key: cord-0869467-pw9r1sji authors: Ritchie, Christine S.; Gallopyn, Naomi; Sheehan, Orla; Sharieff, Shanaz Ahmed; Franzosa, Emily; Gorbenko, Ksenia; Ornstein, Katherine A.; Federman, Alex D.; Brody, Abraham A.; Leff, Bruce title: COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic From a National Survey date: 2021-06-08 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.05.016 sha: d7ffa149f76b59e0e6cd81764f5c6478493d121d doc_id: 869467 cord_uid: pw9r1sji OBJECTIVES: Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. DESIGN: Mixed-methods national survey. SETTING AND PARTICIPANTS: HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. METHODS: Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. RESULTS: Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). CONCLUSIONS AND IMPLICATIONS: HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic. Approximately 2 million adults in the United States are homebound; another 5.5 million have some difficulty or need the assistance of another person to leave their homes. 1 People who are homebound often are costlier to health care systems because of a combination of unmet medical, functional, and social needs. 2 Home-based primary care (HBPC) provides a mechanism for such patients to access longitudinal medical care in their homes. Multiple studies 3, 4 have demonstrated that HBPC improves person-and caregiver-centered outcomes and saves money. 5, 6 HBPC practices and the patients they care for have received increased attention during the current COVID-19 pandemic. 7e9 HBPC has been promoted to reduce emergency department (ED) visits, minimize iatrogenic COVID-19 exposure, augment COVID-19 testing, and ensure that urgent and chronic medical issues are addressed to prevent escalation. In 2 Italian regions during the pandemic, the region that utilized home-based clinical services more aggressively had lower COVID-19 mortality rates. 10 Despite the value of HBPC in the COVID-19 era, unique challenges also emerged in the provision of HBPC. Understanding these challenges and eliciting strategies for navigating them is essential to provide ongoing support to practices and patients as the pandemic continues and as new pandemics threaten to appear. The purpose of this study is to describe the challenges and adaptations experienced by HBPC practices across the country during the first surge of the COVID-19 pandemic with the aim to support other HBPC practices as they navigate subsequent COVID surges, plan for future pandemics, and prepare for other public health emergencies. We conducted a mixed methods study of HBPC practices' response to the early phase of the COVID-19 pandemic by distributing a national survey that included quantitative and open-ended questions. The online survey was open to all HBPC practices in the United States and was distributed to members of the American Academy of Homecare Medicine (AAHCM) and the Home-Centered Care Institute (HCCI) training programs. The survey was distributed via the list servers of AAHCM and HCCI. The AAHCM, the professional society of home-based medical care professionals, includes approximately 1000 individual members. The HCCI is a national nonprofit organization focused on advancing HBPC and has about 3800 people on their list server. Because the AAHCM and HCCI list servers are person-based and not practice-based, and individuals may be on both list servers, the total number of distinct practices that the survey was sent to cannot be determined; thus, a practice-level survey response rate cannot be calculated. The survey was iteratively developed, informed by issues raised by HBPC clinicians and implemented via an online Qualtrics survey tool. The final survey consisted of 31 close-ended questions regarding practice characteristics, practice responses to COVID-19, practice strain from COVID-19 ("Is the current status of COVID-19 in the US putting unusual strain on your practice?" "How much strain?"), the use of telemedicine (video care and telephone care) and 5 open-ended questions related to (1) challenges with personal protective equipment (PPE), (2) COVID-19 practice adaptations, (3) work with community partners to address patient needs, (4) barriers to telemedicine implementation, and (5) an invitation to describe any other aspects of their experience of providing HBPC in the midst of the pandemic (see Supplementary Material 1) . Responses were collected between May 25, 2020, and June 10, 2020. Responses from 79 practices met completeness criteria for analysis (2 responses from one practice were combined). We used descriptive statistics to determine frequency distributions of nominal and categorical data. Chi-squared tests, Student t tests, and Fisher exact tests were used, as appropriate, to compare the differences in COVID adaptation strategies between larger (practices with an average daily census [ADC] of 501 patients) and smaller HBPC practices (those with an ADC of 500 patients) to see if any specific COVID responses were more likely in larger or smaller practices. We chose this ADC threshold because previous work has suggested differences in practice patterns at this threshold. 11 We also evaluated whether COVID responses were different between practices with a higher proportion of ALF patients (20% vs <20%), between practices affiliated and unaffiliated with larger health systems, or by region of the country. All analyses were conducted using SAS, version 9.4. For the 5 open-ended questions, the responses ranged from several words to several sentences. With the exception of the fourth question, "Describe barriers to telemedicine implementation," where all respondents reported no barriers to telemedicine implementation, up to 66 practices (84.0%) provided responses to the other open-ended questions. Participants from larger and smaller practices responded to open-ended questions at an equal rate. We used qualitative content analysis to summarize responses to the open-ended questions related to PPE access challenges, adaptations, and community partnerships. Most of the responses to describe HBPC practice