"At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19

Strategies to strengthen the resilience of primary health care in the COVID-19 pandemic: a scoping review

BACKGROUND

Primary Health Care (PHC) systems are pivotal in delivering essential health services during crises, as demonstrated during the COVID-19 pandemic. With varied global strategies to reinforce PHC systems, this scoping review consolidates these efforts, identifying and categorizing key resilience-building strategies.

METHODS

Adopting Arksey and O'Malley's scoping review framework, this study synthesized literature across five databases and Google Scholar, encompassing studies up to December 31st, 2022. We focused on English and Persian studies that addressed interventions to strengthen PHC amidst COVID-19. Data were analyzed through thematic framework analysis employing MAXQDA 10 software.

RESULTS

Our review encapsulated 167 studies from 48 countries, revealing 194 interventions to strengthen PHC resilience, categorized into governance and leadership, financing, workforce, infrastructures, information systems, and service delivery. Notable strategies included telemedicine, workforce training, psychological support, and enhanced health information systems. The diversity of the interventions reflects a robust global response, emphasizing the adaptability of strategies across different health systems.

CONCLUSIONS

The study underscored the need for well-resourced, managed, and adaptable PHC systems, capable of maintaining continuity in health services during emergencies. The identified interventions suggested a roadmap for integrating resilience into PHC, essential for global health security. This collective knowledge offered a strategic framework to enhance PHC systems' readiness for future health challenges, contributing to the overall sustainability and effectiveness of global health systems.

Characteristics Associated With Homebound Vaccination Against COVID-19

OBJECTIVES

Homebound patients are older and suffer from multiple comorbidities, and many experienced difficulties getting vaccinated because of their inability to routinely leave the home due to health and function. Home-based primary care (HBPC) programs offer vaccination at home to reach this high-risk population. We evaluated an urban HBPC program's COVID-19 vaccination campaign to explore whether home-based vaccination can reduce inequity in vaccine administration or improve vaccine efforts.

DESIGN

We conducted a cross-sectional study to examine characteristics of homebound patients who were vaccinated through an HBPC program or were vaccinated elsewhere.

SETTING AND PARTICIPANTS

We analyzed 795 patients enrolled in the HBPC program who were eligible for vaccination at home in 2021.

METHODS

We collected vaccination data from patients, demographic data from the electronic medical record, and neighborhood-level characteristics for each patient based on census tract.

RESULTS

Homebound patients vaccinated by HBPC were significantly more likely than homebound patients vaccinated outside of the program to have a history of dementia (P = .003), live in public housing (P < .001), have Medicaid (P = .005), be enrolled in HBPC for longer (P = .03), and live in neighborhoods with higher proportions of immigrants (P = .022), lower English proficiency (P = .007), lower computer usage (P = .001), and greater poverty (P < .001).

CONCLUSION AND IMPLICATIONS

Home-based vaccination campaigns may help lower-resourced patients get vaccinated by mitigating logistic barriers and using the influence of trusted patient-provider relationships established through HBPCs.

Innovations produced in Primary Health Care during the COVID-19 pandemic: an integrative literature review

Primary Health Care (PHC) proved to be an important part of the prevention, control and treatment measures against COVID-19, a situation in which it was challenged to keep up its provision of regular services as well. This article identifies the main arrangements made to provide PHC care in the context of the COVID-19 pandemic. An integrative literature review of articles found in PubMed, SciELO and LILACS databases was performed using the descriptors "Primary Health Care" and "COVID-19". Findings were analyzed considering three questions: Information and Communication Technologies (ICT), Organizations of Work Processes and Non-COVID Chronic Diseases. The use of different forms of ICT to provide PHC is highlighted regarding patients with respiratory symptoms and chronic patients. Changes in team composition, service flows, physical spaces and working hours were also introduced. Although strategies aimed at monitoring chronic patients and at remote care may have helped minimize deterioration of their health, the decrease in the number of visits performed during this period could have resulted in an increased demand for PHC in post-pandemic years.

Response and innovations of advanced practice nurses during the COVID-19 pandemic: A scoping review

AIM

Identify and map international evidence regarding innovations led by or involving advanced practice nurses in response to COVID-19.

BACKGROUND

COVID-19 necessitated unprecedented innovation in the organization and delivery of healthcare. Although advanced practice nurses have played a pivotal role during the pandemic, evidence of their contributions to innovations has not been synthesized. Evidence is needed to inform policies, practices, and research about the optimal use of advanced practice nurses.

METHODS

A scoping review was conducted and reported using the PRISMA-ScR checklist. Electronic databases were searched for peer-reviewed articles published between January 2020 and December 2021. Papers were included that focused on innovations emerging in response to COVID-19 and involved advanced practice nurses.

RESULTS

Fifty-one articles were included. Four themes were identified including telehealth, supporting and transforming care, multifaceted approaches, and provider education. Half of the articles used brief and mostly noncomparative approaches to evaluate innovations.

CONCLUSION

This is the first synthesis of international evidence examining the contributions of advanced practice nurses during the pandemic. Advanced practice nurses provided leadership for the innovation needed to rapidly respond to healthcare needs resulting from COVID-19. Innovations challenged legislative restrictions on practice, enabled implementation of telehealth and new models of care, and promoted evidence-informed and patient-centered care.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses led, designed, implemented, and evaluated innovations in response to COVID-19. They facilitated the use of telehealth, supported or transformed models of care, and enabled health providers through education, mentorship, and mental health support.

IMPLICATION FOR POLICY

Advanced practice nurses are a critical resource for innovation and health system improvement. Permanent removal of legislative and regulatory barriers to their full scope of practice is needed.

