Home-Based Medical Care: High-Value Health Care During Coronavirus Disease 2019 and Beyond

Impact of the COVID-19 Pandemic on Home Medical Care Utilization in Japan: An Interrupted Time Series Analysis

BACKGROUND

The COVID-19 pandemic affected healthcare utilization worldwide, but changes in home medical care utilization have not been fully revealed.

OBJECTIVE

This study aims to clarify the changes in the use of home medical care services in Japan due to the pandemic.

DESIGN

Interrupted time series analysis of national medical claims data.

PARTICIPANTS

Individuals with home medical care use occurring in Japan between April 2019 and March 2022.

INTERVENTIONS

The declaration of a state of emergency (April 2020) by the Japanese government.

MAIN MEASURES

The outcomes were the monthly uses of regular home visits, emergency house calls, terminal care, and in-home deaths. Terminal care was stratified by care setting (home or nursing home) and the type of home medical care facilities (enhanced home care support clinics and hospitals (HCSCs), conventional HCSCs, and general clinics and hospitals).

KEY RESULTS

Regular home visits showed no significant change, but emergency house calls exhibited an upward trend (1258 uses/month, 95% CI 43 to 2473). Both terminal care and in-home deaths experienced an immediate increase in level (1116 uses/month, 95% CI 549 to 1683; 1459 uses/month, 95% CI 612 to 2307), followed by a gradual increase in trend (141 uses/month, 95% CI 73 to 209; 215 uses/month, 95% CI 114 to 317). The immediate increase of terminal care occurred only for home patients. Enhanced HCSCs showed the most prominent increase in both level and trend, followed by conventional HCSCs, and general clinics and hospitals.

CONCLUSIONS

The COVID-19 pandemic increased the use of emergency house calls and terminal care among home medical care in Japan, particularly for home patients and enhanced HCSCs. These findings suggest that the pandemic revitalized the importance of home medical care as a patient-centered care delivery model and highlight the need for strategic healthcare planning and home medical care resource allocation to anticipate future pandemics.

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.

Targeted Telehealth Education Increases Interest in Using Telehealth among a Diverse Group of Low-Income Older Adults

Telehealth allows older adults to take control over their health and preventive care; however, they are less likely to use telehealth. Minority older adults use telehealth services less than their White counterparts. During COVID-19, the U.S. Medicare system allowed for telehealth delivery of Annual Wellness Visits, which are known to improve use of preventive services. To increase telehealth use, we targeted vulnerable, low-income, minority older adults and provided education to improve knowledge of and identify barriers to telehealth use. Ultimately, this could serve as a means of improving health and preventive care services. Participants resided at independent living facilities, low-income housing, and elders of the Native American coalition; N = 257. Participants received written education materials; a subset attended a 20-min presentation. In this quasi-experimental study, participants completed a pre-post survey. Results were analyzed using Chi-Squared and Fisher's Exact tests. Participants included 54 'in-person' and 203 'at-home' learners. Most were female (79%), single/widowed (51%), and white (65%). At baseline, 39% were familiar with telehealth; following education 73% stated understanding on accessing telehealth. Nearly 40% of participants said they would use telehealth in the future; a larger proportion of "in-person" (73%) learners were willing to use telehealth than "at-home" learners (41%) (p = 0.001). Divorced older adults and Blacks voiced greater likelihoods of using telehealth than their married/widowed and White counterparts, respectively (Χ2(3, N = 195) = 9.693, p = 0.02), (p = 0.01). This education program demonstrates an increase likelihood in health promotion among older adults by increasing confidence in accessing and future use of telehealth; therefore, we achieved our aim of promoting telehealth use and improving health promotion.

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.

Barriers to telehealth access among homebound older adults

Background/Objectives

To identify major barriers to video‐based telehealth use among homebound older adults.

Design

Cross‐sectional survey.

Setting

A large home‐based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community.

Participants

Sixteen primary care physicians.

Measurements

An 11‐item assessment of provider perceptions of patients' experience with and barriers to telehealth.

Results

According to physicians in the HBPC program, more than one‐third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first‐time video‐based telehealth encounters between April and June 2020 during the first COVID‐19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) “unable to interact over video” for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video‐capable device access.

Conclusion

The COVID‐19 pandemic resulted in a large and dramatic shift to video‐based telehealth use in home‐based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video‐based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video‐based telehealth use.