Acute Care Reimagined: Home Hospital Care Can Support the Triple Aim and Reduce Health Disparities.

EXECUTIVE SUMMARY: Home hospital care (HHC) is a new and exciting concept that holds the promise of achieving all three components of the Triple Aim and reducing health disparities. As an innovative care delivery model, HHC substitutes traditional inpatient hospital care with hospital care at home for older patients with certain conditions. Studies have shown evidence of reduced cost of care, improved patient satisfaction, and enhanced quality and safety of care for patients treated through this model. The steady growth in Medicare Advantage enrollment and the expansion in 2020 of the Centers for Medicare & Medicaid Services (CMS) Hospitals Without Walls program to include acute hospital care at home creates an opportunity for hospitals to implement such programs and be financially rewarded for reducing costs. Capacity constraints exacerbated by the COVID-19 pandemic suggest that now is the ideal time for healthcare leaders to test and advance the concept of HHC in their communities.

Post-acute sequelae of COVID-19 in a non-hospitalized cohort: Results from the Arizona CoVHORT.

Clinical presentation, outcomes, and duration of COVID-19 has ranged dramatically. While some individuals recover quickly, others suffer from persistent symptoms, collectively known as long COVID, or post-acute sequelae of SARS-CoV-2 (PASC). Most PASC research has focused on hospitalized COVID-19 patients with moderate to severe disease. We used data from a diverse population-based cohort of Arizonans to estimate prevalence of PASC, defined as experiencing at least one symptom 30 days or longer, and prevalence of individual symptoms. There were 303 non-hospitalized individuals with a positive lab-confirmed COVID-19 test who were followed for a median of 61 days (range 30-250). COVID-19 positive participants were mostly female (70%), non-Hispanic white (68%), and on average 44 years old. Prevalence of PASC at 30 days post-infection was 68.7% (95% confidence interval: 63.4, 73.9). The most common symptoms were fatigue (37.5%), shortness-of-breath (37.5%), brain fog (30.8%), and stress/anxiety (30.8%). The median number of symptoms was 3 (range 1-20). Amongst 157 participants with longer follow-up (≥60 days), PASC prevalence was 77.1%.

Impact of the COVID-19 Pandemic on Health System Use in Canada.

The Canadian Institute for Health Information has compiled health system data to investigate the impact of the COVID-19 pandemic on Canada's healthcare system. Information was aggregated from four distinct sectors of care: emergency department visits, in-patient hospital stays, physician care and home care. Across the sectors, there were two compelling themes: rapid transformation and change in human behaviour.

The Development and Operation of a Home Management System during the COVID-19 Pandemic: Experience of the Local Government Gyeonggi-do in Korea.

During the three the coronavirus disease 2019 (COVID-19) surges in South Korea, there was a shortage of hospital beds for COVID-19 patients, and as a result, there were cases of death while waiting for hospitalization. To minimize the risk of death and to allow those confirmed with COVID-19 to safely wait for hospitalization at home, the local government of Gyeonggi-do in South Korea developed a novel home management system (HMS). The HMS team, comprised of doctors and nurses, was organized to operate HMS. HMS provided a two-way channel for the taskforce and patients to monitor the severity of patient's condition and to provide healthcare counseling as needed. In addition, the HMS team cooperated with a triage/bed assignment team to expedite the response in case of an emergency, and managed a database of severity for real-time monitoring of patients. The HMS became operational for the first time in August 2020, initially managing only 181 patients; it currently manages a total of 3,707 patients. The HMS supplemented the government's COVID-19 confirmed case management framework by managing patients waiting at home for hospitalization due to lack of hospital and residential treatment center beds. HMS also could contribute a sense of psychological stability in patients and prevented the situation from worsening by efficient management of hospital beds and reduction of workloads on public healthcare centers. To stabilize and improve the management of COVID-19 confirmed cases, governments should organically develop self-treatment and HMS, and implement a decisive division of roles within the local governments.

Long-term care at home and female work during the COVID-19 pandemic.

This study analyzes the impacts of COVID-19 on two elements: long-term care at home, which is available for care recipients who live in their own home, and working status in Japan. A regression analysis of municipality data reveals that the number of users of adult daycare is negatively correlated to COVID-19, both nationally and regionally. This finding is intuitive because people avoid daycare due to the increased risk of exposure to infection. However, the number of users of home care is positively correlated to users of daycare, which implies that home care has not functioned as a replacement for daycare, despite government encouragement. Furthermore, a regression analysis using prefecture data shows that working hours for both females and males were negatively correlated to the national status of the pandemic, while the regional status of the pandemic was negatively correlated only to female working hours. This implies that female labor status is more vulnerable to such outbreaks in Japan. Also, we find consistent results with a situation in which informal care compensated for the decline in daycare use; and this care has been provided primarily by especially females who have reduced their working hours by COVID-19.

