Swamped ERs Mean Opportunity and Danger for Home-Care Industry

Jennifer Burger worries that her elderly parents were exposed to Covid-19 by a kindly source: their home-care aide.

First, Burger got a call informing her that the woman, who cooked, cleaned and helped her parents with such activities as bathing, couldn’t work because she’d been diagnosed with pneumonia. Later, Burger learned she was being tested for the new coronavirus. By the time Burger, an Atlanta physician, drove three hours to her parents’ home in Albany, Georgia, the caregiver had tested positive and was on a ventilator.

“This is just awful,” Burger said. “This is just the tip of the iceberg. I don’t know what to do on a national level to make people see how serious this is.”

While doctors and nurses work the front lines of the coronavirus pandemic, nearly 3.5 million home-health workers form a kind of rear guard — one composed largely of a female, minority and immigrant workforce. Now, as the virus is overwhelming emergency rooms and ambulatory-care centers, these workers could be thrust into the center of the fight. Hospital emergency rooms in Washington, Oregon and Louisiana have already begun directing people to seek home care instead.

Some public-health experts worry that the industry, which ranges from small local operations to nationwide providers, might lack adequate training and supplies to handle the potentially deadly infectious disease. These workers face the same nationwide shortage of protective gear as hospital workers, and the scarcity of testing means they may not know if they’ve contracted the virus. As a result, they’re at risk of becoming unwitting vectors for Covid-19 for the multiple clients they visit each day.

“They could be tracking the virus within the community from house to house,” said David Grabowski, a professor of public health at Harvard Medical School. “It’s not feasible that they’ll just go in without any protective gear. It’s really a bit of a tinder box.”

In-home healthcare providers — who typically range from personal-care aides to nurses — visit the homes of the sick, elderly and disabled. Their services run the gamut from bathing to cooking to physical therapy or more advanced tasks such as caring for wounds or administering prescription medication. Often, they are their clients’ sole outside contacts, offering them a last, best chance to stay out of a hospital or assisted living facility.

Amid the pandemic, in-home providers could see different sorts of patients from those they’ve historically treated. “We’re going to have to ask a lot more out of agencies in the way of infection control and protection of the workforce, and they haven’t had staff training or expertise around doing this care safely,” Grabowski said.

Burger’s parents, who may have been exposed during the first half of March, are now in quarantine at home, and Burger is self-quarantining. At 84 and 86, her mother and father are at elevated risk from the deadly virus, which has killed more than 16,000 worldwide and 400 in the U.S.

Despite the risk, leaders of the home-health industry see opportunity in the crisis, particularly because of the danger that Covid-19 poses in group settings like nursing homes.

“Isolating people socially and clinically is the best way to prevent the spread of this disease,” said William Dombi, president of the National Association of Home Care and Hospice. “While hospital beds number less than a million, pretty much everyone except for the homeless has their own bed.”

Meanwhile, at least some home-health companies are ramping up to meet the demand. Kindred at Home, the largest such provider in the U.S., has boosted training on infection control and the use of personal protective equipment, like masks, said Nick Stengle, the chief operating officer of the Atlanta-based company’s home-health division.

Others are still finding their way. Sunshine Lopez, a home-health worker in Spokane, Washington, who cares for three immunocompromised clients, said she recently asked her agency to clarify its Covid-19 policy after she had to ask for extra gloves. She has yet to receive an adequate response, she said, and the 41-year-old single mother fears bringing the virus home to her 20-year-old daughter, who is also immunocompromised.

Questions about how home-health firms will manage their own workers’ health remain largely unresolved. On March 7, the CDC revised its guidelines to address potential worker shortages by saying that health care providers, including home-health companies, should “consider allowing” exposed employees to continue seeing patients if they’re not yet symptomatic. Agencies should take that step only “after options to improve staffing have been exhausted,” the new guidance said.

The agency’s previous guidelines had required workers who’d had the riskiest exposures to stay home for 14 days. The CDC also made it optional, not mandatory, for healthcare employers to verify their workers’ absence of symptoms, including fever.

Home-health agencies are telling workers to screen new patients by telephone for Covid-19 symptoms when they call for service and prior to each visit, said Melissa O’Connor, who chairs the board of trustees at the Visiting Nurse Association of Greater Philadelphia. “We’re also telling nurses, if you are not well do not go to work.”

For some, whose employers don’t provide paid sick leave, the temptation to work while ill will be powerful. Unlike physicians, whose median annual wage is $208,000, or nurses, who earn almost $72,000, home-health aides and personal-care aides earn just above $24,000, according to the U.S. Bureau of Labor Statistics. It’s unclear whether emergency sick leave provisions that President Donald Trump signed into law last week will apply to home-health workers; the measure exempted healthcare workers, but the U.S. Labor Department will have to decide if that includes home aides.

Whether home-care services can help ease the challenges posed by the virus may depend on the degree to which people trust the industry. Dombi noted that while the virus has stirred many to opt for home care over nursing homes or assisted living facilities, “you have people refusing to have someone come in.”

Nick Riviere, 22, had been a live-in care provider for a young adult with disabilities in Virginia. He loved his job, he said, and took pride in watching his client become more independent. But as the virus began spreading, the client’s parents decided they couldn’t risk their son contracting the disease and brought him to their home. Now Riviere is out of work and living with a family member.

“Right now it’s just kind of a wait and see feeling,” he said. “I’m also a licensed massage therapist, but no one’s really looking for massages in these times.”

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