Abstract
Objectives:
In the U.S., home health agencies (HHAs) provide essential services for patients recovering from post-acute-care and older adults who are aging in place. During the COVID-19 pandemic, HHAs may face additional challenges caring for these vulnerable patients. Our objective was to explore COVID-19 preparedness of U.S. HHAs and compare results by urban/rural location.
Design:
Cross-sectional study.
Setting/Participants:
Using a stratified random sample of 978 HHAs, we conducted a 22-item online survey from April 10 to 17, 2020.
Methods:
Summary statistics were computed; open-ended narrative responses were synthesized using qualitative methods.
Results:
Similar to national data, most responding HHAs (n=121, 12% response rate) were for-profit and located in the South. A majority of HHAs had infectious disease outbreaks included in their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster preparedness (84%), and had provided their staff with COVID-19 education and training (97%). More urban HHAs had cared for confirmed and recovered COVID-19 patients than rural HHAs, but urban HHAs had less capacity to test for COVID-19 than rural HHAs (9% vs 21%).
Most (69%) experienced patient census declines and had a current and/or anticipated supply shortage. Rural agencies were impacted less than urban agencies. HHAs have already rationed (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective equipment (PPE). Many HHAs reported accessing supplemental PPE from state/local resources, donations, and do-it-yourself efforts; more rural HHAs had accessed these additional resources compared to urban HHAs.
Conclusions/Implications:
This survey reveals challenges that HHAs are having in responding to the COVID-19 pandemic, particularly among urban agencies. Of greatest concern are the declines in patient census, which drastically impact agency revenue, and the shortages of PPE and disinfectants. Without proper protection, HHA clinicians are at risk of self-exposure and viral transmission to patients and vulnerable family members.
Keywords: home healthcare, infection prevention, pandemic preparedness, COVID-19
BRIEF SUMMARY:
This survey of U.S. home health agencies identified specific challenges that agencies are having, as well as mitigating strategies they are using, while providing care to patients in their homes during the COVID-19 pandemic.
INTRODUCTION
In the U.S., home healthcare, defined as care delivered in a patient’s home by healthcare professionals,1 plays an important role for post-acute and chronically ill patients. Most home care patients are older adults with multiple chronic conditions.2 During the COVID-19 pandemic, caring for this group of vulnerable patients at home is complicated and issues may differ in urban and rural settings. Our objective was to explore the COVID-19 preparedness of U.S. home healthcare agencies (HHAs) and examine any urban and rural differences.
METHODS
We used a stratified random sample of 978 HHAs with available email addresses drawn from a national survey conducted in 2019 (n=1,502). The original sample was drawn from U.S. Medicare-certified HHAs in the June 2018 Provider of Services (POS) file, stratified by Census region, ownership, and urban/rural location. After receiving Institutional Review Board determination, we used Qualtrics CoreXM™ (Provo, UT) software to email a 22-item survey (including 2 open-ended questions) on April 10, 2020. Our COVID-19 preparedness survey was adapted from one recently conducted in Michigan nursing homes.3 After two email reminders, we closed survey data collection on April 17, 2020.
For national comparisons, we merged the survey data with the 2019 (the most current) POS, Home Health Compare (HHC) and Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) data. Summary statistics were computed, and open-ended narrative responses were synthesized using qualitative methods and exemplar quotes are provided.