Barriers to telehealth access among homebound older adults.

BACKGROUND/OBJECTIVES: To identify major barriers to video-based telehealth use among homebound older adults. DESIGN: Cross-sectional survey. SETTING: A large home-based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community. PARTICIPANTS: Sixteen primary care physicians. MEASUREMENTS: An 11-item assessment of provider perceptions of patients' experience with and barriers to telehealth. RESULTS: According to physicians in the HBPC program, more than one-third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first-time video-based telehealth encounters between April and June 2020 during the first COVID-19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) "unable to interact over video" for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video-capable device access. CONCLUSION: The COVID-19 pandemic resulted in a large and dramatic shift to video-based telehealth use in home-based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video-based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video-based telehealth use.

Patient-Directed Home Drain Removal in Head and Neck Surgery.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients. METHODS: The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes. RESULTS: One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved. CONCLUSIONS: The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2471-2477, 2021.

Gemelli decision tree Algorithm to Predict the need for home monitoring or hospitalization of confirmed and unconfirmed COVID-19 patients (GAP-Covid19): preliminary results from a retrospective cohort study.

OBJECTIVE: To develop a deep learning-based decision tree for the primary care setting, to stratify adult patients with confirmed and unconfirmed coronavirus disease 2019 (COVID-19), and to predict the need for hospitalization or home monitoring. PATIENTS AND METHODS: We performed a retrospective cohort study on data from patients admitted to a COVID hospital in Rome, Italy, between 5 March 2020 and 5 June 2020. A confirmed case was defined as a patient with a positive nasopharyngeal RT-PCR test result, while an unconfirmed case had negative results on repeated swabs. Patients' medical history and clinical, laboratory and radiological findings were collected, and the dataset was used to train a predictive model for COVID-19 severity. RESULTS: Data of 198 patients were included in the study. Twenty-eight (14.14%) had mild disease, 62 (31.31%) had moderate disease, 64 (32.32%) had severe disease, and 44 (22.22%) had critical disease. The G2 value assessed the contribution of each collected value to decision tree building. On this basis, SpO2 (%) with a cut point at 92 was chosen for the optimal first split. Therefore, the decision tree was built using values maximizing G2 and LogWorth. After the tree was built, the correspondence between inputs and outcomes was validated. CONCLUSIONS: We developed a machine learning-based tool that is easy to understand and apply. It provides good discrimination in stratifying confirmed and unconfirmed COVID-19 patients with different prognoses in every context. Our tool might allow general practitioners visiting patients at home to decide whether the patient needs to be hospitalized.

Facilitators and challenges in the adoption of a virtual nurse visit in the home health setting.

The COVID-19 pandemic created an opportunity to incorporate nurse-led virtual home care visits into heart failure patients' plan of care. As a supplemental nurse visit to traditional in-person home visits, the Virtual Nurse Visit (VNV) service was deployed using Zoom teleconferencing technology enabling telehealth nurses to remotely communicate, assess, and educate their patients. This mixed methods study explored heart failure patients' abilities, experience, and satisfaction to use and adopt a virtual nurse visit. Sociodemographic, semi-structured interview questions, and the System Usability Scale data were collected. Thirty-four participants completed the study. Over half of participants perceived the VNV usable and four qualitative themes emerged: perceived safety during COVID-19, preferences for care delivery, user experiences and challenges, and satisfaction with the VNV service. Findings from this study builds the science around telehealth that will inform future studies examining this type of nurse-led virtual visit and subsequent patient outcomes.

Place and Underlying Cause of Death During the COVID-19 Pandemic: Retrospective Cohort Study of 3.5 Million Deaths in England and Wales, 2014 to 2020.

OBJECTIVE: To describe the place and cause of death during the coronavirus disease 2019 (COVID-19) pandemic to assess its impact on excess mortality. METHODS: This national death registry included all adult (aged ≥18 years) deaths in England and Wales between January 1, 2014, and June 30, 2020. Daily deaths during the COVID-19 pandemic were compared against the expected daily deaths, estimated with use of the Farrington surveillance algorithm for daily historical data between 2014 and 2020 by place and cause of death. RESULTS: Between March 2 and June 30, 2020, there was an excess mortality of 57,860 (a proportional increase of 35%) compared with the expected deaths, of which 50,603 (87%) were COVID-19 related. At home, only 14% (2267) of the 16,190 excess deaths were related to COVID-19, with 5963 deaths due to cancer and 2485 deaths due to cardiac disease, few of which involved COVID-19. In care homes or hospices, 61% (15,623) of the 25,611 excess deaths were related to COVID-19, 5539 of which were due to respiratory disease, and most of these (4315 deaths) involved COVID-19. In the hospital, there were 16,174 fewer deaths than expected that did not involve COVID-19, with 4088 fewer deaths due to cancer and 1398 fewer deaths due to cardiac disease than expected. CONCLUSION: The COVID-19 pandemic has resulted in a large excess of deaths in care homes that were poorly characterized and likely to be the result of undiagnosed COVID-19. There was a smaller but important and ongoing excess in deaths at home, particularly from cancer and cardiac disease, suggesting public avoidance of hospital care for non-COVID-19 conditions.

