terms of primary-secondary level of care, day care services, short-stay surgeries, home care services, etc if managed professionally. Few players like Apollo-Nova Super Specialty Centers, Currae hospitals, etc are evolved and extended version of nursing homes which are already competing with super specialty hospitals. In developed parts of the cities, nursing homes are in a critical condition due to multi-factorial reasons like cost of real estate.

While the service-mix and bed-mix offered in the nursing homes may simulate super specialty hospital; the quality of care, skill sets, preparedness of hospital staff to handle criticality, medical emergencies, mass casualties, disaster management, etc in hospitals is far more evolved and cannot be compared with nursing homes,” explains Pawar.

Family Run Businesses

Earlier nursing homes were perceived as family-run businesses. With changing times, there are many doctors with similar or allied clinical specialties who have come together to run a nursing home. “If the second-generation is not from a medical background a NH is either shut down or acquired/leased by single or group of doctors,” explains Pawar.

“People in India feel comfortable walking to nursing homes in nearby vicinity of about two to four kilometres”

Nikhil Apte, Chief Product Officer, Royal Sundaram Health Insurance.

Grey Areas in Nursing Home Model

Despite the explosive growth of personalized care segment and m-health, investors are not keen on nursing homes as its often person-driven, unorganized and lack of standardization of services and poor or no quality assurance checks.

In 2012, licenses of several private nursing homes in Bihar were cancelled for unnecessary removal of uteruses of hundreds of poor women to claim insurance money under a central government scheme. Many also operate without license. An inspection drive by Municipal Corporation revealed that 68 nursing homes were operating without a license. Many operated from residential premises on city’s outskirts.

“We have nursing homes at every corner of the country, which is in a way good because it gives easy access to healthcare in a populous country like India. However, quality control is doubtful and there is wide variation in quality of services provided across different nursing homes in same city.  There are several reports about doctors practicing with fake degrees and unnecessary surgeries to claim insurance money. Further, there are no standardized costs for nursing homes and prices vary widely,” explains Nikhil Apte, Chief Product Officer, Royal Sundaram Health Insurance.

Nursing homes are here to stay much like the conventional brick and mortar shops which are still functioning in spite of on-slot of e-retailers. “Basically, consumer behaviour is an important factor. People in India feel comfortable walking to nursing homes in nearby vicinity of about two to four kilometres,” he adds.

Table-2

BURNING #4 QUESTION

Can nursing homes survive the onslaught of home healthcare providers?Indian healthcare sector needs to plan for rejuvenation of its existing facilities such as nursing homes as well as build new ones with proper planning and use of new technology.

“The advantage of a nursing home is that doctors of various specializations are available, such as gynaecologist, general physician and some OPD treatments are also available. Home healthcare providers are still extremely small and only few organized players are now emerging. Their availability is also not uniform across the country like nursing homes.

Remedy for a Nursing Home (4)Typically, home healthcare provider if available is hired in case of elderly care or certain disease conditions such as Paralysis, Parkinson, etc. and disease where person is bed ridden and needs constant attendant and regular administration of certain treatments, while a family can go to a nursing home for various healthcare issues where they get a quick access to relevant specialized doctor. If you have a high fever, you are not likely to call home care service but rather go to a nursing home and show to the physician. Therefore, the two segments are totally separate and mutually exclusive. Therefore, nursing homes will stay as a brand,” says Apte.

He also adds that the nursing homes should be looked at a larger perspective.

“Nursing home model is here to stay as not everybody can afford a star doctor and not every small healthcare problem requires a star doctor.

Table-3The general physician model which existed in India till 2005 has disappeared in last 10 years as people have a tendency to go to specialized doctor. Considering the wide population and geography and the fact that communicable diseases and minor ailments will continue to rise, nursing homes will always remain strong in India.

Actually, though our country lacks good number of hospitals with good facilities. The healthcare provider distribution in the country is highly skewed towards metros with 85 percent of hospital beds are in urban India but 76 percent population is in rural India. Even in densely populated urban cities like Delhi, Mumbai, etc. with a population of more than 1.2 crore, the numbers of hospitals are not sufficient to cater to the needs of patients.

Nursing homes therefore provide a very good alternative at low cost of primary care while big hospitals provide secondary and tertiary care. Unless it is a life threatening condition like heart attack or cancer, nursing homes to a large extent are able to take care of patients which do not require immediate hospitalization,” explains Apte.

BURNING #5 QUESTION

Will millenials go to nursing homes?

But will a twenty-year-old go to a nursing home? Apte points out that better quality can improve a nursing home’s balance sheet. “Customers will be willing to pay more as the bar for minimum expected service level goes up. For example, with success of taxi aggregators, today customers expect a cab in good condition and an AC cab. For example, compared to 10 years back, today most nursing homes are air-conditioned because customers expect that as minimum service level and are willing to pay for that,” adds Apte.

