Home Health: A View From the Front Lines

KIRKLAND, Wash. (March 25, 2020) — Home health, hospice and homecare providers should prepare to be called on to handle a surge of patients as hospitals are overwhelmed by the coronavirus epidemic, one provider who has been at the forefront of the crisis said Wednesday. 

Brent Korte is chief homecare officer for EvergreenHealth in Kirkland, Washington; Evergreen’s hospital was the first to register a COVID-19 death and his system has been working under emergency conditions for more than three weeks. He spoke on a webinar hosted by the National Association of Homecare & Hospice (NAHC), outlining their actions and recommending best practices for other agencies. 

“Our industry is uniquely situated because we understand the science and the art of delivering health care in the community and we know that hospitals are going to be completely overwhelemed,” Korte said. “I think we’re all going to be called on.”

Korte, who is a NAHC board member, described his organization’s experience, starting with a call at 10 p.m. on a Friday night in late February—before COVID-19 was in the mainstream news. His health system is just two miles due west of the Washington skilled nursing facility that made news as the epicenter of the outbreak, and the EvergreenHealth hospital reported the first U.S. death from coronavirus.

Fortunately, the EvergreenHealth system had already done a lot of emergency planning and incident command rehearsal, in part because it’s in an earthquake zone. In the earliest days, he said, most of the senior team was working up to 20 hours a day; the CDC was on site and used Evergreen as a model for many policies, he added.

“We were not the fire, we were the fire department, and we had to change our mentality very quickly in order to react to something we had never dealt with before,” Korte said. Here’s the advice he gave:

1. Protect Your People
“Without our people we cannot provide care,” Korte said. “Our focus at Evergreen has been on the safety of our staff. If our staff are heathy, we can go out and take care of people in the field.”

That means caring for their physical safety—more on that below—and ensuring they’re supported.

He said his organization is actually below census, down about 100 patients from a peak of around 1,245. That’s likely because hospitals are cancelling elective surgeries. He said to look at ways to use underbooked physical and occupational therapists to free up registered nurses. Can skilled staff handle simple wound care, for example?

At the same time, he said, it’s worth discussing whether you’re endangering patients by sending caregivers into their homes. By treating people at home, home health can lift the burden on hospitals. But by treating people, are you expanding the infection vectors? At Evergreen, they’ve decided that non-essential visits should be conducted online when possible, but if patients need help or families request in-person hospice services, help will be provided.

“We have 600 highly skilled professionals who know about infection control and we know that they’re a much lesser vector, if not nonexistent compared to the general public,” he said. “But we do need to say out loud that there’s a measured choice that we need to make.”

2. Conserve PPE
Access to personal protective equipment (PPE) played a large part in the discussion and questions from the audience. Korte said that shortages are unavoidable but over-ordering hurts everyone. 

The best approach, he said, is to pay attention to the science and make adjustments to your protocol as necessary. If infection cases are low, use less. As they ramp up, get stricter. But resist the temptation to over-protect, he said. If a mask will do, full coverage is only wasteful.

“We feel that conservation is absolutely as critical as procurement,” he said. “Ask yourself: Would you rather your staff have two weeks of overprotection or eight weeks of adequate protection?”

That may require being firm with your staff and with your vendors. He also recommended making projections about supplies on hand and future needs, even if they’re wrong later.

Molly McDonald, Evergreen’s quality and regulatory manager, said they were also keeping an eye on non-PPE supplies, especially wound care materials and catheters.

3. Communicate Well
Whether it’s shifting rules for PPE usage or other protocols, it’s critical to communicate clearly with staff on the ground. He said his organization has sent a daily update by email, held weekly meetings online for all 600 staff members to answer pre-submitted questions (he said more than 600 people showed up—he’s not sure who the extras were), and done special one-on-one outreach to staff members who were struggling. Hospice volunteers and chaplains took on the company phone list to check in with everyone individually.

“That’s 600 different perspectives, 600 different levels of fear,” he said. “We needed to be sure that everyone was up-to-date during this constant era of change.”

At the same time, be careful about consuming non-medical news, Korte said; listen to the white coats on TV but avoid speculation. Stick to the science, avoid social media and rumors, and encourage your team to do the same

4. Think Globally, Act Locally
While a pandemic is global, treatment for an epidemic is ultimately local, and health care resources have been set in place based on assumptions for what the locality will need for care. He said that reactions in the suburban Northwest will be different from downtown Atlanta or rural Kansas—or in New York, which is being hit hardest right now.

At the same time, he said, home health is designed to provide community-based care and has a critical role to play during the crisis—but may see sicker patients than usual and more of them as hospitals run out of room.

“I feel that home-based care in the United States is really the community health care system,” he said. “We’re already out there in the community. People who are very sick with COVID-19 are going to hospitals to get treatment, but they’re going to be recovering at home.”

He added that one more thing to keep in mind is to make sure leadership is in lock step and prepared to handle the hard questions. And even though it’s hard to imagine right now, think about what you’ll be doing when all this is over.

“I can’t underscore enough that this is health care’s moment and this is homecare’s moment,” he said. “We are the fire department. We are not the fire.”