Reaching Diverse Communities During a Local Public Health COVID-19 Vaccination Response Through a Mobile Clinic Compared to Mass Vaccination Sites

During the COVID-19 vaccine rollout, local public health agencies were responsible for vaccinating a wide variety of communities. Dakota County Public Health (Dakota County, Minnesota) implemented a program that offered COVID-19 vaccines in a variety of settings, such as county public health buildings, community sites, in-home, mass vaccination clinics, and a mobile clinic unit. The purpose of this analysis is to compare the demographics of vaccinations administered at Dakota County COVID-19 vaccination clinics based on clinic site. More than half (52.5%) of vaccinations administered at mobile clinic sites were administered to Hispanic or Latino clients, while at the mass vaccination clinic site, 5.4% of vaccinations were administered to Hispanic or Latino clients. In addition, 59.6% of in-home vaccinations were administered to adults 65 years and older. Offering COVID-19 vaccination clinics in a variety of clinic settings strategically throughout the community helped increase vaccine reach to diverse communities.

A qualitative study of leaders' experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services

BACKGROUND

The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services.

METHODS

The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included.

RESULTS

Three main themes emerged from the thematic analysis: "Navigating the role of a leader during the pandemic," "The aftermath - management of COVID-19 in rural primary healthcare services", and "The benefits and drawbacks of being small and rural during the pandemic."

CONCLUSIONS

Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

Impacts of COVID-19 on Health and Healthcare for Rural Veterans in Home-Based Primary Care

This qualitative study explored the impact of COVID-19 on older rural-dwelling veterans and their caregivers enrolled in home-based primary care (HBPC) through the Birmingham VA Health Care System (BVAHCS). Phone interviews were conducted with 16 veterans and/or their caregivers and rapid qualitative analysis of interview notes was performed. Average age of veterans was 77 (range = 69-97) and 93.7% were white males. Despite a significant number of co-morbidities, 68.8% reported minimal adverse impacts of COVID-19 on overall physical and mental health. Like many healthcare teams, the inter-disciplinary VA HBPC team incorporated Telehealth during COVID-19. Telehealth utilization varied among the 16 participants, with 50% using telehealth independently, 37.5% needing assistance, and 12% lacking access. Our findings are consistent with prior research that identifies resilient characteristics as potentially protective in this high-risk older veteran population during the COVID-19 pandemic.

Use of Telehealth Resources in Primary Care and Its Association with Facing the COVID-19 Pandemic in Minas Gerais, Brazil

Introduction: Use of telehealth (TH) resources increased dramatically during the COVID-19 pandemic. This study set out to examine associations between the level of integration of TH resources and the level of Primary Health Care (PHC) structuring to deal with the COVID-19 pandemic in the State of Minas Gerais, Brazil. Methods: This work was a cross-sectional study conducted through the application of a semistructured questionnaire to a sample of 260 PHC Teams working in the state of Minas Gerais, Brazil, from September to December 2020. This study was approved by the Research Ethics Committee and logged under report number 44.294.637. Results: Two variables were created - Level of the PHC structuring to deal with the COVID-19 pandemic and Level of TH structuring. Variables were grouped into five categories (poor to excellent). Associations between variables were examined using the Tukey's test for multiple comparisons and the Spearman correlation coefficient. Variables associated with socioeconomic dimensions (human development index and Gini index) and health care were also analyzed. Levels of TH structuring in PHC ranged from poor (43%) to regular (40%) in most cases. Most PHC teams had regular (56%) or good (37%) levels of PHC structuring to deal with the pandemic. The greater the availability and use of TH resources at a given unit, the better the structure to face COVID-19 (0.45 - p < 0.001). Conclusion: PHC was structured to tackle the pandemic. However, there is a lot to be done before TH resources are effectively incorporated into PHC. Whenever incorporated, TH resources contributed to a more robust response to the COVID-19 pandemic.

Home-based primary care-mental health integration in the Veterans Health Administration: An updated evaluation of practice patterns

Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (n = 66) and MH providers (n = 136) completed the voluntary, anonymous, and confidential surveys. Descriptive and bivariate analyses of quantitative data, and thematic analyses of open-text responses, were conducted. Comparisons of survey responses were made between the 2019 surveys and those collected in 2010 from MH providers (n = 132) and program directors (n = 112), and indicated similar patterns of variability in program staffing and practices across sites, with ongoing behavioral/mental health education and training needs reported for both MH providers and teams. The perceived degree and value of mental health integration in HBPC also remained high. Survey responses suggest integration of mental health services into HBPC continues to be feasible and improves access to key services. Findings may inform the expansion of home-based mental health services for meeting the needs of an aging population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The role of primary care during the pandemic: shared experiences from providers in five European countries

BACKGROUND

The COVID-19 pandemic necessitated wide-ranging adaptations to the organisation of health systems, and primary care is no exception. This article aims to collate insights on the role of primary care during the pandemic. The gained knowledge helps to increase pandemic preparedness and resilience.

METHODS

The role of primary care during the pandemic in five European countries (Austria, Denmark, France, Hungary, Italy) was investigated using a qualitative approach, namely case study, based on document analysis and semi-structured interviews. In total, 31 interviews were conducted with primary care providers between June and August 2022. The five country case studies were subjected to an overarching analysis focusing on successful strategies as well as gaps and failures regarding pandemic management in primary care.

RESULTS

Primary care providers identified disruptions to service delivery as a major challenge emerging from the pandemic which led to a widespread adoption of telehealth. Despite the rapid increase in telehealth usage and efforts of primary care providers to organise face-to-face care delivery in a safe way, some patient groups were particularly affected by disruptions in service delivery. Moreover, primary care providers perceived a substantial propagation of misinformation about COVID-19 and vaccines among the population, which also threatened patient-physician relationships. At the same time, primary care providers faced an increased workload, had to work with insufficient personal protective equipment and were provided incongruous guidelines from public authorities. There was a consensus among primary care providers that they were mostly sidelined by public health policy in the context of pandemic management. Primary care providers tackled these problems through a diverse set of measures including home visits, implementing infection control measures, refurbishing used masks, holding internal meetings and relying on their own experiences as well as information shared by colleagues.

CONCLUSION

Primary care providers were neither well prepared nor the focus of initial policy making. However, they implemented creative solutions to the problems they faced and applying the learnings from the pandemic could help in increasing the resilience of primary care. Attributes of an integrated health system with a strong primary care component proved beneficial in addressing immediate effects of the pandemic.