RESULTS
One hundred twenty-one HHAs completed the survey (12% response rate). Similar to national Medicare-certified HHAs, the majority of responding HHAs were located in the Southern census region and had for-profit ownership (Table 1). Our sample had more rural HHAs (27% vs 14%) than the nation, given that rural agencies were oversampled in the original sample. Approximately 15% of responding agencies were affiliated with a hospital. Average quality ratings for respondents were similar to national averages of the Quality of Patient Care (QoPC) and HHCAHPS Summary Star Ratings. The Star Ratings range from 1-5 stars (measured in increments of 0.5 and 1, respectively, for QoPC and HHCAHPS); most HHAs in the U.S. receive 3 stars which indicates they provide “good” quality of care.4
Table 1:
Home health agency characteristics, by survey respondents and the nation
| National Home Health Agencies n = 11,189 | Survey Respondents n = 121 | |
|---|---|---|
| Agency Characteristics | N (%) | |
| Census Region | ||
| Northeast | 1,035 (9.3) | 13 (10.7) |
| Midwest | 2,894 (25.9) | 31 (25.6) |
| South | 4,763 (42.6) | 46 (38.0) |
| West | 2,461 (22.0) | 31 (25.6) |
| Puerto Rico | 36 (0.3) | 0 (0.0) |
| Rural | 1,611 (14.4) | 33 (27.3) |
| Urban | 9,578 (85.6) | 88 (72.7) |
| Ownership | ||
| For-profit | 9,223 (82.4) | 82 (67.8) |
| Nonprofit | 1,586 (14.2) | 26 (21.5) |
| Government | 380 (3.4) | 13 (10.7) |
| Value-Based Purchasing Program Participation | 2,005 (17.9) | 18 (14.9) |
| CMS Program Participation | ||
| Medicare only | 2,500 (22.3) | 24 (19.8) |
| Medicare/Medicaid | 8,689 (77.7) | 97 (80.2) |
| Hospital Affiliation | 702 (6.3) | 18 (14.9) |
| Mean (SD) | ||
| QoPC Star Rating * | 3.28 (1.01) | 3.14 (0.97) |
| HHCAHPS Summary Star Rating † | 3.50 (0.90) | 3.75 (0.84) |
Notes: CMS = Centers for Medicare and Medicaid Services; QoPC = Quality of Patient Care; HHCAHPS = Home Health Care Consumer Assessment of Healthcare Providers and Systems; Totals varied due to missing data --
from February 2020 HHC file: n (total) = 8,412, n (respondents) = 103;
from February 2020 HHC file: n (total) = 5,483, n (respondents) = 68
Survey results are in Table 2. The majority of respondents cared for patients in assisted living facilities (79%), and less than 30% of HHAs cared for nursing home patients. Most respondents had infectious disease outbreaks included in their agency’s emergency preparedness plan (76%), and some had specific COVID-19 plans (60%). The majority of HHAs had a staff member in charge of outbreak/disaster preparedness (84%), and half had conducted outbreak simulations in the past 2 years. Most agencies have the capacity to admit COVID-19 patients requiring a lower level of care (69%), but only a few have capacity to test patients for COVID-19 (12%). Rural HHAs (compared to urban) had more COVID-19 testing capacity, but were less likely to have COVID-19-specific preparedness plans.
Table 2:
Measures of COVID-19 home health preparedness by location
| Location |
|||
|---|---|---|---|
| Total | Rural | Urban | |
| N (%) | |||
| Emergency Preparedness | |||
| Components in Current Preparedness Plan | |||
| Infectious disease outbreaks | 92(76.0) | 25(75.8) | 67(76.1) |
| Specific COVID-19 plan | 73(60.3) | 16(48.5) | 57(64.8) |
| Other IPC components | 25(20.7) | 4(12.1) | 21(23.9) |
| Has Staff Member Responsible for Outbreak/Disaster Preparedness* | 100(84.0) | 27(84.4) | 73(83.9) |
| Outbreak Simulations Conducted in Past 2 Years | 62(52.1) | 16(50.0) | 46(52.9) |
| Agency Capacity | |||
| Ability to Test Patients for COVID-19 | 15(12.4) | 7(21.2) | 8(9.1) |
| Access to Lab for Surveillance/Detection | 67(55.4) | 21(63.6) | 46(52.3) |
| Surge Capacity | |||
| Agency could admit COVID-19 patients requiring a lower level of care | 84(69.4) | 26(78.8) | 58(65.9) |
| Agency could admit non-COVID-19 hospital patients requiring a lower level of care | 82(67.8) | 22(66.7) | 60(68.2) |
| Cares for Patients in Residential Care Settings | |||
| Nursing homes | 32 (26.4) | 8(24.2) | 24(27.3) |
