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In The Time Of Covid-19, We Should Move High-Intensity Postacute Care Home

[Original post: Rachel M. Werner, Courtney Harold Van Houtven, In The Time Of Covid-19, We Should Move High-Intensity Postacute Care Home, Health Affairs Blog, April 22, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200422.924995/full/. Copyright ©2020 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.]

Amid a surging Covid-19 pandemic that has overwhelmed hospitals, several states — including California, New York, New Jersey, Pennsylvania, and Washington— have told nursing homes that they must accept Covid-19-positive patients when they are discharged from the hospital. This decision drew immediate pushback from nursing home officials, who care for an extremely vulnerable population. They say an influx of patients with Covid-19 would put their other residents and staff at risk for infection and that they lack the tools — such as adequate staffing and the ability to isolate patients — to care for patients with active Covid-19 infection.

Indeed, nursing homes have been a hotbed for Covid-19 infections. The first outbreak of Covid-19 in this country was reported at a nursing home in Kirkland, Washington. By April 16,  3,466 nursing homes have reported Covid-19 infections in 39 states, representing more than 5,500 deaths. In New York State alone, there have been more than 3,000 deaths from Covid-19 among nursing home residents, over 25% of the state’s death toll.

In response to these concerns, some have suggested creating Covid-only skilled nursing facilities (SNFs)—facilities that would specialize in patients recovering from Covid-19. At least two states—Connecticut and Massachusetts—are implementing this plan in some nursing homes. This eliminates the need for facilities to isolate infectious residents and risk transmission of Covid-19 to frail, susceptible nursing home residents. However, it requires moving existing residents into non-Covid facilities, moves known to be harmful to nursing home residents. To avoid this, hotels and dormitories could be retrofitted into temporary Covid-only SNFs, a solution that is likely very expensive but feasible.

High-intensity Postacute Care Can Be Implemented At Home

There is a third solution. We could send patients recovering from Covid-19 home from the hospital with intensive home-based rehabilitation. This would look similar to “home hospitals,” an approach that has been used successfully to prevent acute care hospitalizations. In a home hospital, acutely ill patients receive multiple daily visits and communications from an interprofessional medical team, treatments like intravenous therapies that are typically confined to an inpatient setting, continuous monitoring, and availability of on-call physicians for urgent issues. A recent rigorous study found that home hospitals are safe and effective, resulting in better patient mobility and fewer subsequent admissions than traditional hospitals. We can adapt this approach to care for patients who are recovering from acute illness at home. 

Currently, Medicare’s home health benefit is too limited to support caring for many of the patients who are recovering from Covid-19, who will require continuous monitoring and intensive rehabilitation. And, while sending patients home with home health care instead of to a SNF saves Medicare over $5,000 for a typical non-Covid patient, it results in worse outcomes, with readmission rates that are 5.6 percentage points higher from home. This isn’t surprising given the current differences in the intensity of care at home compared to SNF. But we can restructure and redefine home care to resemble a home-based SNF, which would increase post-acute care capacity, save lives, and possibly even save Medicare money.

What Is Needed To Implement High-intensity Postacute At Home

What would it take to make home-based rehabilitation possible for patients recovering from Covid-19?

First, we need to use Medicare’s recently extended telehealth benefit to provide more intensive care at home, including many of the rehabilitation services that post-acute patients need  such as physical and occupational therapy. In addition, Medicare regulations should allow home-based SNFs to use remote technologies for institution-level monitoring and treatment of patients 24 hours a day, seven days a week.

Second, to minimize the risk of Covid transmission to and from home health workers visiting multiple homes per day, a home-based SNF needs to formally incorporate caregivers into the care team; such caregivers could be close friends or family members who can share in the daily care of homebound individuals. Caregivers can safely assist with activities of daily living, helping patients get out of bed, bathe, eat, and -- with the help of a remote therapist --  oversee rehabilitation so patients can regain their mobility and independence. Caregivers would also have the full backing of a remote health care team available for regular telehealth as well as in-person visits as needed. 

For this to work, we must first ensure that caregivers are assessed for their ability to safely deliver care, and that all caregivers receive adequate training, including in use of personal protective equipment and infection control.

We must also pay caregivers. While Medicare does not currently pay for caregiving, several states pay caregivers under Medicaid waivers seeking to keep frail older adults out of nursing homes, with success.

We also need to pay health care professionals for supporting caregivers – payments that are on par with what they would be paid for in-person visits. The payments should cover daily telehealth communication that would ideally be in the form of virtual huddles that occur with the caregiver, the patient, remote and onsite therapists and home health workers, and the lead clinician. Reimbursing health professionals for communicating with the caregiver would reduce current financial barriers to fully integrating caregivers into the care team, which is currently unreimbursed, and ensure that the caregiver’s perspective and input are incorporated into the care plan.

Mitigating Risks In Home-based Care During a Pandemic

As a solution to the post-acute care crisis brought on by Covid-19, moving intensive post-acute care home would not be for everyone. Some patients may be too ill or deconditioned to be discharged to home, even with the additional supports described. However, the vast majority of those surviving hospitalization for Covid-19 are young and were healthy prior to infection, making them good candidates to recover at home. Some patients will share their homes with people who are at high risk for complications from Covid-19 infection. For such people,  bringing a Covid-positive patient into the home with the accompanying visits from health care workers would be inadvisable. And some patients may not have a caregiver who can adequately comply with infection control recommendations while the patient remains test-positive for Covid.

Perhaps most concerning is the risk of transmitting Covid-19 to household contacts. While we routinely send non-hospitalized Covid-positive patients home to recover, patients recovering from hospitalization will require more direct contact to help them recover. To make home-based SNFs successful, we can mitigate that risk in the following ways. First, Covid-positive patients should be isolated in one room in their home. Second, patients who test positive for Covid-19 infection at the time of hospital discharge must wear a mask until they test negative and, until that happens, adequate personal protective equipment for household contacts and home care workers is essential. Third, we must limit caregiving to one paid, dedicated caregiver. Paying caregivers is essential to make this approach feasible, as it allows one family member or close friend to take on the responsibility of caregiving without forgoing income rather than spreading the responsibility across multiple unpaid caregivers. Finally, telemedicine and remote monitoring are essential to minimize unnecessary contact and ensure social distancing.

An Opportunity To Rethink Postacute Care At Home

Setting up home-based SNFs to care for recovering Covid-19 patients will serve us well during this pandemic. It will decompress a health system that is being stretched at its seams. It will also provide the push we need to safely and more permanently shift post-hospital care from nursing homes to people’s homes.  Covid-19 gives us the opportunity to reimagine what optimal post-hospital care might look like after the pandemic is over, an opportunity we shouldn’t squander. There is a safe alternative to nursing home-based post-acute care, one that is favored by many patients and their families and might even cost us less. We can help people recover at home.