The first wave of COVID-19 victims are the individuals directly impacted by the virus, the ones who contribute to the mounting death toll listed on news tickers every day. The second wave of victims, though, has yet to receive much air time.
And it’s this second wave that has some home health industry insiders concerned about the future.
When elective surgeries were paused throughout the U.S. in mid-March, the intent was clear: saving hospital capacity and resources for the influx of COVID-19 patients to come. Yet what wasn’t clear was the unintended consequences that would surface because of that “all-in on COVID-19” strategy.
Those unintended consequences, which are becoming more evident by the day, are twofold.
On one hand, patients are not getting surgeries that have been characterized as “elective,” but are actually anything but. On the other, people are afraid to go to the hospital or receive treatment due to concerns over contracting the virus or becoming an unnecessary burden on the system.
That fallout is creating an ugly scenario for some home-based care providers: a significant dip in visit volume in the short term — and a more acute population to care for in the long term.
“[That fallout] is something we should all be very concerned about,” William A. Dombi, the president of the National Association of Home Care & Hospice (NAHC), told Home Health Care News.
As concerns mounted over whether health systems would be overwhelmed by COVID-19 patients, elective surgeries and a slew of other health care services took a backseat.
“I think the problem arose because people used too broad of a one-size-fits-all approach,” Sharmila Dissanaike, the chair of surgery at Texas Tech University Health Sciences Center, told HHCN. “If you anticipate a COVID-19 surge, then trying to get some time-sensitive surgery done early … is a better approach than delaying it indefinitely. Not all elective operations are equal, nor are they all truly elective.”
Examples of time-sensitive surgeries include cancer operations, Dissanaike said, noting that a more proactive approach would also prevent any “crunch” to personal protective equipment (PPE) supplies.
Instead of blanket strategies and guidance from federal health care policymakers, the elective surgeries should have been — and should be — handled differently based on unique circumstances in any given market.
“[You need to] come up with a solution that does the right thing for all your patients as much as you can,” Dissanaike said. “Because otherwise, you create second victims, [people] who are the non-COVID-19 patients who did not get the right care because we were all purely focused on COVID-19. You want to avoid that as much as possible.”
Often, government officials and health system leaders making these tough decisions prefer a black-or-white approach. Operating in the gray could mean life or death for patients experiencing side effects due to a service being delayed, however.
“I think people are going to recognize that much of this stuff that has been postponed or labeled as ‘elective’ is still extraordinarily important,” Dombi said.
From a home health perspective, the phrase “elective procedure” typically translates into hip and knee surgeries. But the postponement of elective procedures and other services has far broader ramifications.
Home health agencies often deal with wound care patients, for instance. In-home wound care isn’t an elective surgery or something that’s always an essential service, but it usually helps prevent patients’ conditions from worsening.
“If we don’t find places and ways to deliver that care that keeps the patient out of the hospital, the very worst of all worlds is for a patient — who could have been cared for with home health — to have to go to the ER,” Dissanaike said. “Now that patient is exposed to much higher risk of COVID-19. And even if they don’t catch it, they may take it home to someone else. And so, we should all be trying really hard to keep patients away from the ER by treating them in the clinic or at home.”
If that proactive-type care is discontinued, patients end up with worse health outcomes and a greater chance of contracting the virus.
“I don’t think that aspect has been given full attention, and I think home health care has huge potential to help in the COVID-19 crisis,” Dissanaike added.
Less visits, less care
But home health providers still have their hands tied.
Although they have the ability to monitor patients’ health, keeping it from worsening while they receive less hands-on care, the Centers for Medicare & Medicaid Services (CMS) has granted less flexibility to home health than it has to other health care stakeholders, mainly on the telehealth front.
In the most recent round of regulatory changes, CMS enabled hospitals to provide reimbursable services in the home, but stopped short of enabling home health providers to be reimbursed for telehealth services.
“I think using home health and telemedicine to keep patients treated away from the hospital is the right thing to do,” Dissanaike said. “I don’t think there was enough focus on home health as a way to [do that].”
Using the same example as above, wound care can be managed by experienced home health agencies via telehealth.
“You’ve got telehealth that has high-resolution cameras that allow for a wound specialist to be able to observe the condition of a wound, determine whether it’s infected, determine whether it needs to breathe and whether or not a particular prescription ointment [needs to be used],” Dombi said.
Of course, home health clinicians can’t change a wound’s dressing remotely. Still, they can teach the individual or a family member how to do so, Dombi added.
The fear surrounding the coronavirus has created a downturn in in-person visits and, in turn, a spike in low-utilization payment adjustments (LUPAs).
Nearly all home health agencies have seen a dip in visits during the COVID-19 crisis. About 67% of agencies have seen LUPAs double, according to data from NAHC.
Agencies are ready for a return to more normal circumstances — and increased levels of elective surgeries and less patients refusing in-home care will theoretically be a big boost for business.
Yet managing that wave of post-surgery patients and patients who have been without care for an extended period of time could prove overwhelming.
“You have agencies being impacted by lack of staff and some of the challenges that go with [procuring] PPE,” Beth Prince, the VP of revenue management for the Corridor Group, told HHCN. “These agencies are really seeing that impact in every facet of their business.”
If demand increases to pre-COVID-19 levels, or even above that, agencies may not be able to shoulder the load.
Currently, an ongoing refusal of care has already led to startling outcomes.
In early April, New York state reported that about 200 people per day were dying of COVID-19 in their homes. Heart attack and stroke victims have been left helpless, not knowing where to go or whether to defy stay-at-home orders.
Amid a persistent U.S. opioid epidemic, patients unable to do with increasingly intense levels of pain could become addicted to certain drugs, Dombi said. Ultimately, all of that means home health providers could be dealing with an even sicker and more vulnerable population than they were used to dealing with before COVID-19.
“These are highly vulnerable individuals, most of them elderly to begin with,” Dombi said. “Those individuals who are going without care are likely to see some deterioration in their condition, which may require emergency services and hospitalization … there’s just a lot of concern here.”