| Assisted living facilities | 96 (79.3) | 25(75.7) | 71(80.7) |
| Changes Due to COVID-19 Pandemic | |||
| Has COVID-19 Patients | |||
| Suspected | 66(54.5) | 17(51.5) | 49(55.7) |
| Confirmed | 33(27.3) | 6(18.2) | 27(30.7) |
| Recovered | 23(19.0) | 2(6.1) | 21(23.9) |
| Patient Census | |||
| Increased | 10(8.3) | 2(6.1) | 8(9.1) |
| Decreased | 84(69.4) | 20(60.6) | 64(72.7) |
| No change | 24(19.8) | 10(30.3) | 14(15.9) |
| Telehealth Usage | |||
| Increased | 70(57.8) | 19(57.6) | 51(57.9) |
| No change | 27(22.3) | 9(27.3) | 18(20.4) |
| No telehealth usage at agency | 21(17.4) | 5(15.2) | 16(18.2) |
| New Procedures/Protocols | |||
| Aerosol-generating procedure policies | 36(29.7) | 9(27.3) | 27(30.7) |
| Barriers when in patient homes | 62(51.2) | 16(48.5) | 46(52.3) |
| PPE donning and doffing in patient homes | 98(81.0) | 28(84.8) | 70(79.5) |
| Not applicable | 10(8.3) | 2(6.1) | 8(9.1) |
| COVID-19 Staff Training and Education Provided^ | 114(97.4) | 32(100.0) | 82(96.5) |
| Challenges Due to COVID-19 Pandemic | |||
| Supplies Currently Without | |||
| N95 respirators | 75(62.0) | 17(51.5) | 58(65.9) |
| Masks (surgical) | 54(44.6) | 15(45.4) | 39(44.3) |
| Gloves | 25(20.7) | 5(15.1) | 20(22.7) |
| Eye protection | 55(45.4) | 11(33.3) | 44(50.0) |
| Gowns | 67(55.4) | 16(48.5) | 51(57.9) |
| Cleaning supplies/disinfectants | 62(51.2) | 15(45.4) | 47(53.4) |
| Hand soap or alcohol-based hand sanitizer | 59(48.8) | 14(42.4) | 45(51.1) |
| Supplies Anticipated to be Without in Next 2 Weeks | |||
| N95 respirators | 48(39.7) | 13(39.4) | 35(39.8) |
| Masks (surgical) | 52(43.0) | 15(45.4) | 37(42.1) |
| Gloves | 25(20.7) | 6(18.2) | 19(21.6) |
| Eye protection | 38(31.4) | 7(21.2) | 31(35.2) |
| Gowns | 56(46.3) | 14(42.4) | 42(47.7) |
| Cleaning supplies/disinfectants | 49(40.5) | 14(42.4) | 35(39.8) |
| Hand soap or alcohol-based hand sanitizer | 50(41.3) | 14(42.4) | 36(40.9) |
| Currently Experiencing Staffing Shortages* | 38(31.9) | 6(18.7) | 32(36.8) |
| Primary Reason for Staffing Shortage† | |||
| Staff at risk, or with family members at risk for COVID-19 | 12(31.6) | 1(16.7) | 11(34.4) |
| Staff infected with/quarantined from COVID-19 exposure | 8(21.0) | 0 (0.0) | 8(25.0) |
| Child care issue due to school closings | 9(23.7) | 0 (0.0) | 9(28.1) |
| Other | 9(23.7) | 5(83.3) | 4(12.5) |
| Anticipated Staffing Shortages during Current Pandemic‡ | 19(23.7) | 4(15.4) | 15(27.8) |
| Mitigating Strategies for COVID-19 Pandemic Challenges | |||
| Addressing Staffing Shortages | |||
| Remaining staff volunteering to work extended hours | 23(19.0) | 2(6.1) | 21(23.9) |
| Remaining staff mandated to work extended hours | 7(5.8) | 2(6.1) | 5(5.7) |
| Contracted temporary staff | 13(10.7) | 1(3.0) | 12(13.6) |
| Non-clinical staff filling different roles | 16(13.2) | 3(9.1) | 13(14.8) |
| Accessing Supplemental PPE | |||
| State or local resources | 77(63.6) | 25(75.8) | 52(59.1) |
| Private/community donations | 63(52.1) | 24(72.7) | 39(44.3) |
| Do-it-yourself efforts | 73(60.3) | 25(75.8) | 48(54.5) |
| Not applicable | 2(1.6) | 2(6.1) | 0(0.0) |
| Current PPE Usage Strategy | |||
| Use expired PPE supplies | 17(14.0) | 8(24.2) | 9(10.2) |
| Extended use | 67(55.4) | 23(69.7) | 44(50.0) |
| Limited reuse | 74(61.2) | 19(57.6) | 55(62.5) |
| Rationing | 83(68.6) | 25(75.8) | 58(65.9) |
| Not currently having to use a strategy | 13(10.7) | 3(9.1) | 10(11.4) |
Notes: IPC = infection prevention and control; Other IPC components included influenza, tuberculosis, multidrug resistant Staphylococcus aureus; Other reasons for staffing shortages included employee fear and competition from other healthcare facilities; Totals varied due to missing data or skip patterns --
n = 119,
n = 117
n=38
n= 80
