Home Health Provider Feeling COVID-19 Heat: ‘We Are Not the Fire, We Are the Fire Department’

On Friday, Feb. 28, just after 10 p.m. PT, Brent Korte — chief home care officer at EvergreenHealth — got a call that changed everything. It was from his boss.

“She asked me if I was sitting down,” Korte said. “She told me that EvergreenHealth not only had patients who had tested positive for COVID-19, … but that a patient passed away in our hospital. This was the first death from COVID-19 in the United States.”

Based just outside of Seattle, EvergreenHealth is one of the largest home health and hospice providers in the Pacific Northwest. The not-for-profit provides about 250,000 visits per year and is affiliated with a local small hospital system.

As one might expect, the news came as a shock to Korte, who shared his organization’s story, as well as lessons learned and advice for other agencies, on a recent webinar hosted by the National Association for Home Care & Hospice (NAHC).

“We know there’s [about] 12,000 home health providers, 4,000-plus hospices and 6,000 hospitals in the United States, and for us to have that first patient and that first death was something we certainly weren’t expecting,” he said.

In the days that followed, Korte and his colleagues mobilized in the best way they knew how. Keep in mind, this was well before COVID-19 was on most people’s radar — and a full two weeks before President Donald Trump declared a national emergency over the outbreak.

As such, EvergreenHealth employees spent the first weekend after the news broke working alongside the Centers for Disease Control and Prevention (CDC) simply trying to understand what the disease was, how it was transmitted and where to go from there.

“[Our] home care [operation] propped up our incident command early Monday morning, and our first goal was to identify patients and employees who would possibly have contracted the infection,” Korte, who is also a NAHC board member, said. “CDC was still on site [at the hospital,] and we were immediately drafting protocols based on our hospital’s response and trying to figure out exactly what the role of home health and hospice would be.”

While those protocols continue to evolve based on best scientific practices recommended by the CDC, changing weekly or sometimes even daily, one thing that remains steadfast is the important role home-based care has to play in solving the COVID-19 crisis.

From Korte’s view, the industry’s mission — to care for people at home, keeping them out of higher levels of care — is more important now than ever.

“Hospitals are overwhelmed,” he said. “We need to be out there to keep people home and to probably take care of folks that are sicker than we’ve ever taken care of. … We are not the fire. We are the fire department.”

Staff first

No fire department can extinguish flames without its firemen. The same holds true for home-based care providers trying to combat COVID-19; Workforce is essential.

As such, EvergreenHealth has put staff at the heart of its COVID-19 planning.

“Without our people, we can’t provide care,” Korte said. “Evergreen has been focusing on the safety of our staff. If staff are healthy and engaged and able to go out into the field, then we can take care of the community.”

That starts with communication. In the beginning, Evergreen was sending its approximately 600 home-based care workers daily email updates with new protocols and relevant news. More recently, it has cut down the frequency of those emails to every other day.

Evergreen also does a weekly call with all 600 staff members, who are able to submit questions and comments ahead of time. One employee recommendation even led to a new communication practice made possible with resources already on hand.

“We’ve heard from individual employees periodically about how they’re feeling, but there’s a lot of people out there we hadn’t heard from, and we were starting to worry,” Molly McDonald, quality and regulatory manager at Evergreen, said on the webinar.

To fix that, the hospital manager at Evergreen came up with a plan: enlist the help of the organization’s volunteer coordinators, bereavement coordinators and chaplains.

“We assigned them basically our telephone list, and they checked in one-on-one with all of our staff,” McDonald said. “We’ve had some positive feedback with that, and [it’s] kind of helped our leaders extend the reach and continue to meet people individually.”

Conserving PPE

While firemen are essential to the fire fighting process, proper equipment — such as water hoses and flame-proof suits — is also important. For home-based care workers, that means masks, gloves and other personal protective equipment (PPE) that reduces the risk of COVID-19 transmission.

Health care providers nationwide are grappling with PPE shortages. That includes Evergreen, which has spent the past month grappling with PPE-related “ethical dilemmas,” as Korte called them.

“Too much PPE is just as dangerous as too little PPE,” Korte said. “I could not emphasize that enough.”

That holds true for home health workers, as well as the broader health care industry. For example, if Evergreen were to secure a large PPE supply or deck workers out with more precautionary supplies than recommended by the CDC, that would mean putting health care workers elsewhere in the country at risk in light of such drastic PPE shortages.

“It’s not helpful if you have scores and scores of masks, and your hospital across the street has no masks whatsoever,” Korte said. “That will hurt public health.”

Instead, Korte recommends PPE conservation based around science. That means making tough choices and being prepared to defend them, while also communicating to staff that overprotecting now may mean no protection later.

But providers should also keep in mind that, as things change, so should their protocols.

“We started with N95 mask respirators for positive patients, and then we moved to droplet precautions, which are goggles, gloves, surgical masks and gowns,” Korte said. “Then we laid off the gowns for some patients; then we went to no masks for all visits; then to limiting visits; and then we chose to start limiting visits to [those] that are only clinically, essentially necessary in person.”

Those changes all happened over the course of 26 days. At the time of the webinar, Evergreen’s protocol was back to mandating surgical masks and droplet precautions for all patients because “infection rates have increased, and we’re trying to make sure that we’re not the vector,” Korte said.

While Korte still believes it’s essential for certain home-based care visits to be done in-person, he’s hoping the federal government relaxes some rules around telehealth for the sake of patients, clinicians and public health.

“We feel that telephone and virtual visits need to be covered and counted as in-person visits as much as possible,” he said. “From Evergreen’s perspective, you have to consider that the more in-person visits that hospice or home health are … regulatorily forced to do in order to be paid, the more we may be providing an infection vector which is unnecessary.”