A shortage of N95 masks. A dire supply of gloves. Major workforce disruptions.
These are just some of the challenges that in-home care providers in the state of New York are already struggling with during the COVID-19 pandemic. In many ways, New York is ground zero for the coronavirus crisis — and a likely reflection of what other states can expect if the pandemic isn’t contained.
As of Thursday, the number of coronavirus cases in the U.S. reportedly surpassed 10,000, though the exact number of cases is still unknown due to a lack of widespread testing. In New York alone, there were reportedly more than 4,000 confirmed cases.
To get a sense of what the situation on the ground looks like for home health and home care agencies, the Home Care Association of New York State (HCA-NYS) recently surveyed hundreds of providers.
“Different states and regions are at different stages in surveillance and monitoring,” Roger Noyes, director of communications at HCA-NYS, told Home Health Care News. “Certainly due to our population and the size of our home care programs, the situation in New York can be instructive for other states, including the scale of remedies under consideration and how well they’ve worked.”
HCA-NYS is a state trade organization that represents nearly 400 home- and community-based care providers and organizations.
Broadly, home health and home care agencies in New York are already experiencing challenges that many others throughout the continuum of care are as well, including hospitals. That’s particularly alarming because the need for home-based care will likely rise in the coming weeks, especially as quarantines become stricter and more patients are sent home from institutional settings.
Among its findings, the HCA-NYS survey found that most home-based providers lack access to adequate personal protective equipment (PPE). More than 300 home health, home care and hospice agencies participated in the survey, conducted over a roughly 40-hour period this week.
Currently, about two-thirds of in-home care providers report an insufficient amount of personal protective equipment, according to the survey, which also included responses from managed long-term care plans. Specifically, items such as hand sanitizer, loop masks, N95 masks, gowns, gloves, goggles and disinfectants are in high demand.
The lack of much-needed supplies is impacting small and large organizations alike.
It’s a topic that even gives pause to the Visiting Nurse Service of New York (VNSNY), the largest nonprofit home- and community-based health care organization in the country.
“We are concerned about the available supply of PPE and are working with NYC and [the state health department] to procure adequate supplies for future needs,” Andria Castellanos, executive vice president and chief of provider services for VNSNY, told HHCN in an email.
VNSNY has been preparing for this type of crisis as part of its training protocol for years, Castellanos said.
“We began mobilizing on [COVID-19] as soon as the first reports came out in December,” she added. “So to a certain extent, training and protocol implementation has gone smoothly — but even so, this implementation has required intensive focus and manpower.”
Aside from the need for PPE, the HCA-NYS survey also found that 86% of in-home care providers don’t have enough staff trained to conduct testing for the coronavirus.
Furthermore, of the 14% of providers that do have staff trained to conduct testing, few are being recruited by public health officials.
One of the most pressing challenges associated with the spread of COVID-19 is the burden the virus places on the U.S. hospital system.
Hospitals in New York and other places are already exhausting capacity, so much so that the federal government is deploying Navy hospital ships for support.
“Another idea for hospital capacity — and I think Governor [Andrew Cuomo] in New York advanced this — is using the Army Corps of engineers to retrofit college dormitories or unused military buildings as hospital space,” David Grabowski, a health care policy professor at Harvard University, recently told HHCN. “One could imagine doing that with facility-based care as well. Both of those options are challenging, whether you’re talking about retrofitting buildings or creating centers of excellence.”
Home-based care can help alleviate hospital-capacity pressure, but few providers are being utilized in that regard.
Currently, less than 8% of home care and hospice agencies that participated in the HCA-NYS survey are being asked to assist with hospital decompression.
Additionally, the survey found that roughly 33% of providers have had to transfer patients to other levels of care due to workforce shortages, about 38% of providers had to transfer patients to other levels of care because of suspected coronavirus, and over 50% had to transfer patients to other levels of care because of safety issues.
Nearly half of agencies in the survey said they have experienced patients or family members refusing entry of home care personnel.
“This speaks to some very important educational and outreach needs to reassure patients and to ensure that vital care can be delivered,” Noyes said.
To support home health, home care and hospice agencies, HCA-NYS has urged New York officials to provide regulatory flexibility to help curb exposure to the coronavirus outbreak.
Specifically, the organization is calling for expanded use of telemedicine and more flexibility timeframes for completing in-home assessments, among other measures.
“[HCA-NYS] is calling on state officials to make available immediate financial aid for home care’s COVID-19 response as well as waivers of certain regulations to relieve workforce pressures while ensuring the safety of patients and the workforce alike,” Al Cardillo, the organization’s president and CEO, said in a statement.
In response to the pandemic, Gov. Cuomo has issued multiple executive orders that have suspended certain health care regulatory requirements, many applicable to home care providers. They include an extension of the deadline for providers submitting new caregivers into the home care registry and the suspension of supervision visits for personal care services, for example.
“Our industry’s need for support from policy-makers has never been greater, and the support that has already been forthcoming is indeed commendable,” Castellanos said. “We have been impressed by the willingness of our state and federal health authorities to work with us on regulatory and compliance adjustments in this crisis, and by the overall support and good will they and others in the health care field have provided.”
But while the government response is well-intentioned, there has been some confusion about which rules actually apply to home care providers, Emina Poricanin, founder and managing attorney at Poricanin Law, told HHCN.
“Governor Cuomo has exercised his executive authority,” Poricanin said. “For example, one of the orders is to reduce the staffing of all private sector businesses by 75%. That does not apply to health care personnel, but it’s not clear if it will apply to office employees, the case managers or the case coordinators working with health care personnel. That’s one area of ambiguity.”
Almost all of VNSNY’s office-based workforce has been working remotely since this earlier this week.
“This has obviously posed a major logistical challenge, which has included supplying staff with secure equipment and developing coordinated workflows for departments working remotely,” Castellanos said. “Another key element in managing health and safety of our workforce has involved establishing and communicating workplace policies to accommodate staff members who might be either diagnosed with the virus or required to self-quarantine due to potential exposure.”
Additionally, home care providers are struggling with the lack of a suspension of training and orientation requirements for new caregivers, according to Poricanin.
“Providers are wondering, ‘How are we going to bring people in and provide training when we are being told to reduce staffing?’”she said.
Despite the ability to help providers stay afloat, numerous regulatory changes can be daunting.
“I think a lot of providers are feeling overwhelmed,” Poricanin said. “They are being hit from many different angles. The government is well-intentioned, but they’re getting hit by a lot of [regulatory updates] at the same time.”
Additional reporting by Robert Holly