COVID-19 and the challenges in homecare
Today I am profiling one of the “forgotten,” but crucially important, health sectors: homecare. With hospitals geared to the pandemic, “decanting” less acute patients to their homes, and less able to attend to non-COVID conditions, homecare plays a central role in keeping persons in their homes and attending to their needs. However, like all community health services in our hospital-oriented health system, homecare is underfunded, neglected, and in pressing need of reform. Let this be one of the silver-linings of this terrible pandemic: We are identifying the weaker points in our health system and where we should focus reform when quieter times arrive.
Homecare, like all other health services, faces serious challenges continuing to provide services through the pandemic. Government guidance for this sector provides instructions for screening as well as use of PPE for clients suspected or confirmed COVID+. For these clients, “care providers should be delaying care if possible and only providing essential medical services.” This has also meant implementing new home care delivery models to support homecare clients and patients, increasing the delivery of virtual care by nurses, physiotherapist, social workers and other home caregivers. The government says its intention is to bring more homecare services online “in the weeks ahead.” The government has also issued guidelines that has nurses, personal support workers (PSWs) and other home care providers screening themselves for symptoms of the virus every morning.
PSWs who care for clients inside their homes are among the essential service providers who don't feel safe on the job due to a lack of PPE amid the pandemic. "It's very, very scary," said Lindsay Couture, the executive director for Ajax/Pickering with the Ontario Personal Support Worker Association. "We just keep going forward, follow precautions and just hope we don't get [COVID-19]." Couture runs her own PSW business, Oakwood Home Healthcare, and says it's been "impossible" for private companies like hers to find PPE. She managed to get some mask donations earlier, but has had a hard time finding more. That's left her and other PSWs in Durham with no choice but to enter homes of clients, many who are elderly or immuno-compromised, unprotected to help them with physical tasks like bathing, dressing, and toileting.
Clients are also tense. As someone who has PSWs enter her condo for several hours a day, six days a week, Mona Kornberg is also taking precautions. Her husband Jacques Kornberg was diagnosed with terminal cancer six months ago. He now requires help for any physical movement. She ensures anyone who enters her home washes their hands properly and regularly and uses the disinfectant wipes often. Mona says it's "been a struggle" having a rotation of PSWs, whose services are funded by the Ontario government, coming into her home. She screens them each time about their social distancing and whereabouts, and those of their other clients. She says she's fought hard to narrow down the roster of PSWs who enter her home each week, but is planning to move onto a private agency in hope of finding more consistent care. "People who are vulnerable like my husband need the consistency to feel safe."
Shirlee Sharkey, president and CEO of SE Health, says the government has to consider new care models that ensure we’re not spreading the virus from home to home. Currently, the home-care model sees nurses or PSWs visit an average of six different homes a day, and could include a nursing home, Sharkey said. That should change to having the same nurse or PSW exclusively visit the same client. If a client needs three PSW visits a day, why not have one worker put in five or six hours a day dedicated to that one client? Sharkey, whose 8,000 employees in Ontario make 20,000 home-care visits each day, said fear of infection is one reason her non-profit agency has seen a drop in home care services by up to 30 per cent. Patients and families were nervous and cancelling visits, at least short term, and the staff are nervous, both with the shortage of PPE and nervous with the community spread of COVID-19. This trend needs to be reversed, she argued, because the more people turn away from home care the more likely their illnesses will force them into already strained hospitals.
Many home care agencies propose temporarily transforming the way home care currently operates into a COVID-19 pandemic response strategy that supports one patient per caregiver staff working on a full-time basis. The current home care model works on ensuring that service planning assessments are completed by case managers, and then optimizing schedules to reduce the total cost of services delivered to the highest number of people. The proposed new temporary model would be about increasing self-isolation of patients by drastically reducing the number of encounters a caregiver has with multiple patients, with the goal to assign one patient per caregiver. Implementing this temporary model requires a ministerial order. RNAO believes such a new model is best for COVID-19 as it improves self isolation for clients and it reduces the chances of spread. It also optimizes continuity of care and caregiver leading to better outcomes.
One of the problems Sharkey mentions is the lack of PPE, a concern that sounds all too familiar for our readers. The amount of equipment that once lasted a full year is now being used up in a month, Sharkey said. It keeps her constantly competing to buy the little equipment available, which increasingly is being reserved for staff in hospitals and nursing homes. A model with one care provider working exclusively with one home-based client would significantly reduce the need for masks. That model would require a fundamental redesign of the provincial approach, which currently sees home care as a piecemeal service divided into specific tasks that get performed by the hour. “Home care has been an afterthought for years and during this pandemic we in the community are saying, ‘Listen, this has to part of the whole central planning,” said Sharkey, arguing that the government’s vision of health care has traditionally been focused on hospitals. “Everyone is being told to stay at home,” she added. “So we want to make sure that we can provide an environment in the health care system where people can stay at home.”
Others share the concerns. If home is the safest place for all seniors to be these days, shouldn’t Ontario do more to keep them out of long-term-care facilities and enable them to live at home again?, asks Steve Paikin. And shouldn’t the province be doing everything it can to improve homecare so that residents who can go home or live with family members are able to do so? He points out there has been no specific relief funding or targeted investment in homecare during this pandemic. “In fact, in Ontario, we’re actually reducing the availability of homecare services,” said a leading provider. Furthermore, hospitals are discharging older patients into long-term-care homes or hotels, where they’re less safe, rather than to their own or their family’s homes, where, with some beefed-up care, they’d be in far less danger.