As COVID-19 spreads from country to country, clinicians unfortunate enough to call themselves experienced with the virus are trying to advise their peers all across the globe.
When Dr. Maurizio Cereda — a professor at the University of Pennsylvania’s hospital — recently listened to the concerns of his counterparts in Italy, he came away with two major conclusions.
The first: it is essential that patients are cared for in the home for both prevention and treatment of the coronavirus. The second: this initial surge likely will not be the last time the U.S. health care system battles COVID-19s.
“[The coronavirus] is not going to go away. This surge of patients will fade and then come back [repeatedly],” Cereda told Home Health Care News. “We have to be proactive in managing and preventing infection, but also be proactive in having a meaningful plan to keep patients away to protect the institutions, the hospitals.”
Cereda is among multiple authors of a recent article in The New England Journal of Medicine that examined the reflections of exhausted clinicians in Italy, which is on a COVID-19 timeline just a few weeks ahead of the U.S. In their article, the authors tried to turn those reflections into lessons for dealing with what lies ahead.
If home health and home care agencies believe it’s too late to vie for a larger role in contributing to the solution, or too late to implement useful protocols and practices to manage COVID-19 patients, they’re dead wrong, Cereda said.
“It’s not just a matter of building ventilators. Who’s going to assess these people? How many nurses do we have who can deal with these patients?” Cereda said. “That’s not what it is about. It’s about managing patients on the spot as much as possible, trying to keep them away from the hospital as much as you can. And then you’ll end up with a more manageable number of patients.”
Waiting for patients to get to the hospital or relying on hospitals to manage the crisis on their own is bound to fail, he added.
“The lesson I’ve learned from my Italian colleagues is the idea that waiting for the patients to come to the hospital is a mistake, because it’s already too late.” Cereda said. “The moment you start wondering how many people you can place on mechanical ventilation, you’ve already failed on the public-health aspect of this. And what I found to be an extremely attractive approach … is the idea of keeping patients at home. Keep the virus at home as much as you can.”
In other words, in-home prevention of hospital stays for those with or without COVID-19 should be prioritized.
What’s also worth considering is how much more care can be provided in the home.
Less severe cases of coronavirus can be treated at home with basic care, but tools used in the hospital to combat the effects of the coronavirus can be administered there as well.
“We need to try to manage patients who don’t need to be in the hospital by keeping them in their home and providing them what they need, like food,” Cereda said. “Even if they get sicker, first try to monitor them using telemedicine and video conferencing. … [Then], you can even provide them with oxygen concentrators and home oxygen therapy if they get [worse].”
Italian clinicians were clear in their message that only severely sick patients need to be treated in the hospital. If the rest of patients are treated elsewhere, however, home-based care models need to be invested in so that home health and home care agencies have the ability to manage them.
“There’s a lot of patients who have mild to moderate symptoms that could be managed at home,” Cereda said. “That’s the key message.”
In-home care organizations have focused on lobbying for more freedom from the Centers for Medicare & Medicaid Services (CMS) in terms of telehealth. CMS has responded by allowing more leeway for remote monitoring and visits, but has told providers that it is “prohibited by statute” when it comes to paying the same for remote visits as in-person ones.
But the homebound requirement, which is a prerequisite for a patient to receive care in the home, has been broadened to include COVID-19 patients or those with conditions that would make them especially vulnerable to the effects of the virus.
If Cereda’s point is correct — that the coronavirus will threaten the U.S. health system for an extended period of time — agencies need to continue pressing CMS for more relevant liberties and readying their own staff to take on the virus.
“The ability to deploy large amounts of prepared, trained home care workers is key,” Cereda said.