"Second set of eyes:" Family caregivers and post-acute home health care during the COVID-19 pandemic

OBJECTIVES

This study aimed to explore how the COVID-19 pandemic shaped the experiences of family caregivers of older adults who were hospitalized with COVID-19 and discharged to post-acute, skilled home health care (HHC) services.

METHODS

Thirty semi-structured interviews with family caregivers of older adults who received services from a large, not-for-profit HHC agency following hospitalization with COVID-19 infection were conducted between March-July 2021 and analyzed using thematic analysis.

RESULTS

During the pandemic, family caregivers encountered societal and institutional barriers to assisting older adults across post-acute care transitions. These barriers included hospital visitation restrictions as well as difficulties accessing community-based resources and medical equipment. Despite limitations and delays in HHC services, many family caregivers identified post-acute HHC, delivered in-person or via telehealth, as important to addressing care gaps for older adults, as well as their own needs for training and support during the pandemic.

CONCLUSIONS

Policies intended to reduce the spread of COVID-19 introduced new challenges for caregivers during HHC. However, HHC agencies and their staff adapted within this context to provide a needed bridge of support.

Care Disruptions and End-Of-Life Care Experiences Among Home-Based Primary Care Patients During the COVID-19 Pandemic in New York City: A Retrospective Chart Review

Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC's multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.

Digital health interventions and quality of home-based primary care for older adults: A scoping review protocol

Introduction

The use of digital health interventions has expanded, particularly in home-based primary care (HBPC), following the increase in the older adult population and the need to respond to the higher demand of chronic conditions, weakness and loss of autonomy of this population. There was an even greater demand with COVID-19 and subsequent isolation/social distancing measures for this risk group. The objective of this study is to map and identify the uses and types of digital health interventions and their reported impacts on the quality of HBPC for older adults worldwide.

Methods and analysis

This is a scoping review protocol which will enable a rigorous, transparent and reliable synthesis of knowledge. The review will be developed from the theoretical perspective of Arksey and O'malley, with updates by Levac and Peters and respective collaborators based on the Joanna Briggs Institute manual, and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). Data from white literature will be extracted from multidisciplinary health databases such as: the Virtual Health Library, LILACS, MEDLINE/PubMed, Scopus, Web of Science, Cinahl and Embase; while Google Scholar will be used for gray literature. No date limit or language restrictions will be determined. The quantitative data will be analyzed through descriptive statistics and qualitative data through thematic analysis. The results will be submitted to stakeholder consultation for preliminary sharing of the study and will later be disseminated through publication in open access scientific journals, scientific events and academic and community journals. The full scoping review report will present the main impacts, challenges, opportunities and gaps found in publications related to the use of digital technologies in primary home care.

Discussion

The organization of this protocol will increase the methodological rigor, quality, transparency and accuracy of scoping reviews, reducing the risk of bias.

Home-Based Care Provider Perspectives on Care Refusal During the COVID-19 Pandemic

Acute and chronic disease management continues to shift toward a health care in the home model, yet literature discussing continuity of home-based care services during public health emergencies, such as infectious disease pandemics, is scant. In the current study, we used semi-structured telephone interviews with 27 home-based care providers (HBCPs) from Medicare-certified home health care agencies located in eight U.S. counties to explore older adults' decision making around home-based care service continuation during the coronavirus disease 2019 (COVID-19) pandemic. Four themes emerged, including two related to older adults' decision making around refusal of in-home care and two related to HBCPs' responses to care refusals. Fear of COVID-19 infection motivated older adults to make care-related decisions that were incongruent with their health needs, including refusal of care in the home, despite receiving education from HBCPs. These data highlight a need for tools to help HBCPs better support patients through decision-making processes about care continuation during COVID-19 and future infectious disease pandemics. [Journal of Gerontological Nursing, 49(1), 35-41.].

Care disruptions among the homebound during the COVID-19 pandemic: An analysis of the role of dementia

INTRODUCTION

Seriously ill people with dementia living at home may be particularly vulnerable to disruptions in their care during times of crisis. The study sought to describe care experiences of those receiving home-based primary care in New York City during the COVID-19 pandemic and compare the experiences of people with and without dementia.

METHODS

We conducted a retrospective review of all electronic medical record notes between March 1, 2020 and December 30, 2020 among a sample of home-based primary care recipients (n = 228), including all deaths that occurred in the spring of 2020. Drawing from administrative records and using an abstraction tool that included both structured (e.g., documented COVID-19 exposure) and unstructured (e.g., text passage describing caregiver burden) data, we identified salient COVID-19 related care experiences and identified and categorized major disruptions in care.

RESULTS

Both people with and without dementia experienced significant disruptions of paid caregiving, family caregiving, and home-based services during the COVID-19 pandemic. While the paid caregivers of people with dementia reported more burden to the home-based primary care team as compared to people without dementia, we found little evidence of differences in quantity or type of COVID-19 related disruptions relative to dementia status.

DISCUSSION

While those with dementia have distinct care needs, our findings emphasize the way that dementia may be one piece of a larger clinical picture of serious illness. In order to support all patients with high care needs in crisis, we need to understand the interdependence of clinical care, long-term care, and family caregiving support for older adults and view dementia within the larger context of serious illness and care need.

Tasks of COVID-19 prevention and control management teams at primary health care facilities in mainland China: a nationwide online cross-sectional survey

Background

This research aimed to investigate the tasks performed by Coronavirus Disease 2019(COVID-19) prevention and control management teams at primary healthcare (PHC) facilities during COVID-19 pandemic across the mainland China.

Methods

An online survey was performed and COVID-19 prevention and control management teams at PHC facilities were invited to participate in this research. The top 7 most important tasks in the three different periods of COVID-19 containment were selected and ranked. Participations of tasks were surveyed.