experiences fell within the domains of the first 3 questions related to PPE, practice adaptations, and community partners; we combined non-PPE challenges and PPE challenges answers to create an overall challenges theme. We created a preliminary codebook based on inductive coding of the data set. Two investigators (T.T. and U.U.) reviewed and coded all data. All codes were reviewed with 2 additional investigators (V.V. and X.X.) and discrepancies addressed to achieve consensus. Consent to participation was given at the beginning of the survey; the research protocol was approved by the relevant institutional review board. We received 123 individual responses to the survey. Two practices submitted 2 responses that answered different aspects of the survey; their responses were combined to reflect 1 response from that practice. Our final sample represented responses from 79 practices across 29 states. Thirty percent represented practices from the northeast, 19% from the midwest, 30% from the south, and another 19% from the west. Four practices were part of the Veterans Health Administration. Demographic characteristics of the respondents and practices are presented in Table 1 . Survey respondents were primarily physicians (42.5%) and nurse practitioners (28.8%). Some survey respondents reported having more than one role in their practice. Most practices (68.4%) reported having 10 or fewer full-time equivalent billing clinicians, and 57.0% reported having 500 or fewer active patients enrolled in their practice at the time of the survey. Close to two-thirds (64%) of practices were affiliated with a larger health system. Most practices (54%) reported that 20% or fewer of their patients lived in HBPC Practice Responses to COVID-19 Table 2 presents quantitative findings pertaining to HBPC practices and their responses to COVID-19. Nearly two-thirds of practices (63.3%) had capacity for COVID-19 testing in the time frame of the survey (May through June 2020). On average, practices reported that 3.8% of their patients were COVID-positive (range 1%-25%). Close to three-quarters (73.1%) of practices accepted new patients known to be COVID-19 positive into their practice, and most (84.8%) reported seeing patients in their homes. Practice size influenced the likelihood of providing care to COVID-positive patients but otherwise did not affect workforce issues, supply chain issues, or the ability of practices to see patients in the home. There were no differences in COVID response between practices caring for a higher proportion (20%) of ALF patients vs lower, between practice affiliated with large health systems and those that were unaffiliated, or by region of the country. Twelve practices (15.2%) stated they were not seeing patients in the home at the time of the survey. Of these 12 practices, two-thirds reported a lack of access to PPE or being prohibited by an institutional policy (such as from an ALF) as the main barrier; close to onequarter reported inadequate staffing. Other reasons given for not seeing patients in the home included a perception that telehealth was sufficient, patients' fear of clinicians potentially bringing COVID-19 with them, and practice concerns about transmitting COVID-19 between homes. The majority of practices described pivoting to telephone or video visits. Most practices (80.3%) started to use videoconferencing or remote patient monitoring (gathering of patient data such as oxygen saturation through technology); most (57.9%) also reported substituting telephone visits for in-person visits. Just under a quarter (23.7%) reported already having video visits in place prior to COVID-19 and expanding the number of video visits during the pandemic. Practices reported being under considerable strain due to COVID-19. Of 62 practices who responded to the strain question, 22.6% reported "severe strain or impact" and 64.5% reported "some strain or impact" due to COVID-19. More than half of the practices reported experiencing shortages of personnel, social supports, or other service and resource challenges. Of practices reporting shortages experienced by patients, they described shortages in access to home health aides (74.5%), home nursing (42.6%), durable medical equipment (27.7%), Meals on Wheels (23.4%), hospice care (17.0%) and access to medications (10.6%). More than 80% of practices reported navigating personnel loss because of COVID-19 positivity and having to reassign staff (52.3%) or recruit new staff (18.5%). Practices also managed personnel loss by involving quarantined staff in the conduct of video visits, working with reduced staffing, and canceling patient appointments. Among COVID-19 practice-related challenges, more than half of practices reported challenges with patient lacking familiarity with video care (81.9%); patient anxiety about COVID-19 risk (77.8%); clinician anxiety about COVID-19 risk (69.4%); technical difficulties reaching patients, for example, due to connectivity challenges (66.7%); practice supply shortages (55.6%); testing for COVID-19 status (54.2%); underpreparedness for use of telemedicine (52.8%); and clinician strain (51.4%) ( Table 2 ). Less common, but prevalent, challenges included lack of clinician familiarity with telemedicine (45.8%); COVID-19 testing shortages (44.4%); overall challenges of accepting new patients (40.3%); screening patients and families for COVID-19 symptoms or exposure (41.7%); communicating with patients (37.5%); communicating with families (33.3%); managing financial issues (33.3%); screening clinicians for COVID-19 symptoms or exposure (29.2%); and staff shortages (25.0%). Practices described severe financial strain due to lost revenue, inability to access patients in domiciliary facilities, unavailable mental health resources for clinicians, and the stress of working from home (often in the presence of their children). Qualitative content analysis elucidated similar challenges (Table 3) . Providers reported difficulty accessing supplies of all kinds, including PPE and sanitation products, because of supply chain issues. One practice