AccentCare CMO: Home Health, Hospice Turning into the ‘Forgotten Front Line’

Home health and hospice workers have played a critical role on the front lines of the COVID-19 pandemic.

But despite being included in many states’ top-priority groups, they’re now being all-too-often overlooked when it comes to vaccine access, AccentCare Chief Medical Officer Dr. Anna Loengard told Home Health Care News.

Initially, a large portion of in-home care providers felt confident that their clinicians and caregivers would receive vaccinations along with hospital workers and skilled nursing facility (SNF) staff. As state and local governments continue their distribution efforts, however, it has become clear that there’s no well-defined system for vaccinating the often “invisible” professionals who care for America’s seniors and other vulnerable populations within the home.


Even Dallas-based AccentCare — one of the largest home health organizations in the country — has faced an uphill battle. As of mid-February, just 20% or so of its workforce had received at least a first dose of a COVID-19 vaccine, Loengard said.

AccentCare’s team includes about 30,000 professionals who deliver care to more than 145,000 patients and clients annually across 17 states. The Advent International-backed provider merged with Seasons Hospice & Palliative Care in December.

Home Health Care News recently caught up with Loengard to learn all about AccentCare’s vaccination experience. Highlights from that conversation are below, edited for length and clarity.


HHCN: You joined AccentCare in August. Because this is the first time we’re connecting, can you briefly start by telling me a little bit about yourself and the road that got you to AccentCare?

Loengard: Absolutely. I’m an internist and geriatrician, a hospice and palliative medicine physician, by training. I started my career in academia at the Department of Geriatrics at Mount Sinai in New York City. I primarily focused on home-based primary care and in-patient palliative care.

After that, I spent about eight years in Hawaii, first as a hospice medical director with St. Francis, then as their chief medical officer for what was a post-acute system. I spent the last three years of my time in Hawaii doing population health work. I was the chief medical officer at the largest clinically integrated physician network within The Queen’s Medical Center. After that, back on the mainland, I was the chief medical officer with Caravan Health, which is a company that supports about 250 hospitals and their physicians in the Medicare Shared Savings Program (MSSP).

I’ve come back to my roots in health care by coming to AccentCare. I’m very excited by the company’s vision. AccentCare is ahead of the curve, thinking about how we can provide a continuum of care that really serves patients and their families. The health care system is difficult to navigate for most people, particularly when they have chronic and serious illnesses.

We’re going to focus on vaccine progress within home health care today. Overall, what are you seeing and hearing in terms of your staff’s access to the vaccine? Good in some states? Poor in others? Kind of spotty everywhere?

I would say it’s spotty everywhere. Some states have done this better than others. We have had to do this on a state-by-state basis, almost even on a locality-by-locality basis. In a sense, our scale is a disadvantage. AccentCare is so large that we don’t have an opportunity to, say, partner with a Walgreens or a CVS. It can be difficult to ensure that our workers are being prioritized, even though they were in the top tier in every single state’s plan.

This undertaking, it’s made so much more complicated by the fact we’re essentially starting over in every state. We’ve had to frequently rely upon our joint venture partners in some places. Some of our joint venture partners — UCSD in California, Fairview in Minnesota, Stewart in Massachusetts and others — have really stepped up. Some of them immediately, as part of their initial plans, said, “We will vaccinate our JV workers.”

But outside of that framework, it has been much more challenging. We have had to have a whole team of people calling state health departments, calling our hospital referral partners, calling pharmacies in states like Texas, which actually did disseminate some of the initial supply of vaccine to pharmacies. So we’ve had to try finding vaccines for some of our workers at Kroger’s and elsewhere, even in the initial weeks. It has been a very grassroots effort of leaving no stone unturned. In the end, we’ve had to source new options for vaccines every day, then disseminate those options to our workers.

I would say, today, we probably have about 20% of our staff vaccinated, at least with the first dose. It’s obviously less than that when we’re talking about the second dose.

It seems like there’s almost a contradiction. The health care system is pushing more and more care into the home, but the people delivering that care are having such a difficult time getting vaccinated.

As everyone knows, this is an unprecedented operational challenge — getting everyone vaccinated. It’s an unprecedented operational challenge even getting just the front-line health care workers vaccinated.

But in hindsight, I think our staff members were the front-line health care workers who were forgotten. Most states gave their vaccines to their hospital systems. So most hospital systems have been able to vaccinate their front-line workers who are most at risk — their emergency room physicians, their ICU physicians and others. SNFs were given priority, for obvious reasons related to vulnerability and the likelihood of widespread transmission among people in congregate living.

I feel like we were kind of the ones who were left out in this process.

I think it was probably an oversight. What is a little bit disappointing is that, even though I’m trying to talk to everyone I can about how we actually right this wrong, there just doesn’t seem to be any willingness to say, “Oh, goodness. There’s a whole sector of front-line health care workers that we forgot in this process! How do we make this easier for them before we start moving on to vaccinating the community?”

Getting to community vaccination is incredibly important, but I think we need to take a moment and ask, “How do we support our home health and hospice workers — or anyone who provides front-line care in the home? How do we provide a mechanism for them to easily get signed up for vaccines in a way that we have for other front-line workers, before we start moving on to all people 65 and older?”

