“I depend on her for everything”: A mixed-methods analysis of the role of home care workers caring for medically and socially complex patients during the COVID-19 pandemic

ABSTRACT

Background: The devastating impact of the COVID-19 pandemic on long-term care facilities has illustrated the need for quality home-based care. Home care workers (HCWs) have played critical roles in meeting the medically and socially complex needs of homebound adults during COVID-19, yet their essential work is often undervalued and understudied. Our purpose was to explore the association between patients' medical and social circumstances and HCW services during COVID-19. Methods: In this mixed-methods study, we collected demographic and clinical data and performed a thematic analysis of medical records from 53 homebound patients with HCWs in a home-based primary care program in New York City. We ed unstructured clinical notes from 12/1/19 - 12/31/20 into a priori and emergent categories, including patient medical and social risk and changes to HCW responsibilities. Core themes were identified via team meeting discussions. Results: Of the 53 patients, 24.5% died during the initial COVID surge, 34% lived alone, and 41.5% had 24-hour HCWs. 50.9% of the patients lived with dementia and the mean Elixhauser Comorbidity Index was 3.66. Three themes emerged from our analysis: 1) Among this high-risk, high-need population, patients with certain risks (i.e. dementia diagnosis, living alone) had more intense and dynamic medical and social needs than others, 2) Patient medical status and risk factors influenced HCW tasks in meeting patient needs, such as managing progressing dementia behaviors or helping food-insecure patients obtain food, and 3) The combined effect of COVID-19 and HCW disruptions (i.e. unstable schedules, aide turnover) created difficult situations for patients and their caregivers, including increased risk of hospitalization and nursing home placement. Conclusions: During COVID-19, HCWs were essential in meeting the existing and new needs of homebound older adults. HCW disruptions were particularly challenging for patients who had more complex medical and social needs, leading to risk of hospitalization. This analysis can inform policies to better integrate HCWs on medical teams, further develop HCW training to identify social as well as medical risks, and address workforce shortages to expand access to adequate HCW services for homebound older adults and their caregivers.