key: cord-0799025-ridwy1vg authors: Reckrey, Jennifer M. title: COVID‐19 Confirms It: Paid Caregivers are Essential Members of the Healthcare Team date: 2020-05-18 journal: J Am Geriatr Soc DOI: 10.1111/jgs.16566 sha: abb7d252b3ea99a9cfe7e6fc546c44843bc49bcc doc_id: 799025 cord_uid: ridwy1vg nan The arrival of COVID-19 in New York City resulted in widespread disruption of these essential care arrangements. When my patient with advanced dementia developed a new cough and her home care agency pulled its live-in paid caregiver from her home, her granddaughter contemplated sending her to the hospital so that she could get her needed daily care. One daughter struggled to provide daily care for her mother's pressure ulcer after, out of fear of introducing COVID-19 into the home, she had asked her mother's longtime paid caregiver to stay away. Another patient found that despite the effort her paid caregiver made to avoid infection as she took public transportation to work daily, she developed COVID-19. Without her caregiver, my patient had fallen twice in one week trying to get out of bed independently. For my patients and their families, these caregiving changes were not simply logistical challenges but true health emergencies with clear medical consequences. While paid caregivers' work is often considered "unskilled," patients cannot live safely in the community without it. Furthermore, paid caregivers often perform health-related tasks beyond providing functional support like reporting changes in symptoms, enacting exercise recommendations, and providing emotional support. 3 Yet paid caregivers are not routinely considered part of the healthcare team and research suggests that communication between paid caregivers and healthcare providers is limited. 4 COVID-19 truly drove this point home: while I have long considered my patients' paid caregivers partners in home-based care, I lacked the necessary information to contact their agencies (if they worked with one) and to help them procure and effectively use the personal protective equipment they needed to safely care for patients with suspected COVID-19. The medical system's response to COVID-19 exemplifies the problematic separation between medical and long-term care that currently exists within our healthcare system. The best health advice for older, frail patients was to stay home and health care providers offered televisits and telephonic symptom management to avoid unnecessary emergency department visits. Yet what this meant for paid caregivers working in the home was not considered: early on in the COVID epidemic in New York City homecare agencies reported inadequate COVID-19 training, limited workforce capacity, and inadequate personal protective equipment. 5 This left both patients and paid caregivers vulnerable. As COVID-19 accelerates existing trends to move long-term care from facilities into the community, 6,7 better integration of paid caregivers into the healthcare team will be necessary. One of the most important barriers to integration is a lack of standard training for paid caregivers. 8 Medicaid is the largest public funder of paid caregiving, yet training and supervision of the Medicaid-funded paid caregiver workforce varies considerably from state-tostate, 9 with very limited training in coordinating care with other health providers. 8 Physicians and other medical care providers must partner with advocacy groups and community-based long term care providers to develop consistent, competency-based training for paid caregivers. This will ensure both that paid caregiver have the essential skills to meaningful participate in teambased care and that healthcare providers can reliably count on this participation. The COVID-19 pandemic makes clear: caring for our most vulnerable older adults in a time of crisis takes the coordinated efforts of the full healthcare team. This team must include the paid caregivers who support these patients at home every day. This article is protected by copyright. All rights reserved. Homebound Status and the Critical Role of Caregiving Support Living in the Community With Dementia: Who Receives Paid Care? Beyond Functional Support: The Range Of Health-Related Tasks Performed In The Home By Paid Caregivers In New York Paid Caregiver Communication With Homebound Older Adults, Their Families, and the Health Care Team COVID-19 Survey Results: Statewide Home Care, Hospice &MLTC Impacts Medicaid home and community-based services: national program trends Measuring State Medicaid Home Care Participation and Intensity Using Latent Variables The Future of the Home Care Workforce: Training and Supporting Aides as Members of Home-Based Care Teams Home care workers: interstate differences in training requirements and their implications for quality Conflict of Interest: The author has no conflicts. Author Contributions: The author is responsible of all aspects of the letter. 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