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Addressing Patient and Family Concerns During COVID-19 

By: Sharon Harder, Trella Health Consultant| April 30, 2020

For the last several weeks we have heard stories of patients and their families refusing care from home health and hospice providers. In this article published by Home Health Care News, they referenced statistics from agencies that participated in the Home Care Association of New York State survey (HCA-NYS) and stated, “Over 80% of the home-based care respondents reported at least one patient refusing care, with roughly one-quarter saying they had between one and 10 patients doing so.”

The reason? Fear of COVID-19, and the potential for inadvertent transmission of the virus to individuals already in fragile or failing health. Patients are understandably hesitant to allow outsiders, even healthcare providers, into their home, no matter how great the need.   

With all that said, there is one thing we know for sure; the number one job of home health and hospice providers continues to be keeping patients safe at home and out of the hospital – perhaps now more than ever. To do that, they need to be able to visit and convince patients and their families that getting needed care is important. Persuasion will likely require equal doses of time, patience, calm, and education that will open the door for making better, and more informed, decisions about care. 

Here are some things that agency teams should consider when talking with patients and/or their families about needed care. 

Infection Control, Patient Safety, and the Question of PPE 

From the patient’s perspective, his or her home health clinicians or other workers are in contact with several patients almost every day. Most patients know this and, from their perspective, that level of contact simply compounds the opportunity for a clinician to bring the virus into their homes.  To resolve resistance to care on this front, agencies must respond with education about the proactive measures being taken to protect patients at home during visits. 

PPE works, so we must explain how it works and why clinicians are relying on it for their protection as well as the safety of their patients.  

• Both home health and hospice providers must be prepared to educate patients about how visiting staff will use personal protective equipment (PPE) for their safety by donning PPE before entering the home, and their removal process once they leave.  Also inform the patient what elements of PPE will be in use. 
• Patients should know that use of PPE will not be limited to only those patients with known or suspected COVID-19 – any patient with concerns about transmission of the virus will need assurance that PPE will be adequate and in use for every visit.  

• For patients who are COVID-19 positive, providers will have to provide education about effective home isolation techniques, infection control, and preventive measures which may include helping family members to acquire PPE of their own. In this vein, we know of agencies that are asking hospitals to provide PPE to patients being discharged after being treated for COVID-19 in the hospital.

Minimizing Visits Through the Use of Technology 

Many agencies have not traditionally used remote patient monitoring or telehealth as extensions of care. The reason is easy to understand – Medicare won’t directly pay for it. However, as a tool that will allow the provider and patient to reduce the number of in-person visits while still maintaining contact and care, telehealth affords real opportunities for the public health emergency and well beyond.  

Patients’ vital signs can be monitored through telehealth as long as patients have the items of minor equipment to enable oxygen saturation readings, blood pressure, or glucose levels. Teaching on disease process topics and medication management can be easily accomplished through telehealth. Even attention to wound dressing changes can be monitored by a nurse working remotely with the patient’s caregiver to evaluate a wound and observe that dressing changes are proceeding as ordered by the physician. Therapists can work with patients on safe ambulation and monitoring of exercise routines without a visit provided the patient has been instructed previously and has stand by assistance for safety. 

While CMS has not made the move to allow telehealth encounters to be billed, it has acknowledged that home health agencies can perform the minimum number of visits to meet LUPA thresholds and to fill visit gaps with telehealth services, as long as the approach to care is integrated into the patient’s Plan of Care. For patients who are nervous about so many visits, telehealth is being well received as an alternative to going without care that they know is needed. 

The Dilemma of Patients in SNFs 

In addition to caring for patients in their own homes, home health and hospice teams also regularly visit patients in assisted living facilities and, for some hospice patients, the SNFs where they reside. However, gaining access during the pandemic was difficult at first and has now become all but impossible due to escalating infection control concerns for the facilities.   

Some are allowing home health and hospice nurses to visit on a very limited basis with full PPE and to see a single patient at a time, and when that is the case, telehealth can be interspersed to continue to monitor the patient and provide remote care between visits.  

For hospices that are simply unable to gain access to SNFs where their patients are residing, it appears CMS is  allowing claims to be paid without evidence of billable visits; but, of course, the hospice should be able to demonstrate that even without access ongoing care has been delivered through remote means. 

Managing Outcomes 

The pandemic has provided more than its share of challenges in equal parts for all post-acute providers.  One thing is certain, though. While CMS has granted us some latitude in providing home-based care, we are still going to be held accountable in the end for the quality of care that we provide, and the outcomes achieved. For that reason, it will be imperative to ensure that patients can be made to be comfortable with the notion of receiving at least a limited amount of in person care at home and agencies must be comfortable and able to provide it even as staffing shortages may loom. Agencies must also take seriously their obligation to continually monitor their patients for change and to work with physicians to ensure the safety and wellbeing of all those served. This, too, shall pass but if we do things right, it will likely open up much greater opportunities for flexibility in how we provide care in the future. 

About the Author:

Sharon Harder, Trella Health Consultant

Sharon works with post-acute healthcare providers to improve compliance and bolster sustainable growth in an era of escalating regulatory scrutiny. By developing strategic, common sense approaches to handling operational, financial and regulatory challenges, her clients are far more likely to achieve long term success.

Sharon specializes in home health and hospice process improvement, regulatory compliance, acquisition due diligence and post-acquisition integration. She is an expert in Federal and State regulation of home health and hospice with over 20 years of executive management and post-acute consulting experience.