Results

A total of 998 valid responses (an effective rate of 99.11%) were collected. The respondents were divided into Group A (≤5 respondents within each PHC facility, n₁ = 718) and Group B (> 5 respondents within each PHC facility, n₂ = 280). The consensus was selected from top 7 most important tasks including screening at travel centers/intervals and screening at entry centers, at-home/centralized quarantine management, transferring, pre-examination/triage and fever sentinel surveillance clinic/fever clinic. Pre-examination/triage and fever sentinel surveillance clinic/fever clinic works became more significant in the regular prevention and control period. Adjusted analysis found that team members of Group A with a college, undergraduate college and graduate school educational background were less involved in pre-examination/triage works (aOR: 0.28; 95%CI: 0.09-0.86, P = 0.026; aOR: 0.30; 95%CI: 0.10-0.90, P = 0.031; aOR: 0.21; 95%CI: 0.05-0.82, P = 0.024). Those who were over the median age were twice more likely to be engaged in managing fever sentinel surveillance of clinic/fever clinic visitors (aOR: 2.18; 95%CI: 1.16-4.08, P = 0.015). Those being specialized in nursing and other specialties were less likely to participate in fever sentinel surveillance of clinic/fever clinic works (aOR: 0.44; 95%CI: 0.24-0.81, P = 0.009; aOR: 0.30; 95%CI: 0.16-0.58, P < 0.001). Those came from central and western China were less likely to participate in centralized quarantine management (aOR: 0.61; 95%CI: 0.38-0.98, P = 0.042; aOR: 0.64; 95%CI: 0.42-0.97, P = 0.037). Team members came from central and western China were twice less likely to participate in screening at travel centers/intervals (aOR: 1.75; 95%CI: 1.14-2.70, P = 0.011; aOR: 1.63; 95%CI: 1.07-2.48, P = 0.024).

Conclusion

In mainland China, team members of COVID-19 prevention and control at PHC facilities are mainly responsible for screening, quarantine, transferring and monitoring during the COVID-19 pandemic. Pre-examination/triage and the fever sentinel surveillance clinic/fever clinic were gradually valued. Team members with lower educational background are competent in pre-examination/triage works, but more experienced general practitioners are more likely to be in charge of fever sentinel surveillance clinic/fever clinics work. The necessity of COVID-19 prevention and control management teams to participate in screening at travel centers/intervals is subjected to further discussions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01703-0.

The experience of primary care teams during the early phase of COVID-19: A qualitative study of primary care practice leaders in Ontario, Canada

BACKGROUND

The COVID-19 pandemic has caused a rapid shift to virtual care in primary care practices around the globe. There has been little focus on the experiences of interprofessional teams through the lens of primary care practice leaders. The objective of this study was to examine the experience of primary care teams during the first wave of the COVID-19 pandemic from the perspective of primary care leadership.

METHODS

Qualitative study using qualitative description methods. Executive Directors of interprofessional primary care teams belonging to the Association of Family Health Teams of Ontario (AFHTO) were invited to participate. Executive Directors were interviewed and the interview transcripts were analyzed using thematic analysis.

RESULTS

Seventy-one Executive Directors from across all regions of Ontario were interviewed for the study, representing 37% of the AFHTO member clinics. Four themes were identified in the data: i) Complexities of Virtual Care, ii) Continuation of In-person Care, iii) Supporting Patients at Risk, and iv) Stepping up and into New Roles.

CONCLUSIONS

Primary care teams rapidly mobilized to deliver the majority of their care virtually, while continuing to provide in-person and home care as required. Major challenges to virtual care included technological infrastructure and unfamiliarity with virtual platforms. Advantages to virtual care included convenience and time savings. Virtual care will likely continue to be an important mode of primary care delivery moving forward.

Providing community services for persons with disabilities during the COVID-19 pandemic: A scoping review

Community organisations and municipalities support people with disabilities by providing resources and services that are essential for their engagement in the community. Their services were particularly impacted by restrictions related to the COVID-19 pandemic. The aim of the study is to identify scientific literature that examines how community organisations and municipalities adapted services and resources provided to people with disabilities as a result of the COVID-19 pandemic. A scoping review was conducted by searching the databases Medline, Embase, CINAHL, PsycINFO and Web of Science Core Collection in January 2021. Fifteen studies were included from the initial search strategy of 7651 individual studies. Most of the studies were quantitative studies (73.3%; n = 11) and aimed at describing the adaptations put in place during the COVID-19 pandemic (66.7%; n = 10). Most services and resources involved some form of preventive healthcare (66.7%; n = 10). The adaptation of modalities for delivering resources and services varied widely across organisations (e.g. online or a combination of online and in-person) but mostly led to an improvement of the studied outcome (e.g. social skills, quality of life). Barriers (e.g. need for a reliable internet connection, lack of technology literacy from the member) and facilitators (e.g. flexibility and planning from the organisations) for these adaptations have been identified, but there is little information surrounding their cost. The results highlight that the delivery of online services has increased since the inception of the COVID-19 pandemic with valuable outcomes. However, further research is needed to better identify the barriers, facilitators and outcomes of remote services to better face future large-scale disasters like the COVID-19 pandemic and to better support individuals who cannot reach in-person services.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services. Thirty participants were recruited via posters placed throughout the building and semi-structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma-free care. Close proximity and convenience of drop-in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre-existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low-barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.

Community healthcare workers' experiences during and after COVID-19 lockdown: A qualitative study from Aotearoa New Zealand

Shortly after the COVID-19 pandemic reached Aotearoa New Zealand, stringent lockdown measures lasting 7 weeks were introduced to manage community spread of the virus. This paper reports the findings of a qualitative study examining how lockdown measures impacted upon the lives of nurses, midwives and personal care assistants caring for community-based patients during this time. The study involved nationwide surveys and in-depth interviews with 15 registered nurses employed in community settings, two community midwives and five personal care assistants. During the lockdown, nurses, midwives and personal care assistants working in the community showed considerable courage in answering their 'call to duty' by taking on heightened care responsibilities and going 'the extra mile' to help others. They faced significant risks to personal and professional relationships when they were required to take on additional and complex responsibilities for community-based patients. Despite the hypervigilant monitoring of their personal protective equipment (PPE), the need to safeguard family and community members generated considerable stress and anxiety. Many also faced personal isolation and loneliness as a result of lockdown restrictions. Moreover, the negative impacts of experiences during lockdown often continued to be felt once restrictions had been lifted, inflecting life during periods in which community transmission of COVID-19 was not occurring. This article makes five core service delivery and policy recommendations for supporting community-based nurses, midwives and personal care assistants in respiratory disease pandemics: acknowledging the crucial role played by community-based carers and the associated stress and anxiety they endured by championing respect and compassion; demystifying the 'heroism' or 'self-sacrifice' projected onto care workers; the timely provision of adequate protective equipment; improving remuneration, with adequate provision for time off; and regular counselling, peer support groups and education on work-life balance delivered by support workers in recognition of stressors arising from these complex and isolated working conditions.

Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature

BACKGROUND

The COVID-19 pandemic has resulted in the diversion of health resources away from routine primary care delivery. This disruption of health services has necessitated new approaches to providing care to ensure continuity.

OBJECTIVES

To summarize changes to the provision of routine primary care services during the pandemic.

METHODS

Rapid literature review using PubMed/MEDLINE, SCOPUS, and Cochrane. Eligible studies were based in primary care and described practice-level changes in the provision of routine care in response to COVID-19. Relevant data addressing changes to routine primary care delivery, impact on primary care functions and challenges experienced in adjusting to new approaches to providing care, were obtained from included studies. A narrative summary was guided by Burns et al.'s framework for primary care provision in disasters.

RESULTS

Seventeen of 1,699 identified papers were included. Studies reported on telehealth use and public health measures to maintain safe access to routine primary care, including providing COVID-19 screening, and establishing dedicated care pathways for non-COVID and COVID-related issues. Acute and urgent care were prioritized, causing disruptions to chronic disease management and preventive care. Challenges included telehealth use including disparities in access and practical difficulties in assessing patients, personal protective equipment shortages, and financial solvency of medical practices.

CONCLUSIONS

Substantial disruptions to routine primary care occurred due to the COVID-19 pandemic. Primary care practices' rapid adaptation, often with limited resources and support, demonstrates agility and innovative capacity. Findings underscore the need for timely guidance and support from authorities to optimize the provision of comprehensive routine care during pandemics.

Home-based primary care visits by nurse practitioners

BACKGROUND

With rapidly growing numbers of homebound older adults, the need for effective home-based health interventions is increasingly recognized. Advanced practice registered nurses (NPs) are one of the most common providers of home-based primary care. Limited information is available to address the scope and nature of NP-led home-based primary care and associated outcomes.

OBJECTIVE

To synthesize research evidence of NP visits in home-based primary care.

DATA SOURCES

Six electronic databases-PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Web of Science, and Scopus-were searched to identify peer-reviewed research articles addressing home-based primary care interventions led by NPs. Independent screening resulted in 17 relevant articles from 14 unique studies to include in the review.

CONCLUSIONS

Nurse practitioners provided health assessments, education, care planning and coordination primarily by face-to-face home visits. Despite a variability in terms of study design, setting, and sample, NP-led home-based primary care was in general associated with less hospitalization and fewer emergency department visits. Evidence was mixed in relation to patient-reported outcomes such as subjective health, functional status, and symptoms. Costs and patient or caregiver satisfaction were additional outcomes addressed, but the findings were inconsistent.

IMPLICATIONS FOR PRACTICE

Recent policy changes to authorize NPs to independently assess, diagnose, and order home care services directly affect how NPs approach home-based primary care programs. Our findings support NP-led home-based primary care to decrease consequential health utilization and suggest the need for further evaluating the care models in diverse populations with more patient-reported and caregiver outcomes.

Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis

BACKGROUND

Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care.

OBJECTIVE

To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks.

DESIGN

Semi-structured interviews.

PARTICIPANTS

Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center.

APPROACH

Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives.

KEY RESULTS

Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work.

CONCLUSIONS

Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans.

Home-Based Care Reimagined: A Full-Fledged Health Care Delivery Ecosystem Without Walls

The COVID-19 pandemic exposed the dangers of tying health care delivery to brick-and-mortar health care facilities. Both before and, more intensely, during the pandemic, health systems have struggled to support high-need patients, especially those unable to engage with virtual technology or needing urgent care in the home. The pandemic has highlighted an ongoing need to create a distributed health care delivery ecosystem centered in patients' homes and the community. This age-friendly ecosystem would initially focus on high-need patients, expand access, improve equity, and be of high value. It would integrate episodic and longitudinal care and expand to serve broader populations as it matures. We briefly describe the evidence base for home-based care models that constitute this ecosystem, define the guiding principles underlying it, and discuss what will be required to build out and scale it.

Recognizing careworkers' contributions to improving the social determinants of health: A call for supporting healthy carework

Workers engaged in reproductive labor-the caring work that maintains society and supports its growth-contribute to societal health while also enduring the harms of precarious labor and substantial work stress. How can we conceptualize the effects of reproductive labor on workers and society simultaneously? In this commentary, we analyze four types of more relational and less relational careworkers-homeless shelter workers, school food workers, home care aides, and household cleaners-during the COVID-19 pandemic. We then make a case for a new model of societal health that recognizes the contributions of careworkers and healthy carework. Our model includes multi-sectoral social policies supporting both worker health and societal health and acknowledges several dimensions of work stress for careworkers that have received insufficient attention. Ultimately, we argue that the effects of reproductive labor on workers and society must be considered jointly, a recognition that offers an urgent vision for repairing and advancing societal health.

Impact of COVID-19 on Structure and Function of Program of All-Inclusive Care for the Elderly (PACE) Sites in North Carolina

Objectives

The novel coronavirus disease 2019 (COVID-19) deeply affected all forms of long-term care for older adults, highlighting infection control issues, provider and staff shortages, and other challenges. As a comparatively new, community-based long-term care option, the Program of All-Inclusive Care for the Elderly (PACE) faced unique challenges. This project investigated the impact of COVID-19 on operations in all PACE programs in one US state.

Design

Qualitative study.

Setting and Participants

Structured interviews with administrators of all 12 PACE programs in North Carolina.

Methods

Interviews were conducted December 2020 to January 2021 by trained interviewers over Zoom; they were transcribed, coded, and qualitatively analyzed using thematic analysis.