Almost all responding HHAs (97%) had provided their staff with education and training on COVID-19. Furthermore, most had new protocols and procedures in place regarding personal protective equipment (PPE) donning and doffing and using protective barriers while in patients’ homes, which are critical to reducing SARS-CoV-2 transmission. In a text response, one staff member at an urban for-profit HHA in Pennsylvania highlighted the importance of early and ongoing education to protect staff: “[We provided] education for all staff regarding how COVID-19 is identified, plus daily temp checks for all staff since the beginning, and daily screening of all patients prior to home visits. … screening of all new patients prior to admission to home care, and infection control reeducation. ”
A majority of responding HHAs (61%) had already cared for suspected, confirmed and/or recovered COVID-19 patients. Urban HHAs had cared for more confirmed (31% vs. 18%) and recovered (24% vs. 6%) COVID-19 patients than rural HHAs. Most respondents (58%) had increased their use of telehealth, while some (17%) still did not have telehealth capacity. A staff member at an urban, for-profit agency in North Carolina explained how telehealth helped: “We are not discharging patients, instead we are performing virtual visits and phone visits. This is to ensure our patients are at least being monitored for any signs and symptoms. We are trying to prevent trips to the doctor and hospital.” Even with telehealth capabilities, difficulties exist with remote visits and monitoring, as described by an urban, for-profit HHA in Texas: “[We’ve had] difficulty in reaching/communicating with patients who have no phone or signal or Wi-Fi connection.”
Despite increased telehealth usage, most responding HHAs (69%) had experienced a decreased patient census; rural agencies were impacted less than urban agencies (61% vs. 73%). A staff member at a rural, non-profit HHA in Kentucky explained: “The hospitals have cut out most surgeries and other services, which has greatly decreased our census and also, patients are requesting no services due to the fear of the virus.” The consequences of a declining census to agency revenues was described by an urban, for-profit HHA in Texas: “We have lost 30% of our census to patients not wanting visits in their homes, and due to the lack of scheduled procedures that result in home health utilization. We will have staff layoffs in the next 14 days if we are not approved for the Paycheck Protection Program.” Another staff member at a rural, for-profit agency in Hawaii explained: “Our agency [discharged] many patients to reduce the risk of exposing them to COVID-19… [We] had to furlough 50% of [our] field staff. It’s been heartbreaking.”
Current and/or anticipated supply shortages were widespread among respondents. Urban HHAs, more than rural HHAs, lacked N95 respirators (66% vs. 52%), gloves (23% vs. 15%) and eye protection (50% vs. 33%). More urban HHAs anticipated shortages in eye protection in the next 2 weeks, compared to those in rural locations (35% vs. 21%). A staff member from a rural, non-profit agency in New Mexico lamented: “PPE is highly needed to ensure the safety of our patients and staff. All of our orders were taken by the government. Just does not seem fair to take away PPE that has always been ordered by our agency and leave us without. We have purchased material to make disposable gowns and have volunteers and staff making these, and face masks.” Another staff member from an urban, for-profit agency in Colorado explained their situation: “We are hampered most by not having enough PPE… That will be our most limiting factor in the next two weeks. We have the staff but the PPE is the problem.”
Despite challenges with sourcing PPE from established vendors, many responding agencies accessed PPE from other avenues: state/local resources (64%), private/community donations (52%) or do-it-yourself efforts (60%). Rural HHAs appeared to have more access to these sources than urban HHAs. Many HHAs have followed new CDC guidelines5 for extended (55%) or limited (61%) use of current supplies. Despite the high need, one staff member from a rural, for-profit agency in Ohio grieved over the guideline changes: “It is appalling [the CDC] would change the standards of proper disinfection, make our non-reusable PPE now reusable.”