“Branded hospitals come at their own price points and so does home care”

Anitha Arockiasamy, who is the president of India Home Healthcare

Most nursing homes are in an environment where understanding consumers have become different. Anitha Arockiasamy, who is the president of India Home Healthcare, says, “Nursing homes have traditionally been a neighbourhood facility for both acute and chronic care. With the rapid growth and expansion of branded hospitals, most of the acute care treatment and procedures are preferred in these facilities. Moreover, the Indian market in the last two years has seen a huge interest in home care, which is capable of handling most of the chronic care requirement at home, in addition to some basic acute care, through highly skilled staff backed by high end technology. Hence, it is not just the home health care providers that are affecting the demand for nursing homes. I believe it is the combined effect of the growth of hospitals and home care industry.”

Clearly, disparity in the income also cuts across various cities, where patients have their own peculiarities.

“I do not think nursing homes are at the verge of extinction. India is a country with 1 billion plus population from varied economic strata, with huge gaps in availability of quality health care. Branded hospitals come at their own price points and so does home care. With no insurance coverage for the latter, there will still be a significant percentage of our population that will be dependent on the nursing home for chronic care and also acute care for the foreseeable future,” says Arockiasamy.

National Health profile shows that the number of doctor per 1000 population is lesser than the WHO prescribed benchmark. However, Arockiasamy points out that

Nursing homes are a great alternative as it makes health care more accessible for a majority of our population in smaller cities and towns. “We cannot deny the fact that quality comes at a cost. I think when the system itself changes, with more and more nursing homes being accredited and being included in payer network, the cost would also be more palatable for the general public. Clearly, in newer, affluent parts of the metros, it is becoming difficult to find nursing homes which corroborate the fact that the people in higher economic strata prefer branded hospitals”.

According to Dr Aniruddha Malpani, nursing homes and home healthcare are complementary areas, not competitive.

“Nursing Homes are under threat because of the onerous regulatory burden the government is putting on them.”

Dr Aniruddha Malpani

“Nursing Homes are under threat because of the onerous regulatory burden the government is putting on them. In certain specialties, they will not be able to survive. However, for many areas (for example, ophthalmology, general surgery, ENT, day care surgery and Gynaecology) they will continue to do well, because they are very cost effective and provide personalized care and attention.

It’s a great model providing the patients are selected sensibly and carefully. Thus, they are great for elective surgery for healthy patients (for example, hernia repair or appendectomy), but not a good choice for critically ill patients or emergencies,” explains Malpani.

If the insurer will not bear this, then unless the government provides subsidies to doctors for providing an essential public service, then nursing home owners will be forced to pass on the additional costs to patients.

Given the high cost of real estate, it is no longer cost effective for a doctor to run a nursing home in a metro, which is why doctors will no longer start new nursing homes, that is true. The problem is not the competition which big hospitals provide – each player has their own role to play in this ecosystem.”

He also adds that ego can be a biggest concern for merger of nursing homes. However, he shares his concern about being part of a hub and spoke model of a bigger hospital. “Yes, they can offer to be bought over; or be part of a franchise. However, I doubt if this is cost effective given the commercial rates nursing homes are being charged at present by the municipality. Nursing Homes need to learn to carve out a niche for themselves, and restrict themselves to doing procedures in which they specialize,” adds Malpani.

“Nursing homes need more practical guidelines”

Dr. Ketan Parikh, former president of Association of Medical Consultants

He adds that the rules should be designed so that they are realistic, and add value to the care patients receive. “If they don’t meet this requirement, they are seen to be an onerous burden. They need to be adapted and modified for the ground reality in India Today, patients are happy to go to good nursing homes. Yes, they prefer 5-star hospitals, but only when the care is paid for by their health insurer.

What Nursing Home owners say

There is no easy answer to whether we need nursing homes or not. But Dr. Ketan Parikh, former president of Association of Medical Consultants, says that they will die soon.

According to Parikh, nursing homes face several operational challenges. “Availability of trained staff, equipment maintenance (cost and personnel), equipment turnover, patient hooliganism are some of them.” He also adds that the real competition to nursing homes has been from corporate hospitals and home health-care would only supplement nursing homes.

AMC-FEQH standards

He also sees the NABH guidelines are impractical and only theoretical. “They are a cut-copy-paste from imported standards. Many bigger hospitals also flout them and only comply for the sake of medical tourism.  The AMC-FEQH standards are far more practical and also define infrastructural necessities, which the NABH is silent about. Standards are important but they should not plague effective and reasonable health care delivery,” he says.

“An evolving regulatory landscape and stricter requirements will make it difficult for some nursing homes to operate.”