Change of Use in Community Services among Disabled Older Adults during COVID-19 in Japan.

During the COVID-19 pandemic, social interactions were restricted, including community services for disabled older adults. This study aimed to describe the change of use in community services related to long-term care insurance (LTCI) during the pandemic in Japan. A retrospective descriptive study was conducted using data collected via a cloud-based management support platform for older adult care provider "Kaipoke", by a private-sector company "SMS Co., Ltd.", in which care-managers of LTCI manage their office work. Data collection occurred from July 2019 to June 2020. Study subjects were LTCI service users aged 65 years and above. Subjects were living at home. We examined changes in the number of users of LTCI services before and after the COVID-19 pandemic began, using an interrupted time-series analysis. Results indicated that the use of outpatient services was reduced; however, home-visit services were maintained. The decrease in use was significant in the seven prefectures where the infection initially spread. There are concerns that older adults or surrounding caregivers can be affected by such changes in LTC service use. It is therefore necessary to implement sustainable measures from a long-term perspective and investigate their influence as part of future studies.

Don't stop walking: the in-home rehabilitation program for peripheral artery disease patients during the COVID-19 pandemic.

We studied the outcomes of peripheral artery disease (PAD) patients enrolled in a structured in-home walking program right before the lockdown due to the SARS-CoV-2 epidemic emergency, to determine whether this intervention ensured the maintenance of mobility even in the case of movement restrictions.We selectively studied 83 patients (age 72 ± 11, males n = 65) enrolled in the program within 9-month before the lockdown. The usual intervention was based on two daily 8-min sessions of slow intermittent in-home walking prescribed in circa-monthly hospital visits. During the lockdown, the program was updated by phone. Six-minute (6MWD) and pain-free walking distance (PFWD) were measured pre- and post-lockdown as well as body weight (BW), blood pressure (BP), and ankle-brachial index (ABI). Sixty-six patients were measured 117 ± 23 days after their previous visit. A safe, pain-free execution of the prescribed sessions was reported (median distance: 74 km). Overall, the 6MWD was stable, while PFWD improved (p < 0.001). The improvement was not related to age/gender, comorbidities, type of home but to the time of enrollment before lockdown. The new-entry subjects (≤ 3 months; n = 35) obtained significant improvements post-lockdown for 6MWD and PFWD, while those previously enrolled (> 3 months; n = 31) were stable. Decreased BW with stable BP and ABI values were also recorded, with better outcomes for new-entry subjects. In PAD patients, a structured walking program performed inside home and purposely guided by phone was adhered to by patients and favored mobility and risk factor control during the COVID-19 pandemic, regardless of walking ability, type of home and external conditions.

Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults.

Importance: Home health care is one of the fastest growing postacute services in the US and is increasingly important in the era of coronavirus disease 2019 and payment reform, yet it is unknown whether patients who need home health care are receiving it. Objective: To examine how often patients referred to home health care at hospital discharge receive it and whether there is evidence of disparities. Design, Setting, and Participants: This cross-sectional study used Medicare data regarding the postacute home health care setting from October 1, 2015, through September 30, 2016. The participants were Medicare fee-for-service and Medicare Advantage beneficiaries who were discharged alive from a hospital with a referral to home health care (2 379 506 discharges). Statistical analysis was performed from July 2019 to June 2020. Exposures: Hospital referral to home health care. Main Outcomes and Measures: Primary outcomes included whether discharges received their first home health care visit within 14 days of hospital discharge and the number of days between hospital discharge and the first home health visit. Differences in the likelihood of receiving home health care across patient, zip code, and hospital characteristics were also examined. Results: Among 2 379 506 discharges from the hospital with a home health care referral, 1 358 697 patients (57.1%) were female, 468 762 (19.7%) were non-White, and 466 383 (19.6%) were dually enrolled in Medicare and Medicaid; patients had a mean (SD) age of 73.9 (11.9) years and 4.1 (2.1) Elixhauser comorbidities. Only 1 284 300 patients (54.0%) discharged from the hospital with a home health referral received home health care services within 14 days of discharge. Of the remaining 1 095 206 patients (46.0%) discharged, 37.7% (896 660 discharges) never received any home health care, while 8.3% (198 546 discharges) were institutionalized or died within 14 days without a preceding home health care visit. Patients who were Black or Hispanic received home health at lower rates than did patients who were White (48.0% [95% CI, 47.8%-48.1%] of Black and 46.1% [95% CI, 45.7%-46.5%] of Hispanic discharges received home health within 14 days compared with 55.3% [95% CI, 55.2%-55.4%] of White discharges). In addition, disadvantaged patients waited longer for their first home health care visit. For example, patients living in high-unemployment zip codes waited a mean of 2.0 days (95% CI, 2.0-2.0 days), whereas those living in low-unemployment zip codes waited 1.8 days (95% CI, 1.8-1.8 days). Conclusions and Relevance: Disparities in the use of home health care remain an issue in the US. As home health care is increasingly presented as a safer alternative to institutional postacute care during coronavirus disease 2019, and payment reforms continue to pressure hospitals to discharge patients home, ensuring the availability of safe and equitable care will be crucial to maintaining high-quality care.

