Table 3.

Challenges and Adaptations for Home-Based Primary Care Practices During COVID-19: Themes from Qualitative Content Analysis

Themes	Examples	Number of Responses (N = 64)
Challenges
Supply chain issues	Normal supplier unable to provide supplies Concerns about counterfeit/poor-quality supplies Supplies available but not sufficient or difficult to obtain Unpredictable availability or inflated costs Engagement in creative supplies procurement, including purchasing from other practices	49
Workforce	Overall care provider strain Targeted staff for COVID patients Staff concerns and training Staff challenges with video care Need for patient visit prioritization due to workforce issues Workforce issues leading to suspension of house calls Loss of senior volunteers	37
Access to masks	No access to surgical or N-95 masks No access or difficulty with fit testing	27
Inadequate access to other PPE affected ability to deliver care (face shields, gowns, shoe covers, gloves, etc)	Lack of PPE necessitated cessation of in-person home visits Reuse of equipment designed for single use Poor-quality supplies, eg, face shields Need to make own supplies, eg, face shields and wipes	13
Communication and patient care	Challenges communicating with patients about PPE Exacerbation of sensory concerns (eg, hearing and seeing) with video care or PPE use Concerns about digital literacy of patients Resistance from assisted living facilities and patients to receiving care Patient distrust or fear and unwillingness to see clinical team members Negative impact of social isolation/loneliness More decline and death at home More challenges with dementia care	9
Financial	Constant change of billing regulations and frustrations with reimbursement Urgent need for more financial resources Amplified financial uncertainty	9
Adaptations
Telemedicine	Initiation or expansion of video or telephone-based care	55
Changes in processes of care	COVID testing New patient triage/risk stratification strategy New patient monitoring approaches, including the use of remote patient monitoring Targeted staff/care teams for COVID patients Group visits Driveway calls to ensure infection precautions in the home Medication refill or prepour for longer intervals Augmented attention to advance care planning Changes in documentation practices Shorter visits or reduction in overall home visits Initiation of patient triage systems	36
Infection control	Initiation of COVID-19 screening calls Changes in infection control re to PPE/sanitation Monitoring of staff for COVID	32
Engagement with community partners to optimize patient care	Engagement with community to fund raise on behalf of patient needs (eg, groceries, PPE, TP, etc) Partnership with community organizations (eg, food pantries, meals on wheels, and other nutrition support programs)	23
Collaborations within the health care ecosystem and with payers	Communication with hospital physician groups Supportive contracts for staffing Engagement with medical service businesses Engagement with local health departments Outreach to assisted living facilities, residential care facilities for the elderly, skilled nursing facilities (SNFs), and other home care organizations Risk/capitated payment programs more flexible and supportive	23
Increased recognition of the value of home-based care and focus on provision of HBPC by leadership and health systems	Home care seem more prepared than office-based care More home care because of fear of hospitals, clinics, and SNFs Recognition of the overall benefit of home care in the context of COVID	20
Practice changes	Billing for telemedicine Restrictions on which clinicians could provide in-person care (eg, due to age and comorbid conditions) Increased team meetings, huddles, and support Personnel layoffs Use of remote staff Staff rotation, reassignment, or redeployment Reduction in program size Suspension of home visits	16
Proactive patient and caregiver outreach	Proactive patient outreach to assess for and address caregiver burnout, food insecurity, and isolation Drop-off of medications and equipment Distribution of digital tablet devices to facilitate remote communication Goals of care and end-of-life care communication	8