Dr. Anant Bhan, Researcher, Global Health, Health Policy and Bioethics

He adds that insurance companies have been unfair to nursing homes and this is purely for commercial benefits. “They have not lost faith but wish to exploit nursing homes maximally. As far as RSBY is concerned, they too have imported some standards from the west and the bigger hospitals are using the RSBY as a tool for training their juniors. Nursing homes need more practical guidelines. Reduce unnecessary burden on nursing staff who can then concentrate on nursing duties and patient care.

I think collaboration and hub and spoke models are excellent options. Hope these become operational as soon as possible in the interest of health care in future,” concludes Parekh.

Dr. Anant Bhan, researcher, global health, health policy and bioethics, seconds his views. “Competition is high, including the entry of corporate healthcare chains in smaller cities and towns. Paucity of well-trained (and high attrition of) healthcare personnel is a major issue. An evolving regulatory landscape and stricter requirements will make it difficult for some nursing homes to operate. Space constraints and rising rentals/costs also have an impact on nursing homes that often focus on providing cheaper healthcare services in comparison with a larger hospital.” However he adds that home healthcare service providers as a service stream is just picking up steam in India.

“While they fulfil an important healthcare need by providing much needed services at the doorstep, the sector is new and has limited reach. Many individual nursing homes have a long history behind them, and are well respected in the communities they serve. Often being accessibly located, they can provide a range of services which might not be amenable to be carried out through a home healthcare service provider – for example labor/delivery services,” adds Bhan.

According to Dr. Bhan, the nursing model is under challenge, but not really at the verge of extinction. “This is because the model is now well established in many parts of India, and has flourished in a lax regulatory environment. It works especially well in smaller cities, towns where while healthcare demand is high, provisioning through public facilities is often poor, and there are few corporate healthcare facilities or branches. Accessibility is also a big plus—especially for those nursing homes set up close to or in residential areas.”

How to transform your nursing home?

Is the nursing home sector ready for a disruption? And what factors should doctor-entrepreneurs focus on?

“Delivering quality, ethical healthcare is a good start—there is a dearth of facilities which offer quality, evidence based and patient focused treatment. Those who invest in building relationships with patients, and provide healthcare services tend to thrive, often through word of mouth. A key aspect is investing in well trained workforce, and also having support services such as diagnostic services which provide reports in a timely and reliable fashion. It’s often not possible to offer all healthcare services under one roof if you are a smaller health facility as a nursing home, so it helps to create a niche expertise area and to excel in care provisioning in that area,” explains Dr. Bhan. Within the current healthcare framework, there are plenty of opportunities for smaller players.

“Most nursing homes are run as family businesses, and often don’t follow quality standards.”

Kavita Narayan, Director, National Institute for Allied Health Sciences

“This is especially true because nursing homes often tend to focus on a few specialties, often linked to the expertise of the owners. If they want to service the healthcare needs of their target communities, then they need to be able to get visiting consultants on board from other specialties. Alternatively, collaborating with other nursing homes which focus on other specialties can help them develop referral pathways, and optimize on each others’ strengths.

Many nursing homes (especially the larger ones) are linking up with corporate chains—while this helps with branding, it’s also important to ensure that the core identity of the nursing home is not completely subsumed by the (much larger) brand,” warns Dr. Bhan.

He also identifies principles that define the reinvention culture, adding, “Home healthcare  has a fair bit of potential—especially in areas which require regular follow-up, and long term residential care which can be offered at home—such as in chronic conditions where nursing help might be required as well as in palliative care. This is going to become a big need with the rising burden of non-communicable diseases in India.

“Nursing homes do not necessarily need to be threatened by this development; rather they can actually tap into it. Developing outreach services through care provisioning at the doorstep can help them increase their footprint in communities, as well as build loyalty with families and communities

“Nursing homes need to invest in providing timely, efficient, quality, ethical healthcare—and tap into emerging trends in healthcare. These include use of rapid evidence-based diagnostics, increasing their family medicine services, linking up with national programs, and building collaborations to increase synergy,” concludes Bhan.

Kavita Narayan, Director, National Institute for Allied Health Sciences, says that nursing homes can survive only if they reinvent themselves. “Nursing homes are popular only in few Indian cities and are more like mom-and-pop shops. Further, needs of an urban patient is not met in a nursing home. Plus, the competition from big brands like Fortis and Apollo is strong. Common man is happy to pay `1000 for a visit today, as they want quality care. Most nursing homes are run as family businesses, and often don’t follow quality standards. They should find a way to rebrand or revamp, if they want to survive in the Indian market. They should transform themselves to high-tech primary care centres, or else they will vanish. Probably, guidelines similar to Indian Public Health Standards (IPH) should be formulated for nursing homes. The state governments could actually look at running these nursing homes and ask doctor-entrepreneurs to run these facilities on behalf of the government,” concludes Narayan.

Remedy for a Nursing Home (1)

Article Source: Healthcare Executive, March 8th 2016

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