Experiences of Home Health Care Workers in New York City During the Coronavirus Disease 2019 Pandemic: A Qualitative Analysis.

Importance: Home health care workers care for community-dwelling adults and play an important role in supporting patients with confirmed and suspected coronavirus disease 2019 (COVID-19) who remain at home. These workers are mostly middle-aged women and racial/ethnic minorities who typically earn low wages. Despite being integral to patient care, these workers are often neglected by the medical community and society at large; thus, developing a health care system capable of addressing the COVID-19 crisis and future pandemics requires a better understanding of the experiences of home health care workers. Objective: To understand the experiences of home health care workers caring for patients in New York City during the COVID-19 pandemic. Design, Setting, and Participants: From March to April 2020, a qualitative study with 1-to-1 semistructured interviews of 33 home health care workers in New York City was conducted in partnership with the 1199SEIU Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest health care union in the US. Purposeful sampling was used to identify and recruit home health care workers. Main Outcomes and Measures: Audio-recorded interviews were professionally transcribed and analyzed using grounded theory. Major themes and subthemes were identified. Results: In total, 33 home health care workers employed by 24 unique home care agencies across the 5 boroughs of New York City participated. Participants had a mean (SD) age of 47.6 (14.0) years, 32 (97%) were women, 21 (64%) were Black participants, and 6 (18%) were Hispanic participants. Five major themes emerged: home health care workers (1) were on the front lines of the COVID-19 pandemic but felt invisible; (2) reported a heightened risk for virus transmission; (3) received varying amounts of information, supplies, and training from their home care agencies; (4) relied on nonagency alternatives for support, including information and supplies; and (5) were forced to make difficult trade-offs in their work and personal lives. Conclusions and Relevance: In this qualitative analysis, home health care workers reported providing frontline essential care, often at personal risk, during the COVID-19 pandemic. They experienced challenges that exacerbated the inequities they face as a marginalized workforce. Interventions and policies to better support these frontline health care professionals are urgently needed.

Impact of the COVID-19 Pandemic on the Utilization of Hospice Care Services: A Cohort Study in Taiwan.

CONTEXT: Hospice care focuses on improving the quality of end-of-life care and respecting patients' preferences regarding end-of-life treatment. The impact of coronavirus disease 2019 (COVID-19) on the utilization of hospice services is unknown. OBJECTIVES: To investigate the utilization of hospice care services before and during the COVID-19 pandemic. METHODS: All patients (n = 19,900) cared for at Taipei City Hospital from January 2019 to April 2020 were divided into three time points: January-April 2019 (before COVID-19), May-December 2019 (interim), and January-April 2020 (during COVID-19). This cohort study compared the monthly utilization of hospice services before and during the COVID-19 pandemic. RESULTS: There was no significant difference in hospice home visits (194 vs. 184; P = 0.686) and new enrollments (15 vs. 14; P = 0.743) to hospice home care before and during the pandemic. However, the bed occupancy rate in hospice units in the hospital was significantly reduced from 66.2% before the pandemic to 37.4% during the pandemic (P = 0.029), whereas that in nonhospice units had a nonsignificant decrease from 81.6% before the pandemic to 71.8% during the pandemic (P = 0.086). During the pandemic, the number of inpatient days was affected more severely in hospice units than in nonhospice units (-42.4% vs. -10.9%; P = 0.029). CONCLUSIONS: This study suggests that hospice home care services were maintained during the COVID-19 pandemic, while the utilization of hospice inpatient care services reduced. Home care for hospice patients is an essential component of palliative care during a pandemic.