key: cord-345725-8ijgmbmr
authors: Shang, Jingjing; Chastain, Ashley M.; Perera, Uduwanage Gayani E.; Quigley, Denise D.; Fu, Caroline J.; Dick, Andrew W.; Pogorzelska-Maziarz, Monika; Stone, Patricia W.
title: COVID-19 Preparedness in U.S. Home Healthcare Agencies
date: 2020-06-04
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.06.002
sha: 
doc_id: 345725
cord_uid: 8ijgmbmr

Abstract Objectives In the U.S., home health agencies (HHAs) provide essential services for patients recovering from post-acute-care and older adults who are aging in place. During the COVID-19 pandemic, HHAs may face additional challenges caring for these vulnerable patients. Our objective was to explore COVID-19 preparedness of U.S. HHAs and compare results by urban/rural location. Design Cross-sectional study. Setting/Participants Using a stratified random sample of 978 HHAs, we conducted a 22-item online survey from April 10 to 17, 2020. Methods Summary statistics were computed; open-ended narrative responses were synthesized using qualitative methods. Results Similar to national data, most responding HHAs (n=121, 12% response rate) were for-profit and located in the South. A majority of HHAs had infectious disease outbreaks included in their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster preparedness (84%), and had provided their staff with COVID-19 education and training (97%). More urban HHAs had cared for confirmed and recovered COVID-19 patients than rural HHAs, but urban HHAs had less capacity to test for COVID-19 than rural HHAs (9% vs 21%). Most (69%) experienced patient census declines and had a current and/or anticipated supply shortage. Rural agencies were impacted less than urban agencies. HHAs have already rationed (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective equipment (PPE). Many HHAs reported accessing supplemental PPE from state/local resources, donations, and do-it-yourself efforts; more rural HHAs had accessed these additional resources compared to urban HHAs. Conclusions/Implications This survey reveals challenges that HHAs are having in responding to the COVID-19 pandemic, particularly among urban agencies. Of greatest concern are the declines in patient census, which drastically impact agency revenue, and the shortages of PPE and disinfectants. Without proper protection, HHA clinicians are at risk of self-exposure and viral transmission to patients and vulnerable family members.

Setting/Participants: Using a stratified random sample of 978 HHAs, we conducted a 22-item 10 online survey from April 10 to 17, 2020. Results: Similar to national data, most responding HHAs (n=121, 12% response rate) were for-14 profit and located in the South. A majority of HHAs had infectious disease outbreaks included in 15 their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster 16 preparedness (84%), and had provided their staff with COVID-19 education and training (97%). 17 More urban HHAs had cared for confirmed and recovered COVID-19 patients than rural HHAs, 18 but urban HHAs had less capacity to test for COVID-19 than rural HHAs (9% vs 21%).

Most (69%) experienced patient census declines and had a current and/or anticipated supply 20 shortage. Rural agencies were impacted less than urban agencies. HHAs have already rationed 21 (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective 22 equipment (PPE). Many HHAs reported accessing supplemental PPE from state/local resources, 23 donations, and do-it-yourself efforts; more rural HHAs had accessed these additional resources 24 compared to urban HHAs. 25 Conclusions/Implications: This survey reveals challenges that HHAs are having in responding 26 to the COVID-19 pandemic, particularly among urban agencies. Of greatest concern are the 27 declines in patient census, which drastically impact agency revenue, and the shortages of PPE In the U.S., home healthcare, defined as care delivered in a patient's home by healthcare 33 professionals, 1 plays an important role for post-acute and chronically ill patients. Most home care 34 patients are older adults with multiple chronic conditions. 2 During the COVID-19 pandemic, 35 caring for this group of vulnerable patients at home is complicated and issues may differ in urban 36 and rural settings. Our objective was to explore the COVID-19 preparedness of U.S. home 37 healthcare agencies (HHAs) and examine any urban and rural differences.

We used a stratified random sample of 978 HHAs with available email addresses drawn 

One hundred twenty-one HHAs completed the survey (12% response rate). Similar to 56 national Medicare-certified HHAs, the majority of responding HHAs were located in the 57 Southern census region and had for-profit ownership (Table 1) . Our sample had more rural 58 HHAs (27% vs 14%) than the nation, given that rural agencies were oversampled in the original 59 sample. Approximately 15% of responding agencies were affiliated with a hospital. Average homes, which are critical to reducing SARS-CoV-2 transmission. In a text response, one staff 77 member at an urban for-profit HHA in Pennsylvania highlighted the importance of early and 78 ongoing education to protect staff: " [ HHAs, more than rural HHAs, lacked N95 respirators (66% vs. 52%), gloves (23% vs. 15%) and 107 eye protection (50% vs. 33%). More urban HHAs anticipated shortages in eye protection in the 108 next 2 weeks, compared to those in rural locations (35% vs. 21%). A staff member from a rural, to moonlight in another SNF, hospital, etc. they would be putting people at risk." Another staff 138 member at a rural, for-profit agency in Ohio indicated: "We actually did not take any steps [to 139 preserve staff]. We had a handful of aides who also worked at dentist and doctors' offices and 140 since they are closed temporarily these aides picked up more shifts. So, we just got lucky."

Most HHAs had an emergency preparedness plan in place, and despite regional 143 differences in COVID-19 cases, the majority of responding agencies were caring for (or had The current/anticipated shortages of PPE and other supplies remain the largest concern.

164 During the week of April 10, 2020, most responding HHAs were already lacking N95 165 respirators, gowns, and cleaning supplies or disinfectants. The lack of PPE has been reported at 166 length in hospitals and nursing homes 9 , but rarely for home health agencies 10 . As in other Totals varied due to missing data --* from February 2020 HHC file: n (total) = 8,412, n (respondents) = 103; † from February 2020 HHC file: n (total) = 5,483, n (respondents) = 68 3(9.1) 10(11.4) Notes: IPC = infection prevention and control; Other IPC components included influenza, tuberculosis, multidrug resistant Staphylococcus aureus; Other reasons for staffing shortages included employee fear and competition from other healthcare facilities; Totals varied due to missing data or skip patterns --* n = 119, ^n = 117, † n=38, ‡ n= 80

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