COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey
Summary: The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%).
In a large, geographically diverse sample of HBPC practices, we identified significant challenges faced due to COVID-19 and the rapid adaptation of processes, staffing, and workflow to accommodate these challenges irrespective of practice size. The pandemic led to more than 87% of practices reporting being under some level of strain. The majority of practices continued to see patients in the home.
The Challenges and Adaptations
Practices reported limited access to patients (self-imposed, access prevented by facilities, patients, or caregivers); workflow disruptions (work from home); adoption of new care modalities (telehealth); increased patient vulnerability (isolation, reluctance, heightened sensory issues); and emotional impact on staff (COVID-related fears, death of patients, understaffing, burden of new modalities of work). The most impactful practice challenges were technical difficulties reaching patients, managing both patient and clinician anxiety, and navigating supply chain shortages. Practices adapted quickly to the new challenges by reducing the number of in-person visits while increasing the use of telemedicine, adopting new infection control measures, and addressing the needs of both patients and staff with creative sharing of health system resources, tapping community-based services to support the nutritional and social needs of patients, and providing new training and support for staff. Findings from our study mirror many of the adaptations described by HBPC providers in New York City.9,12 The emotional toll of the pandemic on both practice staff and patients was high. Clinician anxiety was reported by more than 69% of practices, and perceptions of patient anxiety by clinicians was even higher. Home-based clinicians used to adapting to the unpredictable work environment of the home now faced new workflows, loss of staff and the pressure of patient visit prioritization amid personal concerns of getting or transmitting COVID-19. Practices observed increased social isolation, loneliness, and fear compounded by a reluctance to allow people into their homes. Sensory issues were exacerbated by the use of PPE and video communication. Clinicians reported increases in rates of decline and death at home and highlighted the additional challenges faced by patients and caregivers of those with dementia.
Despite the clear negative impact of the pandemic, many COVID-19 “silver linings” emerged. Although not a comparison between home- and office-based care, HBPC may have been better positioned than traditional office-based care to pivot and adapt to COVID-19 because of an established access-path to patients, strong pre-existing interactions with the community, and connections with community-based service providers. Some practices reported a new recognition by health system leadership of the critical role HBPC care plays in caring for vulnerable older adults and keeping them out of the ED or hospital. Indeed, recent literature advocates for a more integrated role for home-based medical care.13,14 The expansion of telemedicine may allow some HBPC clinicians to increase patient panels by reducing travel time to and between visits. Collaborations with health systems and health departments increased, fostering better access to supplies and workforce and targeted outreach to at-risk groups. Partnerships with health departments and health systems have the potential to foster ongoing benefit to patients if they result in increased access to vaccines and a natural delivery channel for vaccine distribution.15 Increased partnerships with community organizations facilitated identification of those at risk of food insecurity, caregiver burnout, and medication shortages and resulted in shared efforts to better support homebound patients. Although health system affiliation could have contributed to less agility to COVID-19 response, we did not see these differences among those who responded to the survey.