Home Health Services in the Time of Coronavirus Disease 2019: Recommendations for Safe Transitions

To the Editor:

As the coronavirus disease 2019 (COVID-19) pandemic has led health systems to focus on hospital capacity, hospitals are emphasizing early discharges to prepare for and mitigate patient surges. This has resulted in greater numbers of older adults with COVID-19 who require home health (HH) services. HH care of older adults with COVID-19 leads to several unique risk categories: (1) risks to HH providers; (2) risks to patients/families; and (3) risks to subsequent patients/families the HH provider will visit. We describe challenges in providing HH services in the time of COVID-19 and present recommendations to improve transitional care and the safety of older adults, families, and HH providers (Table 1 ).

Table 1.

Available Training Resources for HH Workers for Managing Patients During the COVID-19 Pandemic

Training Material	Link to Resource
National Association for Home Care and Hospice Coronavirus Resources for Home Care and Hospice	https://www.nahc.org/resources-services/coronavirus-resources/1
Centers for Disease Control and Prevention Coronavirus Disease 2019 (COVID-19): Using Personal Protective Equipment (including videos and posters)	https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html2
Infusion Nurses Society COVID-19	https://www.ins1.org/covid-19/3

HH providers are delivering care to older adults who, during nonpandemic times, would have remained in the hospital. Many older adults prefer to be at home instead of in hospitals or residential facilities, because of visitor restrictions and concerns over severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. Furthermore, while hospitalized older adults requiring post-acute care often go to residential facilities, many of these facilities are infection hotspots and may be closed to new patients, particularly persons with COVID-19.

Older adults receiving HH services after hospitalization are at the highest risk of unplanned healthcare utilization compared with other care transitions even during nonpandemic times.⁴ Homebound older adults have increased unmet needs⁵ and are at risk for complications related to social isolation,⁶ challenges that are exacerbated by the pandemic.⁷ Ambulatory care sites conducting telemedicine approaches may leave many older adults at risk for incomplete clinical evaluations. Meanwhile, HH agencies often lack infection prevention professionals⁸ to prepare them to care for patients during a pandemic.

HH Provider Safety

Health care workers in all care locations including HH are experiencing personal protective equipment (PPE) shortages. Attempts to mitigate PPE shortages in hospitals have focused on reuse. However, PPE reuse is difficult in HH, where processes for safe HH PPE reuse without self-contamination and when traveling between homes are not clearly established. Ensuring appropriate PPE use, including donning, wearing, and doffing, is equally essential in keeping HH providers safe.⁹ Hospital-based strategies to ensure appropriate PPE use include repeated trainings, videos, dedicated spaces to don and doff PPE, checklists, and trained observers. However, HH providers lack training materials and strategies tailored to their needs and realities (eg, storing PPE in a backpack or the trunk of a car, placing supplies on home surfaces, etc). HH providers typically drive or walk between patient homes and may lack appropriate locations to don and doff PPE (eg, front porches, apartment hallways).

Attention should also be paid to appropriately cleaning durable medical equipment provided for medical care in the home (eg, hospital beds, oxygen) prior to being provided to another patient.¹⁰ Guidelines on how to clean these durable medical equipment appropriately without contaminating HH employees are essential.

Finally, expanded telemedicine services could be used in HH to reduce employee exposure to COVID-19 for monitoring of and evaluation of older adults.

Older Adult and Family Safety

Family members are essential members of the HH team. They perform tasks including cooking, cleaning, bathing, dressing, toileting, ambulating, dispensing medications or treatments, monitoring the patient, and providing social contact. Meanwhile, the Centers for Disease Control and Prevention recommends household transmission prevention through hand-washing, avoiding touching faces, sleeping in different rooms, using different bathrooms, avoiding sharing personal items, cleaning surfaces, and limiting contact with pets and uninfected family members.¹¹ Performing care tasks while following this infection prevention guidance is difficult for families caring for homebound older adults with COVID-19, especially in a small or crowded household. HH providers are essential in providing guidance on infection prevention practices among families, aiding families with COVID-19 management, and providing emotional support. Specific infection prevention strategies should be provided to HH providers to disseminate to older adults and families.

Strategies to Ensure Optimal Transitional Care Workflows

HH agency and hospital collaborations can ensure adequate information transfer and care provision during hospital-to-home transitions.¹² These collaboratives can also develop optimal home visit workflows, such as scheduling HH providers to visit patients with COVID-19. Finally, HH agencies should develop strategies for the optimal balance of performing in-person visits vs remote monitoring. HH agencies and health systems would benefit from strategies to improve team performance, such as multidisciplinary remote rounds, incident command structures, predischarge checklists, real-time evaluation of care transition quality, and inclusion of HH in the rapid expansion of telemedicine services.

The COVID-19 pandemic has led to a large-scale change to American society. We view this as an opportunity to improve care for at-risk older adults across the health system continuum, including the most common and understudied health care setting—the home.