Interim HealthCare has been part of the nation’s COVID-19 response effort since the virus first reared its head at the Life Care Center in Kirkland, Washington.

An area Interim franchise location deployed its home care team to help transition both COVID-19 positive and negative patients out of the nursing home while also sending additional staff into the facility to help supplement its workforce.

Today, the Sunrise, Florida-based in-home care franchiser is caring for coronavirus patients at more than 50 of its 300 locations across the U.S. While the provider specializes in non-medical home care, it also provides home health and hospice, as well as health care staffing solutions.

The way CEO Jennifer Sheets sees it, all of those services are essential to flattening the curve and combatting COVID-19.

Home Health Care News recently connected with Sheets, who shared how Interim is handling its COVID-19 caseload, what the virus is doing to the company’s bottom line and where she thinks the tragedy could propel the home-based care space in the months and years to come.

You can read that conversation below, edited for length and clarity.

HHCN: How has Interim pivoted to combat the coronavirus, and what do some of those efforts look like?

Sheets: We’re preparing for a surge of patients coming out of the hospital, and we’re already taking care of COVID-19 patients now. Certainly, I think that’s going to increase pretty quickly as we get further down the curve of COVID-19 exposure.

I feel like I’ve become an Interim procurement officer. I’ve never spent so much time on procuring personal protective equipment (PPE) in all of my career.

[We’re doing] lots of advocacy work, trying to raise the hand and go, “Don’t forget home care. Don’t forget we’re the answer here.”

When you’re talking about freeing up capacity at a hospital or skilled nursing facility that has an outbreak, the answer there is getting these patients in the home so you can minimize exposure while providing critical care.

We’ve certainly been a lot busier than normal. COVID-19 has kind of consumed our day-to-day for about three to four weeks now.

We started training and responding to what we thought was coming our way back in November.

We had no idea how it was going to impact us and the extreme nature of it, but we’ve been preparing for a long time. I feel like that gave us an advantage and helped us be better prepared.

We’ve heard that a lot of home care businesses are trending downward right now, though some are anticipating a COVID-19 business boom soon. Can you walk me through what you’re seeing and expecting?

Home care is a solution to offload resource strength.

We did a lot to support the nursing center in Kirkland, Washington — kind of where everything started — to help them pull some patients out of that facility and provide care at home, and then also to help them with staffing.

Home care’s obligation or imperative in this crisis is to respond to the need to free up that capacity and to pull people out of an environment where they’re seeing an increased trend with positive cases.

Home care resources, we have seen, are in extremely high demand, as hospitals really are pushing to discharge patients home.

I think there is a knowledge deficit out there, still, about what home care is and what home care can do: We have patients on ventilators. We bring home four-day-old critical care babies and adults. I don’t think the general population — including, unfortunately, health systems and even some physicians — is really aware of what can be done in the home.

I can say that very honestly, because when I was a hospital CEO, I had no idea about the level of care that could be provided in the home.

[At Interim,] we are seeing some decline in home health cases, specifically therapy-led cases. That’s mainly due to cancellation of elective orthopedic surgeries like knee or hip replacements.

We’ve seen a decline in the non-clinical side of the business, mainly because there are now other family members home that are able to provide those supportive services. That one kind of surprised me.

On the increase side, we’ve seen an increase in the need for skilled home health that’s nurse-led. We’ve also seen an increase in our hospice business, and then we’ve seen a large increase in our staffing side of the business. We will send supplemental staff into a hospital system that is resource strained or into a nursing home.

Seems like it’s balancing out. Overall, would you say total business is up or down?

Across all of the services we provide, we are on pace with where we were last year. Same month, we’re up a little bit. Service-line specific, that’s when you get into some declines and increases.

It wasn’t until the end of March that the Department of Homeland Security (DHS) recognized the home care industry as “essential.” What was your reaction when you finally got that news?

That is the thing that I was shouting from the mountaintops from the beginning.

The reality is that without home care employees being deemed essential, we were seeing clinicians that were being refused access to their patients. If a town was in shelter-at-home orders or something similar, we were seeing law enforcement refusing to let nurses get to the patients who needed their care.

That’s dangerous, right? So we spent a lot of time working with each state governor’s office or department of health to get those folks deemed essential. Then we did a lot of lobbying in Washington, specifically with DHS.

We need people working on the front lines. We want to support our employees, and especially those that are impacted by COVID-19, but the reality in the space is, clinicians know what they signed up for. When it comes to emergency situations like this, this is why we’re here. This is why we got into health care, especially from the clinical perspective.

Another thing a lot of folks were excited about is that the Department of Labor (DOL) said it would exempt the home health industry from the new COVID-19 paid sick leave rules. That only applies to agencies of a certain size, but I’m curious to hear any of your reactions on that.

It’s the same answer.

A large population of our home care clients have no other support. They don’t have anybody else providing for their needs or ensuring they are in a safe environment.

Most of our non-skilled clients are probably [at least] 75 to 80, and those are the high-risk folks.

