In spring, the U.S. recording more than 100,000 new COVID-19 infections per day seemed impossible. Yet surges in nearly every state pushed Wednesday’s daily total to more than 107,000 new infections — a global record.
Armed with months of experience, in-home care providers are now preparing for another round of coronavirus-induced disruption in the form of sudden volume swings, shifting referral sources and personal protective equipment (PPE) shortages.
Many providers have reached a point of operational stability or calm, but they know each day of record-breaking numbers brings them one step closer to a very difficult winter.
“We are certainly seeing an uptick in COVID-19 cases in the geographic areas VNA Health Group serves,” the nonprofit home-based care organization’s president and CEO, Dr. Steven Landers, previously told Home Health Care News.
There’s one segment of the broader in-home care space that’s paying particularly close attention to the worsening public health emergency: home-based palliative and end-of-life care providers.
In normal circumstances, home-based palliative and end-of-life care providers already have their work cut out for them, as their homebound patients are often sicker, frailer and more complex. Individuals with such traits are generally more susceptible to the COVID-19 virus, making them even more vulnerable during the ongoing pandemic.
That’s something the clinicians and leadership at Calvary@Home learned firsthand.
“This was the most unsettling, the most dramatic thing that I think I’ve ever seen in my career,” Nancy D’Agostino, vice president of community patient services at Calvary Hospital, told Home Health Care News. “And many other people would agree with me on that, particularly here in New York.”
Based in the Bronx, New York’s Calvary Hospital is the nation’s only acute care facility solely devoted to caring for individuals nearing the end of their lives. On top of its 200-bed Bronx facility and a 45-bed facility in Brooklyn, Calvary runs a home health and hospice division that’s branded as Calvary@Home.
Between its in-patient, home health and hospice operations, the organization cares for more than 4,000 patients per year, according to D’Agostino, a nurse by training who has led the home-based care program for nearly two decades.
Calvary@Home was originally launched years ago to serve as a bridge between the different settings.
“There were a number of patients who were starting to get discharged, despite the fact that it was thought they would pass away once they were admitted to Calvary,” D’Agostino said. “But they did become stabilized, so they were able to go home. Then, at some point in the future, perhaps their illness advances, so they’ll make the transition to the hospice program.”
While there are dozens of COVID-19 hotspots now, there was once a point in time this spring when New York stood as the main battleground. Once the virus hit the city, Cavalry@Home became “inundated with COVID-19 cases” within two weeks.
Overall, the program was running a census of about 350 patients at home, D’Agostino noted. It’s first cases appeared within that existing population.
“They weren’t new admissions. They were patients who were already living at home, who contracted the illness from people who had come into their homes,” she said. “We went from perhaps one or two patients, then we quickly went up to where we were caring for 60 to 70 patients on a daily basis.”
Across the entire Cavalry organization, there were 300 COVID-19 patients admitted in April alone. Due to the acute and complex needs of those individuals, roughly 200 of them died.
Calvary@Home’s hospice team — RNs, doctors, social workers, pastoral care staff, volunteers and others — was among the first in the region to admit patients with the coronavirus.
The mission of the program is to provide end-of-life care to patients with life-limiting illnesses whose care has transitioned from active curative, to palliative and quality-of-life focused
“It was difficult at first because the testing was not available very early on,” D’Agostino said. “So our patients at home, we just assumed that they had [the virus] largely based on clinical symptoms. These were patients who had no history of any kind of respiratory illnesses, who all of a sudden started with profound respiratory issues.”
Protecting staff with PPE and leveraging telehealth when needed were two of Cavalry@Home’s keys to withstanding the initial wave. Those remain important keys, as do ongoing training and education efforts.
Emotional support for staff has also been paramount, especially as social workers and clinicians are asked to carry out new responsibilities as needed. In at least one instance, for example, a Cavalry@Home social worker had to spend six hours calling 30 different funeral homes to find one willing to take a COVID-19 patient who passed away.
“We just jumped right in, but we made sure that our staff had the PPE that they needed, plus the education, training and other support as well,” D’Agostino said.
Because there isn’t a formal community-based palliative care benefit under Medicare, there aren’t a ton of home-based care providers similar to Cavalry@Home.
That’s rapidly changing, however, partly thanks to the multiple studies highlighting community-based palliative care’s ability to drastically reduce total health care costs.
Since March and April, Cavalry@Home has returned to some sense of normalcy.
But it and operations like it will need to remain vigilant and prepared during the remainder of 2020.