Over the course of the coronavirus (COVID-19) outbreak, we have received information from clients stating that patients and caregivers are beginning to refuse in-home services out of fear of contracting COVID-19. We would like to equip providers with some resources and recommendations for dealing with this situation.
First and foremost, we recommend that providers keep their staff updated on current guidance regarding care of patients with COVID-19 and prevention of COVID-19 transmission. The following websites are reliable sources which provide accurate and up-to-date information on COVID-19:
- Centers for Disease Control (CDC)
- National Association for Homecare and Hospice (NAHC)
- World Health Organization (WHO)
- National Institutes of Health (NIH)
- American Hospital Association (AHA)
- Your local Department of Public Health (DPH) website
Review Internal Processes and Educate Staff
Providers should review their emergency preparedness plans to ensure that they address dealing with pandemic situations such as the current COVID-19 pandemic. A resource for this is the Coronavirus COVID-19 Homecare and Hospice Check List found on the NAHC website.
We recommend that agencies provide re-education to staff on the following areas:
- Standard precautions
- Transmission-based precautions
- Bag technique
- Proper donning/doffing of PPE
We also recommend that agencies ensure their staff are aware of proper protocols for cleansing equipment between patients, including cleansing of laptops or other portable electronic devices used. Ensure staff have appropriate stock of PPE on hand for patient care.
Agencies should provide staff with guidance on caring for patients in the home with known or suspected COVID-19 infection. Consider providing staff with the following handouts found on the NAHC website:
- Patient guide to COVID-19
- Caregiver guide to COVID-19
- Guide for cleaning and disinfecting COVID-19
- Coronavirus Guidance for Home Health & Hospice education sheet
Communicate Effectively and Document Communication with Patients and Caregivers
We suggest that agencies consider providing staff with scripting to use for situations where patients or caregivers are refusing care due to fear of transmission by healthcare workers in their homes. Such scripting should include education of the patient/caregiver regarding a greatly increased risk of COVID-19 exposure or transmission if the patient’s disease process exacerbates enough to warrant a hospitalization or even a visit to the physician’s office. Patients and caregivers should be educated to allow home health clinicians, whom are using proper precautions in preventing transmission, into their home to ensure they receive the care necessary to prevent an exacerbation of their disease while continuing to maintain a low risk of COVID-19 exposure or transmission.
Additional recommendations to ensure patients continue to receive the care needed while limiting their risk to COVID-19 exposure include virtual care visits through HIPAA compliant use of telehealth, video conferencing, or care calls. Though not currently reimbursable for home health under CMS guidelines, these are viable options for monitoring patients, keeping them on home health services and preventing rehospitalization.
Care calls are calls made by clinicians to check on a patient and perform a telephonic assessment using open-ended questions. Care calls are typically conducted when patients are reluctant to accept visits but require assessment and evaluation by skilled professionals. Some suggestions for what care call scripting should assess are:
- Whether the patient can self-monitor vital signs including blood pressure, heart rate, weight and blood glucose levels
- The frequency in which the patient is self-monitoring
- The results since the last skilled assessment
- Ability of the patient and/or caregiver to verbalize parameters that should be reported to the physician
- Ability to safely perform wound care in the absence of skilled professionals
- Patient’s ability to perform wound care
- If there is an available caregiver to assist with the wound care
- Ability of the patient and/or caregiver to verbalize proper wound care protocol
- If there is an adequate amount of supplies in the home to meet patient needs
- Ability of the patient and/or caregiver to verbalize signs of infection or complication and report them to the physician
- Ability to recognize symptoms of disease exacerbation
- Medication management
- If there is a sufficient supply of ordered/prescribed medications for the patient
- Ability of the patient and/or caregiver to verbalize the medication regimen
Finally, staff must be taught to document all conversations regarding patient refusal of visits, including the reason for the refusal. Documentation should include the date, time (beginning and end), the person spoken to and all relevant information as obtained during the care call. In addition, any alteration in the physician-ordered Plan of Care, including missed visits due to patient refusal, must be reported to the physician.
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