The COVID-19 crisis has not spared any component of healthcare delivery, including home-based care, a sector that’s designed to administer care by having providers going into peoples’ homes. Home healthcare workers provide services to millions of people each year in the U.S., and just like all other patient care organizations, this group of providers had to massively pivot in the face of a spreading virus.
While some frontline home healthcare workers are still braving the elements going into peoples’ homes, equipped with the proper PPE of course, the sector—one that has oftentimes struggled with embracing technology—has broadly shifted into a new care delivery environment, similar to its acute care counterparts. Nonetheless, there are unique considerations for home healthcare organizations, and in a recent interview, Mayank Shah, M.D., chief medical officer at Alegis Care, a home-based care program and part of CareAllies, a management services organization and Cigna company; and Joe Nicholson, D.O., chief medical officer of CareAllies, discuss the COVID-19 impact on home healthcare. Below are excerpts of that discussion.
Broadly speaking, how has COVID-19 affected the home healthcare industry?
Shah: Home care delivery is a critical part of healthcare delivery, but at the same time it can be seen as a luxury or ancillary service. There hasn’t been lot of [attention] paid to growing, preserving, and protecting this aspect of care delivery, since healthcare delivery has often been centered in the office setting, or in hospital and nursing home settings. So home-based care has been fragmented over time, but via this epidemic, as we look at stay-at-home orders and peoples’ homes becoming a critical place of security and safety, how do we pivot into a new environment of delivering care in the home setting? Other countries have done a better job in growing home-based care, but we have lagged behind.
Specifically in the COVID-19 context, some of the issues we have struggled with are related to how we provide care in the home while balancing the risks that our patients face. How do we avoid introducing the pandemic into the home environment, and protect both our providers and patients? There has not been a lot of technology investment in home-based care, so how do we quickly deploy technology and create opportunity? That’s been a setback in this space that this crisis has brought forth. One of the key aspects of home-based care has been the relationships we develop with our patients, and face-to-face interaction and non-verbal communication are critical pieces of that. So how do we preserve that with the challenge of telemedicine?
Also, in home-based care, we have a unique ability to build trust, not just with families, but caregivers, too. They look upon you as a source of information, so we [need to] make we are empowered to share the right information, connect patients with the right resources, and bridge gaps around SDOH during a time when this can detrimentally affect patients’ outcomes. Lastly, [we must] understand regulations. Home healthcare has been regulated differently compared to other care delivery [spaces], and as the rules get lifted, they aren’t [very] clear in terms of what’s allowed and which restrictions still exist, so we need to quickly understand that and deploying operations accordingly.
On a practical level, how has home-based care changed since the pandemic?
Shah: It has been impacted in the sense that we aren’t delivering [as much of] those face-to-face encounters, so not being able to do that has affected our ability to roll out our services in an expanded way. For example, for new enrollees that come into the program, we would obviously like to see them face-to-face, but instead we are doing virtual visits. So then you’re dealing with the technology piece of that—remaining connected to the patient—but many homebound patients are not tech-savvy enough to navigate through this scenario.
Some markets have stopped providing home health services and other ancillary resources in the home for things such as blood draws, diagnostic imaging, and physical therapy. All of these services have been restricted. There are also communities with healthcare shortages, meaning providers who were going out there might now be in quarantine. The limit of the workforce, along with the restrictions, and the non-essential classification of home-based care [the home health industry has fought to have home healthcare workers classified as essential so they can get free PPE and hazard pay, among other things], have impacted these services from easily being available in the home environment.
Nicholson: Our current bloated system is clunky and not always ready for change. But this [pandemic] has become a change agent unlike anything I have witnessed in my 30 years as a physician, and has acted as an accelerant for the acceptance of telemedicine and home-based care.
Can you discuss the telehealth deployment and surge that have been seen in this space?
Nicholson: It’s expanded in ways that are almost unanticipated. Because of HIPAA security issues, there were initially limited platforms that you could even step into. But now with expanded allowance, under good faith provisions, the government has made it allowable to do everything from FaceTime, Google Hangout, and Zoom, and even texting allowances, too. In many cases these audio-visual moments in telehealth have taken the place of in-person visits. They have recently changed the reimbursement around that, too. It was previously so low for phone call-only visits that many doctors didn’t want to [engage]; but that’s been expanded by almost 3x for audio-only visits.
Shah: The barriers we saw in telemedicine before this were around the technology limitations in terms of our ability to connect, the adaptability of the technology by the patients we serve, and also the acceptance of telemedicine as a way to access care. For the vulnerable population we serve, there wasn’t an expectation that this would be a standard way to connect. But at Alegis, we have been able to pivot into three different aspects of telemedicine: virtual visits with video and telephonic capability; remote patient monitoring; and the e-visit capability. We have deployed all three aspects in order to preserve the connectivity and access to care. It’s been an amazing experience and critical to preserving our business continuity.
What strategies/advice can you offer for providers in this space to implement effective plans that address care delivered across all facets of the spectrum, including looking at SDOH?
Nicholson: It’s been a hand-holding moment between Dr. Shah’s team and my team. At CareAllies, we have a pilot, a community health advocate (CHAT) team, that does outreach specific around SDOH. The population that Dr. Shah’s team serves is at such risk for these SDOH [elements], they actually implement an SDOH evaluation on almost every patient they touch since they are already in the home. For our team, we have a different way in terms of how we sort and define risk, and there’s a whole other conversation in terms of how we define that risk, because claims data doesn’t really lend itself to highlighting these social disparities that exist.
For SDOH, my headline would be this: any disaster seems to double down on the pain and misery that it inflicts on the less fortunate. It only exaggerates those social disparities. The “have-nots” can be thrown into dire consequences. Prior to COVID-19, you might have had all these people on the bubble, but doing fine, and then the crisis hits and they have lost the ability to make their car and apartment payments, or maybe they’re forced to make decisions between buying food or paying for rent. It gets complex when you think about how to solve such a big social problem on a national level.
Shah: One of the things we have learned from a provider perspective is that we have a lot of tools available from a population perspective, as well as being able to risk stratify patients, and I think we need to have a similar process around SDOH; having that in the back pocket of a public health crisis would be so immensely helpful.
How do you envision the future of home-based care as COVID-19 continues to play out and also as it begins to fade?
Shah: Obviously, this is becoming a safe place for care delivery, with the notion that care could be delivered in the home environment. We will only see the evolution of this, especially when you combine it with virtual care. The key for home-based care is continuity; instead of fragmented care, how do we create a more holistic approach to care in the home environment, where people can heal much faster compared to acute care setting, as studies have shown. Creating a hybrid model of telehealth and face-to-face visits will be [the future].