Results

Reported COVID-19 infection rates among PACE participants for 2020 averaged 12.3 cases, 4.6 hospitalizations, and 1.9 deaths per 100 enrollees. Six themes emerged from analyses: new, unprecedented administrative challenges; insufficient access to and integration with other health care providers; reevaluation of the core PACE model, resulting in a transition to home-based care; reorientation to be more family-focused in care provision; implementation of new, creative strategies to address participant and family psychological and social well-being in the home; and major reconfiguration of staffing, including transitions to new and different roles and a concomitant effort to provide support and relief to staff.

Conclusions and Implications

While facing many challenges that required major changes in care provision, PACE was successful in mounting a COVID-19 response that upheld safety, promoted the physical and mental well-being of participants, and responded to the needs of family caregivers. Administrators felt that, after the pandemic, the PACE service model is likely to remain more home-based and less reliant on the day center than in the past. As a result, PACE may have changed for the better and be well-positioned to play an expanded role in our evolving long-term care system.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review

The COVID-19 pandemic has led health systems to increase the use of tools for monitoring and triaging patients remotely. In this systematic review, we aim to assess the effectiveness and safety of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. We searched five databases (MEDLINE, Embase, Global Health, medRxiv, and bioRxiv) from database inception to April 15, 2021, and included feasibility studies, clinical trials, and observational studies, including preprints. We found 561 studies, of which 13 were included in our narrative synthesis. These 13 studies were all observational cohorts and involved a total of 2908 participants. A meta-analysis was not feasible owing to the heterogeneity of the outcomes reported in the included studies. Our systematic review substantiates the safety and potential of pulse oximetry for monitoring patients at home with COVID-19, identifying the risk of deterioration and the need for advanced care. The use of pulse oximetry can potentially save hospital resources for patients who might benefit the most from care escalation; however, we could not identify explicit evidence for the effect of RPM with pulse oximetry on health outcomes compared with other monitoring models such as virtual wards, regular monitoring consultations, and online or paper diaries to monitor changes in symptoms and vital signs. Based on our findings, we make 11 recommendations across the three Donabedian model domains and highlight three specific measurements for setting up an RPM system with pulse oximetry.

The Experience of Homebound Older Adults During the COVID-19 Pandemic

BACKGROUND

Homebound older adults have heightened risks for isolation and negative health consequences, but it is unclear how COVID-19 has impacted them. We examine social contact and mood symptoms among previously homebound older adults during the COVID-19 pandemic.

DESIGN/SETTING

Cross-sectional analysis using data from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of aging in the USA.

PARTICIPANTS

A total of 3,112 community-dwelling older adults in 2019 who completed the COVID-19 survey in the summer/fall of 2020.

MEASUREMENTS

Homebound status was defined via self-report as rarely/never leaving home or leaving the house with difficulty or help in the prior month. We measured limited social contact during COVID-19 (in-person, telephone, video or email contacts

RESULTS

Among homebound older adults, 13.2% experienced limited social contact during COVID-19 vs. 6.5% of the non-homebound. Differences in social contact were greatest for contacts via email/text/social media: 54.9% of the homebound used this

DISCUSSION

Isolation among homebound older adults increased during COVID-19, partially due to differences in technology use. We must ensure that homebound persons have the connection and care they need including new technologies for communication during and beyond COVID-19.

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Key Words

• COVID-19
• Homebound
• Isolation
• NHATS
• Social contact

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MESH Headings

• Aged
• COVID-19/epidemiology
• Cross-Sectional Studies
• Homebound Persons
• Humans
• Loneliness
• Longitudinal Studies
• Pandemics

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Grants

• P01 AG066605 NIA NIH HHS
• R01 AG060967 NIA NIH HHS
• K23 AG066930 NIA NIH HHS
• P30 AG044281 NIA NIH HHS
• P30 AG028741 NIA NIH HHS
• K01 AG059831 NIA NIH HHS
• K23 AG065438 NIA NIH HHS
• L30 AG060590 NIA NIH HHS
• K76 AG064427 NIA NIH HHS
• National Institute on Aging

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Affiliation(s)

Claire K Ankuda Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, NY, USA.
Ashwin Kotwal Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
Jennifer Reckrey Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, NY, USA
Krista L Harrison Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
Katherine A Ornstein Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, NY, USA

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Barriers and facilitators to providing home-based care in a pandemic: policy and practice implications

Objective

The purpose of this study is to describe the experiences of home-based care providers (HBCP)  in providing care to older adults during the pandemic in order to inform future disaster planning, including during pandemics.

Design

Qualitative inquiry using an abductive analytic approach.

Setting and participants

Home-based care providers in COVID-19 hotspots.

Methods

Telephone interviews were conducted with 27 participants (administrators, registered nurses and other members of the allied healthcare team), who provided in-home care during the pandemic in Medicare-certified home health agencies. Interviews focused on eliciting experiences from HBCP on challenges and successes in providing home-based care to older adults, including barriers to care and strategies employed to keep patients, and providers, safe in their homes during the pandemic.

Results

Data was distilled into four major themes that have potential policy and practice impact. These included disrupted aging-in-place resources, preparedness actions contributing to readiness for the pandemic, limited adaptability in administrative needs during the pandemic and challenges with unclear messaging from public health officials.

Conclusions

Home-based care plays an essential role in maintaining the health of older adults in disaster contexts, including pandemics. Innovative solutions, informed by policy that generate evidence-based best practices to support HBCP are needed to reduce barriers and increase protective factors, in order to maintain continuity of care for this vulnerable population during disruptive events.

What can general practice learn from primary care nurses' and healthcare assistants' experiences of the COVID-19 pandemic? A qualitative study

OBJECTIVES

UK general practice has radically altered in response to COVID-19. The general practice nursing team has been central to these changes. To help learn from COVID-19 and maintain a sustainable nursing workforce, general practice should reflect on their support needs and perceptions of organisational strategies. This study aimed to explore primary care nurses' and healthcare assistants' experiences and perceptions of general practice, and the changes made to it, during the pandemic.

DESIGN

Exploratory qualitative study using semistructured interviews. Interview data were analysed using Braun and Clarke's 'codebook' thematic analysis.

SETTING

General practices in the Midlands, South East and South West England. Interviews were conducted in February and March 2021, as England began to unlock from its third national lockdown.