reported: "We had to put all home visits on hold due to lack of proper PPE and training. For now, we have all the PPE we need, but are starting to save N95's again for potential re-use. We are also likely to have to start making our own wipes. The face shields we first got were awfuldfell apart and were cloudydwhat we have now is better. It has and continues to be a learning curve." Staff experienced strain from adopting new workflows and fulfilling new training requirements, the demands of video care (including providing technical support to patient, navigating hearing impairment, etc), and the loss of at-risk staff or senior volunteers. Patient care challenges ranged from patients', caregivers', or ALFs' unwillingness to see a clinical team member due to fear of contracting COVID-19, to challenges in patient-provider communication due to lack of patient digital literacy, dementia 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 status, or the inability to hear providers through masks. One practice stated: "The assisted living facility had video for patients but not staffing to provide the volume of visits we needed. . That was relevant to a dementia population." Practices saw more functional decline and death in the home and more challenges in particular in the care of persons living with dementia. Financial concerns imbued many of the comments around challenges, including frustration with constantly changing billing regulations, amplified financial uncertainty and constraints, leading at times to reductions in staff. One practice stated: "Prior to COVID we had an avg census of 580 but lost approximately 130 patients primarily in facilities and have had to shrink our care team to keep the program financially viable." Despite uncertainty and innumerable changes, most practices (91.1%) described multiple adaptations to navigate the challenges they were facing. Practices reported using telemedicine (95.8%), reducing physical visits (81.9%), providing staff training (52.8%), and bringing needed resources such as groceries and medications for patients (52.8%). Many practices restricted their in-person visits to patients (45.8%), reassigned staff (47.2%), engaged in new approaches to triage patients (40.3%), conducted inventory to ensure sufficient supplies (40.3%), worked with community partners to provide supportive services and resources for patients (38.9%), provided additional support services to patients (34.7%), collaborated with palliative care, infectious disease, and other consulting clinicians (25.0%), and recruited new staff (19.4%). Practices adapted to supply chain shortages by securing supplies through other channels including state departments, health systems, other HBPC practices, and industrial avenues. One respondent described how she "had to go outside the supply chain and procure PPE from construction teams." Another stated, "We had run out of hand sanitizer and our local distillery made it for us." 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 Table 3 provides additional illustrations of practice adaptations. Practices started engaging in more video care and integrating new infection control directives into their home-based services. They used more remote staff, developed policies regarding who could and could not engage in in-home care (eg, providers aged 65 years were assigned to conduct video visits), and increased the number of their team huddles and support activities. Very few practices completely suspended home visits. Practices proactive outreached to patients and to community partners (eg, Departments of Health, Meals on Wheels, Area Agency on Aging) to address the needs of their patients. One practice described "tracking resources available in the community on Aunt Bertha and other resource sites." Practices began assessing for food insecurity, caregiver burnout, and feelings of social isolation. They worked with community organizations to fund raise on behalf of patients' needs. They also engaged in more goals of care conversations with their patients and their caregivers. When in-home visits did occur, workflows were adapted to minimize time inside the home including pouring medications outside the front door or in the garage, dropping equipment curbside, and calling from the driveway to gather information before entering the house. Practices reported engagement with health systems and payers and noted a general sense that health care systems and payers were increasingly recognizing the advantage in-home medical care offered because of widespread concern about COVID-19 infection risk for their patients in hospitals, clinics, and skilled nursing facilities. In total, the qualitative comments offered by practices revealed predictable patient care challenges experienced in this pandemic while describing agility, silver linings through new partnerships and processes, and ongoing dedication to patient care. In a large, geographically diverse sample of HBPC practices, we identified significant challenges faced due to COVID-19 and the rapid adaptation of processes, staffing, and workflow to accommodate these challenges irrespective of practice size. The pandemic led to more than 87% of practices reporting being under some level of strain. The majority of practices continued to see patients in the home. Practices reported limited access to patients (self-imposed, access prevented by facilities, patients, or caregivers); workflow disruptions (work from home); adoption of new care modalities (telehealth); increased patient vulnerability (isolation, reluctance, heightened sensory issues); and emotional impact on staff (COVID-related fears, death of patients, understaffing, burden of new modalities of work). The most impactful practice challenges were technical difficulties reaching patients, managing both patient and clinician anxiety, and navigating supply chain shortages. Practices adapted quickly to the new challenges by reducing the number of in-person visits while increasing the use of telemedicine, adopting new infection control measures, and addressing the needs of both patients