Q: How can my agency prepare to care for COVID-19 patients?

The novel coronavirus disease 2019 (COVID-19) pandemic poses a major threat to the U.S. healthcare system, from acute to postacute care. As many hospitals across the country focus medical attention on treating these patients, one common strategy has been to discharge patients who can safely be sent home in order to decongest the hospital system and protect non-COVID-19 patients and staff from infection. Recent recommendations have emphasized that the postacute care sector should prepare to care for a surge of COVID-19 patients discharged from the hospital (Grabowski & Maddox, 2020).

Home care is a dominant provider of postacute care in the United States. About 3.4 million homebound patients receive skilled nursing, therapy, social work, and home health aide services from nearly 12,000 home health agencies each year (MEDPAC, 2019). These patients are a group at high risk for poor outcomes if infected-on average 65 years and above, multiple comorbidities with complex care needs (Ornstein et al., 2015). With the COVID-19 outbreak, many home care agencies are challenged to function above capacity to provide home visits and prevent hospitalizations of home care patients. As patients recover and are discharged from the hospital post treatment for COVID-19, many are discharged home with supplemental oxygen therapy and referred for home care services. Home care nurses, therapists, social workers, and home health aides play a crucial role in the nations' response to the COVID-19 pandemic by protecting the nation's homebound population from exposure and providing postacute care to patients treated for COVID-19.

To meet the surge in demand for home care services, one important tool that expands access to home care clinicians is the use of telehealth. This technology, already utilized by several large home care agencies in the United States, is especially useful during this pandemic. The use of telehealth facilitates the process of patient triage while minimizing exposure of home care staff to potential infection. Specifically, it enables home care nurses to screen their high-risk patients, provide timely intervention and physician coordination that prevents unnecessary hospitalization, and emergency department visits (Radhakrishnan, Jacelon, et al., 2013). Despite the known benefits of telehealth, barriers to the widespread implementation of telehealth in the home care industry have included workforce limitations, the cost of workflow redesign, and reimbursement.

With the passage of the Coronavirus Aid, Relief, and Economic Security Act, home health agencies will be reimbursed for telehealth services provided to Medicare beneficiaries (CARES Act, 2020). This provides an opportunity to expand utilization of a tool that has demonstrated to be effective in screening and managing high-risk patients in the home care setting (Radhakrishnan, Jacelon, et al., 2013). The question remains whether home care agencies can rapidly implement a new system if they have not adopted them previously. Agencies lacking telehealth programs prior to the pandemic can consider outsourcing telehealth services. Under such arrangements, structured guidelines to stimulate the effective implementation and coordination of outsourced telehealth services to keep home care clinicians engaged in the process may be needed. Notably, telehealth is not a substitute but complements home care visits. It is only well suited for scenarios in which the home care infrastructure is established and clinicians are available to also provide home visits.

Although telehealth models also provide home care clinicians direct virtual connection to their patients on iPADs or similar devices, these virtual connections are supplements to triage priority for clinical visits. Investing in a telehealth nurse assigned with the task of monitoring all red alert indicators and coordinating the red alerts to patient's primary physician remain of great importance (Radhakrishnan, Bowles, et al., 2013).

Through this pandemic, it remains critical to build a home care workforce, including home health aides-the only home care staff that provides direct personal care for several hours in the home setting. Adoption of strategies to engage, educate, and empower home health aides during this pandemic may be key to achieve better patient outcomes. Engage home health aides in the changing processes including processes around telehealth. Educate home health aides about the evolving COVID-19 infection prevention measures and effective use of personal protective equipment. Empower home health aides as important members of the healthcare team (e.g., provide them real-time information about COVID-19, ask about their own healthcare needs, and encourage them to ask questions). Online meetings and case conferences can be leveraged to discuss the progress of the patient or to ensure that the home health aide feels emotionally supported.

Over the long term, the home care agenda will need to remain focused on the cultivation of a new generation of home care clinicians and aides in order to prepare for the next wave of emerging diseases. Investment in home care nurse residency programs or home health aide dementia training programs are key items for the home care industry that remain even after the COVID-19 pandemic. Despite the severe constraints that attend this pandemic, the mission of home care has always been to meet the healthcare needs of vulnerable homebound patients in their own home and communities, and COVID-19 does not change that focus.

Autoimmunity May Be Rising in the United States

NIH: Autoimmunity, a condition in which the body's immune system reacts with components of its own cells, appears to be increasing in the United States, according to scientists at the National Institutes of Health and their collaborators. In a study published April 8 in Arthritis and Rheumatology, the researchers found that the prevalence of antinuclear antibodies (ANA), the most common biomarker of autoimmunity, was significantly increasing in the United States overall and particularly in certain groups. These groups include males, non-Hispanic whites, adults 50 years and older, and adolescents. The study is the first to evaluate ANA changes over time in a representative sampling of the U.S. population. "The reasons for the increases in ANA are not clear, but they are concerning and may suggest a possible increase in future autoimmune disease," said corresponding and senior author Frederick Miller, M.D., Ph.D., deputy chief of the Clinical Research Branch at the National Institute of Environmental Health Sciences. "These findings could help us understand more about the causes of these immune abnormalities and possibly learn what drives development of autoimmune diseases and how to prevent them."

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