PARTICIPANTS

Practice nurses (n=12), healthcare assistants (n=7), advanced nurse practitioners (n=4) and nursing associates (n=1) recruited using convenience and snowball sampling.

RESULTS

Three themes were identified. Difficult changes describes dramatic changes made to general practice at the onset of the pandemic, creating confusion and anxiety. Dealing with change characterises how negative emotions were intensified by fear of infection, problematic government guidance, personal protective equipment (PPE) shortages and friction with doctors; but could be mitigated through effective practice communication, peer support and individual coping strategies. An opportunity for improvement highlights certain changes (eg, the increased use of telehealth) that participants believed could be adopted long term to improve efficiency.

CONCLUSION

General practice should learn from the COVID-19 pandemic to nurture the clinical role and resilience of nurses and healthcare assistants in the postpandemic 'new normal'. Robust PPE provision could enable them to undertake their patient-facing duties safely and confidently. Judicious implementation of telehealth could help preserve the practical and caring nature of nursing. Improving channels of communication and interprofessional collaboration could help realise their potential within the primary care team.

Responding to the needs of persons living with dementia and their caregivers during the COVID-19 pandemic: Lessons from the Care Ecosystem

Background and Objectives

The COVID-19 pandemic created challenges for persons with dementia, their caregivers, and programs that support them. The Care Ecosystem (CE) is a model of dementia care designed to support people with dementia and their family caregiver dyads through on-going contact with a care team navigator (CTN) and an expert clinical team. CTNs provide support, education and resources and help dyads manage dementia-related concerns as they evolve over the course of the disease. We aimed to understand how the Care Ecosystem responded to the needs of dyads during the initial three months of the COVID-19 pandemic.

Research Design and Methods

We conducted a survey and qualitative interviews with staff members from four established Care Ecosystem programs located in four different states to explore 1) challenges dyads voiced during the pandemic, 2) CE staff approaches to addressing the needs of dyads and 3) programmatic challenges faced and lessons learned.

Findings

Nine staff members from four Care Ecosystem programs with an active collective caseload of 379 dyads were interviewed. Themes were identified that included dyad concerns regarding fear of illness, changing attitudes towards long term care, decreased availability of services and resources, and impacts on patient and caregiver health and well-being. Programmatic challenges included maintaining effective communication with dyads and program staff, technological readiness, workflow restructuring and program sustainability.

Discussion and Implications

Approaches in supporting people with dementia and their caregivers should demonstrate flexibility, responsivity, and creativity and these findings provide insight for understanding how dementia care programs can be positioned to offer continuous support for this vulnerable population.

Translational Significance

During the pandemic, persons with dementia and their caregivers reported concerns relating to viral exposure, functional and behavioral decline of the person with dementia, difficulty accessing resources, changing attitudes towards long term care and experiences of loneliness and isolation. The Care Ecosystem, a supportive dementia care model, faced challenges relating to program sustainability and workflow. Telephone-based and scheduled contacts with dyads, along with strong organizational and community partnerships were factors in supporting dyads. Results from this study inform programs on ways to support persons with dementia and their caregivers during unexpected events that threaten public health and safety.

European Respiratory Society Statement on Long COVID-19 Follow-Up

Patients diagnosed with coronavirus disease 2019 (COVID-19) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection frequently experience symptom burden post-acute infection or post-hospitalisation. We aimed to identify optimal strategies for follow-up care that may positively impact the patient's quality of life (QoL). A European Respiratory Society (ERS) Task Force convened and prioritised eight clinical questions. A targeted search of the literature defined the timeline of “long COVID” as 1–6 months post-infection and identified clinical evidence in the follow-up of patients. Studies meeting the inclusion criteria report an association of characteristics of acute infection with persistent symptoms, thromboembolic events in the follow-up period, and evaluations of pulmonary physiology and imaging. Importantly, this statement reviews QoL consequences, symptom burden, disability and home care follow-up. Overall, the evidence for follow-up care for patients with long COVID is limited.

Follow-up care of patients infected with SARS-CoV-2 is crucial and may improve their quality of life. More evidence and research is emerging to understand the causes, mechanisms and risks of long COVID consequences.https://bit.ly/3J1WMWy

Burnout and Commitment to Primary Care: Lessons From the Early Impacts of COVID-19 on the Workplace Stress of Primary Care Practice Teams

PURPOSE

The COVID-19 pandemic has dramatically affected all areas of health care. Primary care practices are on the front lines for patients seeking health care during this period. Understanding clinical and administrative staff members' strategies for managing the broad-ranging changes to primary care service delivery is important for the support of workforce well-being, burnout, and commitment to primary care.

METHODS

Thirty-three staff members from 8 practices within a single health care system completed short, semistructured interviews from May 11, 2020 to July 20, 2020. Interviews were coded using a combination of conventional and directed content analysis.

RESULTS

Themes emerged from the data that mapped onto the Job Demands-Control-Social Support model. Participants reported that every aspect of primary care service delivery needed to be adapted for COVID-19, which increased their job demands significantly. Several also described pride in their development of new skills, and in most interviews, they expressed that the experience brought staff together. Staff engaged in active cognitive reframing of events during the interviews as they coped with increased workplace stress. However, as the pandemic changed from an acute stress event to a chronic stressor, staff were more likely to indicate signs of burnout.

CONCLUSIONS

Primary care teams absorbed tremendous burdens during COVID-19 but also found that some stress was offset by increased support from management and colleagues, belief in their own necessity, and new development opportunities. Considering high prepandemic strain levels, the ability of primary care teams to persist under these conditions might erode as the crisis becomes an enduring challenge.

A mixed-methods evaluation of home-based primary care in dementia within an integrated system

BACKGROUND

No prior studies have examined the effects of home-based primary care (HBPC) in persons living with dementia (PLWD), within an ecosystem of serious illness care in an integrated healthcare system. Our objectives were to compare the characteristics of PLWD receiving HBPC and their hospital utilization and end-of-life care, with those of a matched comparison group, and to understand the experiences of family caregivers of PLWD receiving HBPC.