and staff with creative sharing of health system resources, tapping communitybased services to support the nutritional and social needs of patients, and providing new training and support for staff. Findings from our study mirror many of the adaptations described by HBPC providers in New York City. 9, 12 The emotional toll of the pandemic on both practice staff and patients was high. Clinician anxiety was reported by more than 69% of practices, and perceptions of patient anxiety by clinicians was even higher. Home-based clinicians used to adapting to the unpredictable work environment of the home now faced new workflows, loss of staff and the pressure of patient visit prioritization amid personal concerns of getting or transmitting COVID-19. Practices observed increased social isolation, loneliness, and fear compounded by a reluctance to allow people into their homes. Sensory issues were exacerbated by the use of PPE and video communication. Clinicians reported increases in rates of decline and death at home and highlighted the additional challenges faced by patients and caregivers of those with dementia. Despite the clear negative impact of the pandemic, many COVID-19 "silver linings" emerged. Although not a comparison between homeand office-based care, HBPC may have been better positioned than traditional office-based care to pivot and adapt to COVID-19 because of an established access-path to patients, strong pre-existing interactions with the community, and connections with communitybased service providers. Some practices reported a new recognition by health system leadership of the critical role HBPC care plays in caring for vulnerable older adults and keeping them out of the ED or hospital. Indeed, recent literature advocates for a more integrated role for home-based medical care. 13, 14 The expansion of telemedicine may allow some HBPC clinicians to increase patient panels by reducing travel time to and between visits. Collaborations with health systems and health departments increased, fostering better access to supplies and workforce and targeted outreach to at-risk groups. Partnerships with health departments and health systems have the potential to foster ongoing benefit to patients if they result in increased access to vaccines and a natural delivery channel for vaccine distribution. 15 Increased partnerships with community organizations facilitated identification of those at risk of food insecurity, caregiver burnout, and medication shortages and resulted in shared efforts to better support homebound patients. Although health system affiliation could have contributed to less agility to COVID-19 response, we did not see these differences among those who responded to the survey. A major strength of the study is the national sample of HBPC practices surveyed. HBPC practices varied greatly in practice size, leadership, provider type, and geography. A limitation of the study was our inability to ascertain the response rate for clinical practices because we surveyed individual providers. The larger proportion of practices with 500 or more patients and the smaller number of practices with more than 50% of patients in ALFs also suggest some limitations in overall HBPC representativeness; nevertheless, the 79 practices included all regions of the United States. Further, the use of mixed-methods approach is a study strength. Our study was conducted in mid-2020. The impact of COVID-19 was felt differently at different time points across the country based on when particular regions experienced surges. It is likely that some practices had already experienced their first COVID-19 surge; for others, the worst was yet to come. HBPC practices experienced profound disruption during COVID-19. At the same time, they nimbly adapted their approach to care. Despite a wide array of difficulties experienced by their patients, they engaged in creative approaches to address them, from driveway medication delivery to fundraisers with community organizations to provide food and other resources to patients. In the midst of staff strain, they described efforts to build team resilience and reduce burnout through increased team meetings and huddles, staff rotation, and increased staff support. These adaptations continue to be relevant, not only for COVID-19, but also for future pandemics and disasters likely to be faced by HBPC practices. Future studies of larger numbers of practices 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 are needed to better understand the long-standing impact of the pandemic on HBPC and whether changes initiated during the pandemic persist. Epidemiology of the homebound population in the United States The invisible homebound: Setting quality-of-care standards to home-based primary and palliative care Home-based primary care interventions. (Prepared by the Pacific Northwest Evidence-based Systematic review of outcomes from homebased primary care programs for homebound older adults Independence at Home Demonstration Performance Year 5 Results Fact Sheet To strengthen the primary care first model for the most frail, look to the Independence at Home Demonstration. Heal Aff Blog Innovation in home care: Time for a new payment model The promise and challenge of home health services during the COVID-19 pandemic At home, with care": Lessons from New York City home-based primary care practices managing COVID-19 Lessons from Italy's response to coronavirus National Home-Based Primary Care and Palliative Care Network. Home-based primary care practices in the United States: Current state and quality improvemet approaches Acute, post-acute, and primary care utilization in a home-based primary care program during COVID-19 Home-based medical care: Highvalue health care during coronavirus disease 2019 and beyond Home-based care for people with Alzheimer's disease and related dementias (ADRD) during COVID-19 pandemic: From challenges to solutions How to vaccinate homebound seniors? Take the shots to them Supplementary data related to this aricle can be found online at https://doi.org/10.1016/j.jamda.2021.05.016.