The path to recovery from COVID-19 can be long and difficult, made even more so when patients are forced by lack of post-acute capacity and other extenuating circumstances to stay within the hospital for longer than is clinically necessary.
That’s where, in select cases, discharge to the home can play a prominent role.
I previously discussed some of the ways hospitals can get creative in order to refer difficult-to-place COVID patients. One additional solution is to give broader consideration to discharging the patient home. Particularly if you reside in an area in which there’s a shortage of PACs capable of taking on your recovering patients, a careful review of whether or not the patient’s condition supports a transition to the home becomes crucial in solving for capacity issues.
When the evidence of the patient’s recovery journey supports a discharge to the home, the successful transition of that individual benefits multiple parties. The patient, of course, gets to be more comfortable because they’re in their own space, so their experience improves while the risk of hospital-acquired infections is reduced. Your hospital benefits because it gets to free up bed space (and thus reduce length of stay) at a time when those same beds may be at a premium due to rising COVID case counts. And post-acute care providers gain because they themselves save on critical bed capacity that might otherwise be under-utilized by a patient who could have continued recovery in the safety of their own home.
Home-based care is less resource-intensive, reduces infection spread in downstream settings and clears up hospital capacity. However, patients refusing care, limits on telehealth visits, and gaps in scaling staff to meet new clinical needs mean home health can’t supplement the full scope of post-discharge needs. As a start, models like hospital-at-home or offering custodial support with skilled home health increases the range of patients that can receive care in the home, reducing inpatient utilization.
Let’s look more closely at the important role home health plays in our nation’s pandemic efforts, including how to assess patients’ ability to successfully progress and how to ensure they remain on the path to recovery.
Suitability for Home Care
First, I want to bring your attention to the CDC’s guidance on gauging suitability for discharge to a residential setting. They provide six considerations that will determine whether or not home healthcare will be appropriate for that individual:
- The patient is stable enough to receive care at home.
- Appropriate caregivers are available at home.
- There is a separate bedroom where the patient can recover without sharing immediate space with others.
- Resources for access to food and other necessities are available.
- The patient and other household members are capable of adhering to precautions recommended as part of home care or isolation.
- There are household members who may be at increased risk of severe illness from COVID-19 infection.
The first five bullets explain the five things that should be in place in order for a home referral to be considered, while the last bullet is something that might actually cause you to rethink home discharge.
Certain things will be beyond your control as an acute care provider or a case manager. For instance, you can’t control the availability of a separate bedroom or the presence of other at-risk residents. And we certainly wouldn’t advise you on determining whether or not a patient is stable enough to receive care; that kind of decision must be left up to your own clinical experts.
However, the other bullets, i.e., the availability of caregivers, adherence to appropriate precautions, and access to resources, are definitely within the control of case management teams, so I’d like to take a closer look at those points to explore how you can see to these topics and potentially reduce the risk of readmission. In addition, I’d like to bring up one more point, transportation, as this has been an under-recognized dilemma when considering discharge of COVID patients.
Eligibility for home health will hinge on not just the person’s health, but their ability to continue on the prescribed recovery regimen. For that, someone must be available who can intervene when necessary.
If a family member or some other in-home caretaker is available, your case management team will need to brief them on the care plan and make sure all parties within the home understand that plan. Included within this plan should be information about hygiene procedures to prevent further infections.
If a family member isn’t readily available, it’s up to your case management team to coordinate with in-home health agencies to ensure the patient’s care needs are seen to. Determine whether the caretaker will be in-home 24/7 or if the patient’s condition is stable enough (and the risk of backsliding small enough) that the caregiver can visit on a set schedule for regular check-ins.
It’s also important to have open lines of communication between the caregiver and the rest of the patient’s care team. If a medication isn’t working as assumed, or if the patient backslides, you’ll want visibility into this so an intervention can occur and the risk of readmission can be reduced.
Working with the in-home caregiver also involves a careful determination of the patient’s socioeconomic needs and making sure that those are addressed as well.
The social determinants of health play a massive role in COVID recovery. Because the individual will be under quarantine, they need to be in a space where they’ll have private access to amenities such as a restroom, laundry and more. They need a supply of healthy food that will provide a balanced diet during their recovery, a diet that’s overseen by a nutrition expert and adjusted depending on the individual’s needs. They also need access to whatever medications have been prescribed, whether via delivery or pick-up, and a means to order additional prescriptions depending on the progress of their recovery.
A careful analysis of all these things and more will be essential prior to discharge to the home, and continued review of these social determinants is critical. The caretaker involved in the patient’s recovery should check in regularly to determine if the patient has everything they could conceivably need, and you should communicate with this person regularly to monitor the patient’s status.
One social determinant that requires special attention is that of transportation. Too often, especially when we’re focused on discharging the patient and freeing up a bed, it’s easy to put blinders on and only think about scheduling transport from the hospital to the post-acute setting.
But with home COVID recovery especially, transportation can play a far bigger role. If the patient has in-person, non-telehealth appointments, he or she needs a means of getting there. It’s a good idea to look ahead and set up transportation early on, ideally with the very same NEMT providers you scheduled for drop-off at home.
Also coordinate with your in-home caregivers when thinking about how transportation can be used in other ways. NEMT can be involved in grocery and prescription delivery as well as the shipping of any other items that can make the patient’s life better and their recovery more assured.
Knowledge Is Power
Finally, you must work diligently to ensure the patient and anyone else within the home understands both the care plan and the precautions necessary to prevent further COVID spread.
This begins at discharge. You will no doubt have a team member thoroughly review the care plan and what patients can expect from their in-home caregivers as they continue their recovery. Make sure, ideally using the teach-back method, that the patient understands the expectations and the progress markers to graduate to the next step in recovery.
Once the patient is out of the hospital, continue to follow up to see how they’re progressing and gauge their ongoing understanding of their care plan. Not only does the patient and everyone within the home need to know the care plan, they also need to know proper quarantine procedures. This complicates case managers’ work, as they now have additional items they need to cover when they check in. But that work is necessary to boost recovery chances.
Home Is Where the Start Is
After the patient is able to go back home, their recovery can truly begin. But that doesn’t mean we can let our guard down.
By adhering to CDC guidelines and continuing to work with in-home caregivers and patients themselves, you can reduce the risk of readmission and ensure that discharge to the home is as successful as it could possibly be.