I’m not privy to all of the thoughts and considerations that went into some of the regulations, but I will say that there should be more of an incentive to work, especially in this time of crisis.

On the [non-medical] home care side, … we already are struggling with low-pay issues. We’re in direct competition and have the same labor pool as fast food restaurants or retail, which is far less stressful, less demanding and, now, certainly less dangerous.

I would love to see something like government-supplemented hazard pay for health care workers dealing with COVID-19. We need to incentivize people to be on the front line, especially in a pool that’s already prone to high turnover.

That gets into these new coronavirus unemployment benefits, which the federal government rolled with good intentions to supplement state payments. But it seems like the lawmakers could also be doing more to incentivize or reward people to work so that people aren’t thinking, “I could make more collecting unemployment.”

We’ve seen that in pockets, where people have requested that we lay them off.

There’s really not a rhyme or reason to where we’re seeing it, but we are seeing it pop up. At this point, I’ve seen about 10 of our locations that have brought that issue forward.

Again, I’m not privy to all the considerations that went into the regulation, but you just scratch your head going, “In a way, this has backfired.”

I know the intention [is good.] But it’s almost like we’re incentivizing people not to work now, which is exactly the opposite of what we need in health care. All of us across any health care setting are struggling with having enough supply of caregivers to meet the demand that we have.

I was unaware Interim helped with the outbreak at Life Care Center in Kirkland, Washington. Can you tell us a little bit more of that backstory?

We partnered with Kirkland Nursing Center [and talked] about our staff, the precautions that we were going to put in place, the education that we could provide around proper use of PPE and how to minimize exposure.

Those patients that were positive that they didn’t want to let back into the nursing center: Were they candidates for home care? How can we transition them home? [We shared] ideas around cohorting positive patients versus negative patients.

It was a challenge right out of the gate because we were in the facility, off and on, right from the get go.

When they started getting positive cases, we had a lot of staff, including our leader, that had to be self-quarantined for 14 days. Our focus was on making sure we weren’t contributing to the exposure or the spread, and instead were only responding as part of the solution.

When it comes to caring for positive patients, what does that look like logistically? I’m curious about everything from where those referrals are coming to precautions your team is taking.

Our most critical focus is keeping front-line workers safe.

We educate first as a baseline. Then every time there’s an update to a CDC recommendation, or state or health department recommendations, we’re giving real-time education there.

We’ve implemented screening tools so nurses can screen not only their patients but themselves for signs and symptoms.

We have put a lot of resources into securing PPE. The challenge to find PPE, especially in a home care setting, is not one to be taken lightly.

We have leveraged our global footprint to find additional vendors. We’ve already deployed more than 200,000 N95 masks. Same thing with gowns, gloves and sanitizer. As soon as we find something, we’re pushing it out to locations that need it.

We’re also being really creative to think about preparing for a surge. The reality is we may run out of PPE. Then what?

Is there another barrier that we can use that meets the needs of a plastic isolation gown? Can you use disposable raincoats? We’ve already ordered a stockpile of those.

The other thing we did is rolled out specific training for clinicians about best practices to keep their families safe. We actually found that it was very, very well received because that’s the main concern that these folks had.

We’ve also revised caregiver schedules so that if they have a combination of COVID-19 positive versus negative patients, they will see all of their COVID-19 positive patients at the end of their shift. In locations where we have a big enough COVID-19 population, we have one set of clinicians that all they’re doing is COVID-19 work.

Where are those COVID-19 patients mostly coming from?

We have probably 50 locations currently providing care for COVID-19.

Mainly, we’re seeing them come from hospitals. We’re also seeing them come from nursing homes.

When a patient is sent out from a nursing home and they test positive, the nursing homes are refusing to allow the patient to return to the nursing home in some cases. So in those scenarios, we’ve seen referrals directly from either the nursing home or the physician.

To wrap things up, what trends and impacts do you expect COVID-19 to have on the home-based care space both short- and long-term?

The trend that I expect is an increased demand for our services. As we watch the curve start to shift, those people being cared for in the hospital are going to need to transition home.

It’s going to create challenges with the workforce and also with the allocation of personal protective equipment, but I’m hoping that we will see some continued work on regulations that need to be temporarily amended for this crisis.

For example, telehealth [reimbursement in home health]. CMS has not changed the requirement for an in-person visit.

In the short term, I think home care agencies are going to struggle with the increased cost of PPE and the things that we don’t get reimbursed for. We’re going to struggle with the lack of the ability to use telehealth for skilled visits, the decline in therapy-led cases in home health and non-skilled cases for personal support.

In-home care is critical for those at highest risk of coronavirus. It’s the place that minimizes exposure of transmission more than any other setting.

My hope is that, through all of this in the long term, there is a real awareness of the role of home care providers in the continuum of care.

Once we get to that point, if the folks that are designing regulation or incentivizing accountable care organizations (ACOs) or bundled payments are truly thinking of the whole continuum, we really could have an impact in health care delivery across our country.