If we had forgotten emergency room physicians or nurses in the ICU, I think people would be righting that wrong right away. But for some reason, it’s just a different issue with us. Many people don’t understand what home health and hospice are. And certainly, protecting our staff means protecting our patients — often very, very frail patients, much like those in SNFs.

On the other side of the coin, do AccentCare’s home health and hospice workers want the vaccine, as far as you could tell?

We did a poll early on in December, before any of the vaccines came out. I would say about 50% of our clinical staff said, “Me first. Put me in the first wave.” Then the rest of them had a more wait-and-see approach. I don’t know how many — or what percentage — said, “I never want the vaccine.” As we get closer to having a vaccine available to everyone, I think that it will become clear, who’s really declining to be vaccinated.

But even since we’ve sent out our first poll, we’ve had people who have emailed and said, “I want to change my mind. I’d like to be in the first wave.” As people see tens of millions of others receive these vaccines, see how incredibly safe and effective they appear to be, people have gotten more comfortable.

I’ve personally felt that way, though I’m by no means close to getting a vaccine myself. It’s been an interesting rollout in Chicago. We’ve had a lot of Chicagoans actually gaming the system.

And that’s frustrating. Our staff, they see those things happening. They see people who are so far from front-line patient care getting vaccinated. They’re looking at us, asking, “Why aren’t you doing more?” I do very much feel like there’s a certain sense of personal responsibility to all of our front-line clinicians. And that’s why I’m speaking to anyone who will listen to me, including HHCN. This is the forgotten front line. How do we do this better?

What has been your approach at AccentCare to informing staff members who are on the fence about the vaccine?

We send out a weekly message, from myself and our chief nursing officer. That goes out to all of our staff. It’s really about highlighting the data around how safe and effective this vaccine has been. We’re working to reassure them. Part of that includes diving into how these vaccines work and what their efficacy rates have been. When you think about how fast these vaccines have been rolling out, it’s kind of extraordinary how safe they appear to be.

It’s really just arming our workers with that vital information. As we hopefully get to having a third vaccine, with Johnson & Johnson, that’s a more traditional vaccine, too. Maybe people will be more comfortable with it. It’s one dose, which has its benefits. It’ll be a while before there are enough doses for that to be felt in the marketplace, in terms of that being available.

But again, it’s about education. What we’re going to get to, at some point, will be different requirements for people who are vaccinated and people who aren’t vaccinated. There could be different requirements in terms of personal protective equipment (PPE) and masking, similar to what we do around flu vaccinations. If you don’t take a flu vaccine, you must be masked when you’re with patients.

We’ll need to establish all of these [protocols] as we continue to see what happens with this virus. And like the flu, will there be a new variant that we’ll end up having to be vaccinated against each year? It’s anyone’s guess where this is going. But as potential new waves come down, we can hopefully move faster than these variants and get a significant portion of the population vaccinated.

If we can really cut down the number of infections dramatically, then I think we move into a new era of, “How do we deal with this on a more chronic basis for all health care systems? What are the policies? What does the CDC recommend for employment and health care?”

Have you started to get questions from clients or patients about who’s coming into their home? Any concerns about patients refusing visits from unvaccinated caregivers?

It’s a great question. And we are seeing that.

We’ve actually gotten a written notice from one of the assisted living facilities where we see patients. The facility said that, as of May 1, they will require people to be vaccinated to come on their premises. And we have heard patients who are saying, “Please don’t send anyone who’s not vaccinated into my house.” That will just continue to grow.

Today, not everyone in the public knows some people have access to the vaccine. As that changes, that’s something that we will hear more and more. It’s going to be interesting how we — as the health care system, writ large — approach this.

Once a vaccine is available to the broader community, do you think AccentCare can maybe have a role in delivering vaccines to homebound seniors? I know there are a ton of logistical challenges.

It’s another good question. I’ve had some conversations with some of our partners on the topic. I have a call with a partner next week to talk about this in their home-based primary care program. There are certainly logistical challenges — making sure that the vaccine is kept at the proper temperature, for example.

There are some of the same challenges as with flu vaccination. When I used to do home-based primary care, one challenge was monitoring patients and being able to respond to any threatening allergic reaction, for instance. We have to figure out how we do that. Do we have to have our nurses have EpiPens? What would that look like? It’s possible that, if there is just such a low occurrence of [adverse effects], that becomes no longer necessary.

Or with the one-dose Johnson & Johnson vaccine, that could be a real game-changer. It doesn’t require the same freezing temperatures. It’s a little bit more stable as a vaccine. I think that could present a real opportunity to get our entire homebound population vaccinated. And yes, I do think that home health care should and can be part of that solution.

In your career, has anything come close to this Herculean task at hand?

This is so unprecedented. We just had a call internally to talk about, you know, communications to our staff and boosting awareness. I was like, “As much as I love meeting with you all, I can’t wait to get back to the normal health care conversations.” I joined AccentCare five months ago, and I think we have a really interesting and exciting future. I can’t wait to get back to the main focus being, “How do we really innovate? How do we keep moving forward? How do we expand what we can do in the home and how care is provided in the home?”

I look forward to what I came here to do. But right now, there’s a lot of work left. At first it was about getting people tested and making sure we had that in place so we knew who was infected and who wasn’t. Now, it’s about trying to get everyone vaccinated and moving this process forward. Hopefully, maybe in a few months, we can talk more about innovation and where we’re headed.

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