METHODS

This mixed-methods study used a retrospective observational cohort design with PLWD receiving HBPC (n = 287) from 2015 to 2020 and a strata-matched comparison group (n = 861), and qualitative phone interviews with 16 HBPC family caregivers in 2020. Inverse probability of treatment weighting propensity score-adjusted models were used to compare time-to-first hospital-based utilization and, for decedents, home palliative and hospice care and place of death. Care experience was captured through caregiver interviews.

RESULTS

Patients receiving HBPC had a similar risk of hospital utilization [adjusted hazard ratio, 1.06 (95% CI: 0.89-1.26), p = 0.51] as a matched non-HBPC comparison group after a median follow-up of 199 days. However, HBPC decedents (n = 159) were more likely to receive home palliative care or hospice [rate ratio, RR: 1.23 (95% CI: 1.07-1.42), p < 0.01] and to die at home [RR: 1.66 (95% CI: 1.35-2.05), p < 0.001] than were non-HBPC decedents (n = 423). Caregivers reported that HBPC provided coordinated, continuous, and convenient care that was aligned with families' priorities and goals; however, some expressed unmet needs, especially for help paying for personal care and medical supplies/equipment, and a desire for clearer communication about program operations and more quality oversight for contract services.

CONCLUSIONS

Although HBPC for PLWD was associated with a similar risk of hospital utilization compared to a matched non-HBPC comparison group, HBPC resulted in more patient-centered end-of-life care for decedents. Prospective studies of HBPC that further elicit and address unmet needs are warranted.

A qualitative study of high-performing primary care practices during the COVID-19 pandemic

BACKGROUND

Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations.

METHODS

We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study.

RESULTS

Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time.

CONCLUSION

Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.

A National Evaluation of Surgeon Experiences in Telemedicine for the Care of Hernia and Abdominal Core Health Patients

Background

Surgeons are increasingly utilizing telemedicine to provide perioperative services to patients. Safety, satisfaction, and feasibility of these programs in general populations have been established, but it is unclear how telemedicine can be integrated into subspecialty care. We report results of a national survey related to telehealth practices among members of the Abdominal Core Health Quality Collaborative (ACHQC).

Methods

Survey responses were analyzed to determine current strategies in telemedicine utilization. Surgeon preferences, perceptions of validity, and identified barriers to implementation of telemedicine were assessed.

Results

Forty surgeons within the ACHQC responded, with 90% of respondents reporting use of telemedicine to deliver perioperative care to patients with hernias and abdominal core health concerns. Surgeons appeared to be more comfortable managing preoperative patients with image-confirmed diagnoses of hernias. Surgeons were universally more comfortable delivering postoperative care via telemedicine. Connectivity, patient engagement, and reimbursement were identified as potential barriers to expansion of telemedicine. Seventy-eight percent of respondents reported that they would increase telemedicine utilization if current regulations were maintained in the future.

Conclusions

This study found that hernia specialists are utilizing telemedicine at a higher rate than before the COVID-19 pandemic, with surgeons reporting interest in continued use of this modality beyond the pandemic. These findings suggest that future work in telemedicine optimization may improve the quality of care that can be delivered to patients with abdominal core health concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06332-9.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

"There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19

The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.

COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey

Objectives

Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. 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.

Design

Mixed-methods national survey.

Setting and Participants

HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs.

Methods

Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions.

Results

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%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%).

Conclusions and Implications

HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.

Home palliative care professionals perception of challenges during the Covid-19 outbreak: A qualitative study

BACKGROUND

Home palliative care services have played an essential role during the first wave of the SARS-CoV-2 outbreak by providing symptom control, drug procurement, and psychological support for frail patients and their families unable to leave their homes.

AIM

To understand how home palliative care professionals were affected by the outbreak, describing changes and challenges in their daily work as well as their reactions to the Covid-19 pandemic in Italy.

DESIGN

Qualitative study conducted using telephone semi-structured interviews, with thematic analysis.

SETTING/PARTICIPANTS

Thirty home care professionals working for an Italian non-profit organization which provides home palliative care for cancer patients and their families.

RESULTS

Three main themes were identified. The first theme showed both patient-related and practice-related challenges participants faced in their daily work, requiring the implementation of different communication methods and patient and family education on risk prevention. The second theme showed the perception of increased responsibility and being the only landmark for family played a decisive role in participants' positive attitude. The third theme highlighted the participants' perception of the critical role of a home care setting in this emergency situation.

CONCLUSIONS

The first wave of the Covid-19 pandemic brought many challenges and stressors for home palliative care professionals. On the other side, they reported a satisfaction with their critical role in carrying out their work with patients at risk.

Factors associated with postponed health checkups during the COVID-19 pandemic in Germany

Objectives

The COVID-19 pandemic has serious social, economic and health consequences. Particularly in these times, it is important to maintain individual health. Therefore, it is important to take part in routine health checkups. Consequently, our objective was to describe the frequency and to identify the determinants of postponed routine health checkups.

Study design

Cross-sectional data from the nationally representative online-survey “COVID-19 Snapshot Monitoring in Germany (COSMO)” was used (wave 17; July 2020).

Methods

In sum, 974 individuals were included in our analytical sample (average age was 45.9 years, SD: 16.5, 18–74 years). Postponed routine health checkups (yes or no) since March 2020 due to the COVID-19 pandemic were assessed.

Results

More than 16% of the individuals reported postponed routine health checkups in the past few months due to the COVID-19 pandemic. Particularly, individuals aged 30–49 years had postponed health checkups (21%). The probability of postponed health checkups was positively associated with the presence of chronic diseases (odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.15–2.47), higher affect regarding COVID-19 (OR: 1.44, 95%-CI: 1.16–1.78), and higher presumed severity of COVID-19 (OR: 1.17, 95%-CI: 1.01–1.35), whereas the outcome measure was not associated with socioeconomic factors. Data showed that a sizeable part (about one of six individuals) of the population reported postponed routine health checkups due to the COVID-19 pandemic between March and July 2020.

Conclusions

Postponed checkups should not be neglected during the COVID-19 pandemic. Individuals at risk for postponed health checkups should be appropriately addressed.