While hospital nurses are carrying the largest portion of the burden in caring for COVID19 cases, skilled and non-skilled home health care and hospice nurses are also seeing increasing numbers of cases. These cases are being cared for primarily in private homes as residential care homes, assisted living facilities and skilled nursing homes and rehab facilities are reluctant to accept patients back if they’ve been hospitalized for COVID19. 

When possible, if patients haven’t been hospitalized, facilities are trying hard to arrange other options during their convalescence. Some families are taking loved ones home for the duration to protect them from COVID19 exposure. 

In efforts to contain and prevent exposure and disease, facilities have also prohibited or severely restricted home health and hospice visits to their facilities even for non-COVID19 patients. Visits from family and friends have been suspended or restricted and in many cases mail and other deliveries are not being accepted during the crisis. 

Infections spread like wildfire

Commonly flu and other infective or communicable diseases such as C-Diff and other GI disturbances, pneumonia and other respiratory issues, as well as scabies and shingles can have fast and large outbreaks in these facilities. Facilities have to act swiftly to prevent disastrous events and outcomes that can also affect staff and visitors as well as home health and hospice workers. Infections can spread like wildfire in a facility. These may be familiar situations for home health and hospice staff, but with the COVID virus, extreme measures are being enforced.

Home health and hospice agencies are rising to the challenge to care for patients with active COVID19 as well as those who are convalescing post hospitalization. There is expected to be a rise in hospice patients for those who refuse ventilation. The challenge is also making sure agencies have staff willing to take COVID19 patients or risk exposure to possible cases. With better testing options, and improved PPE access, some of this may change. 

Regulations temporarily updated to meet needs

The Centers for Medicare and Medicaid (CMS) have taken quick action to support alternative measures for providing care during this crisis. One of the first steps taken by CMS was to declare any patient with a diagnosis of the corona virus is to be considered homebound as part of the qualification for skilled home health. Further they have softened some of the regulations for both home health and hospice for the duration of the crisis. One is the requirement for onsite supervision of the home health or hospice aides during this time. For the time being, this is not essential. It is recommended to continue the conversation of course to ensure quality of care.

Another change being allowed at this time is virtual visits for a variety of services for all patients. These must include video as well as audio using applications such as FaceTime, Skype, Zoom or Teams. The nurse, therapist, social worker and spiritual counselor can make virtual visits as needed. Telephonic visits are allowed if there is no other option but should be kept to a minimum. Documentation is essential. The face-to-face visits by the hospice physician or nurse practitioner for recertification can be done electronically as well. The requirement for an RN to see the patient at a minimum every 15 days for care plan oversight has been relaxed to every 21 days. Virtual visits are encouraged to be limited as possible to deliver care. In-person care is encouraged as it is superior. But the safety and well being of all involved always takes precedence. 

Challenges with PPE

One of the biggest issues for home health and hospice agencies to deal with is the availability of PPE. It is not unusual for a home health or hospice nurse to have one PPE kit in his/her care for a year and never needed or used. So, it’s logical to understand that an agency doesn’t have large quantities available. 

In this crisis, the use of PPE is the standard, and everyone is scrambling to keep up. Masks and gloves are in short supply and gown and goggles and other pieces are even more rare. The demand is huge. Home health and hospice nurses and other professionals typically see 6-8 patients per day; some see more and others less. In some instances, the scheduled case load for the day will all be in one facility, or maybe 2. In those cases, stretching the PPE and using one set for each facility is not ideal, but may be necessary. However, traveling from one private patient’s home to another requires one set of PPE per home. 

Nurses have had to be creative to protect themselves as well as patients and family or caregivers. Using one set of PPE per house, some of it is being removed and stored in that house for the next visit and as long as it’s not soiled, may continue to be used. This is usually the gown, goggles and perhaps shoe booties. As a general rule, PPE is not being provided to caregivers and family members with the exception of small amounts of gloves. Homemade masks are encouraged for non-medical workers and patients to use. An outer layer of clothing to protect their clothing could be a plastic garbage bag. 

Education is essential 

Education is needed to ensure all parties involved are protected and safe. This begins with the basics of appropriate handwashing and extends to safely donning and doffing gloves and other protective gear. Isolation measures including using linens and utensils that aren’t shared with other household members must be taught. Additionally, measures for trash disposal are essential. This includes the patient’s own trash as well as disposal of PPE.  

Meeting other challenges

The patient and families always have the right and responsibility to participate in the plan of care. This includes limiting the number of visits being made and even specifying who can come or not. Patient and family safety and needs are priority. Sudden drops in visit counts are to be expected during this crisis and this can present revenue issues for the agency, especially the smaller agencies. 

Careful coding and documentation is essential to ensure reimbursements especially in these challenging times. Even with the relaxation of some regulations, agencies should take care to not take advantage and exceed the limits. It’s also important to document well in the event of review at some later date. Two to five years from now, it might not be evident that this case was handled during the COVID crisis. If the documentation is thorough, it will be easy to identify. 

In honoring the heroes of these times, we need to remember home health and hospice workers as well. Thank you for all you do!