Most responding HHAs (62%) had not or were not anticipating significant staffing shortages due to COVID-19. Of those with staffing challenges (38%), more urban HHAs reported that those challenges were due to both not wanting to put staff at risk or staff not wanting to put family members at risk than rural HHAs. Other agencies noted in their text responses: “stafffear” or “competition from nearby [agencies/facilities/hospitals] for qualified healthcare providers”. A staff member at an urban, for-profit agency in California described their situation: “We have a significant reduction in staff due to childcare issues, as well as staff members who are in high-risk populations themselves and are now on leave of absence.” Of those experiencing staffing shortages, some HHAs (19%) had remaining staff volunteer to work extended hours. More urban HHAs (than rural) utilized this mitigating strategy (24% vs 6%). At one urban, for-profit agency in Connecticut, a staff member explained how taking early action preserved staffing: “[Our] clinicians have a designated area --whether that is a sector of community or an assisted living building --and they have remained in only that community… Most of my team decided to only work for our agency through this. They understood if they were to moonlight in another SNF, hospital, etc. they would be putting people at risk.” Another staff member at a rural, for-profit agency in Ohio indicated: “We actually did not take any steps [to preserve staff]. We had a handful of aides who also worked at dentist and doctors’ offices and since they are closed temporarily these aides picked up more shifts. So, we just got lucky. ”
DISCUSSION
Most HHAs had an emergency preparedness plan in place, and despite regional differences in COVID-19 cases, the majority of responding agencies were caring for (or had cared for) suspected, confirmed or recovered COVID-19 patients. Urban HHAs appeared to be struggling more than rural HHAs, with less capacity to test patients for COVID-19, larger decreases in their patient census, shortages of PPE, not having additional sources for PPE, more staffing challenges, and caring for more confirmed and recovering COVID-19 patients. With the density of urban areas, this is not unexpected but is alarming. For rural agencies, prior relationships or partnerships with local health departments and hospitals may be aiding them in accessing supplemental PPE supplies and COVID-19 testing for their patients. In rural locations, there are also fewer healthcare providers, and, thus, less competition for PPE supplies than urban agencies are facing.
The decreased patient census of HHAs is also concerning. Home health patients receiving care prior to COVID-19 may not be currently receiving care due to fear, staffing shortages, or lack of access to telehealth visits. For smaller HHAs, declining revenue resulting from a decreased census may jeopardize their financial viability. Even for agencies with telehealth capabilities, difficulties with reimbursement for telehealth services adds to the financial issues. On March 30, 2020, CMS did add more flexibility to provide services to Medicare beneficiaries via telehealth,6 but receiving reimbursement still remains problematic and any such visits must be physician-ordered.7 Because of the decreased census and revenue, some HHAs need to terminate or furlough staff; these agencies may have a diminished ability to assist with any future surge capacity.8
The current/anticipated shortages of PPE and other supplies remain the largest concern. During the week of April 10, 2020, most responding HHAs were already lacking N95 respirators, gowns, and cleaning supplies or disinfectants. The lack of PPE has been reported at length in hospitals and nursing homes9, but rarely for home health agencies10. As in other healthcare sectors, most HHAs have struggled to secure more supplies because of intense competition. A survey conducted in late March, 2020 of organizations serving the home and community-based care needs of New Yorkers found that 80% of respondents were having difficulties in obtaining PPE supplies.11 Due to this, most HHAs are rationing PPE and several agencies are extending the use of current PPE supplies or implementing limited reuse guidelines. This is of great concern because lacking proper protection, home health clinicians are at high risk for self-exposure and have additional challenges in preventing viral transmission to other patients and vulnerable family members.
Limitations
Of note, this is a relatively small sample and may not represent the entire population of U.S. HHAs. To obtain a quick response and reduce the burden to responding staff, our survey only included 22 items, was open for one week and, therefore, captured what HHAs were experiencing at that specific point in time during the pandemic.
CONCLUSIONS AND IMPLICATIONS
Nevertheless, our survey provides a first glimpse of HHAs during the COVID-19 outbreak and shows that there may be important differences in the ability of an agency to respond to the pandemic. In the U.S., home healthcare is a vital service for patients that are recovering from acute care, as well as for adults who are aging in place. However, this healthcare sector has not received the attention that hospitals and nursing homes have had. This survey sheds light on the problems this crucial sector is having in responding to the current pandemic and highlights the potential for long-term problems in the industry. Furthermore, HHAs were already facing challenges related to the Patient-Driven Groupings Model (PDGM), which is considered the largest payment overhaul in U.S. home health industry since 2000.12,13 In the future, researchers will need to disentangle how HHAs respond long-term to the COVID-19 pandemic and PDGM to understand the capacity that HHAs have to deal with future public health crises.
Acknowledgments
FUNDING SOURCES: National Institute of Nursing Research; Office of the Director of the National Institutes of Health (R01NR016865). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.
Footnotes
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CONFLICT OF INTEREST: The authors have no other conflicts of interest, including personal and financial, to report.
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