key: cord-0703199-ths72euh
authors: Videon, Tami M.; Rosati, Robert J.; Landers, Steven H.
title: Early versus late COVID‐19 Home Health Care patient population: Shifting sociodemographics and comparable outcomes
date: 2022-04-24
journal: Res Nurs Health
DOI: 10.1002/nur.22230
sha: fb977b71ca889ef8de483d74bb25a0b505b3d3e4
doc_id: 703199
cord_uid: ths72euh

Early in the pandemic when hospitals reached capacity, Home Health Care (HHC) became a critical source of care for COVID‐19 patients and continues to be an important source of care for recovering COVID‐19 patients. Little is known about the COVID‐19 patient population treated in HHC. This retrospective observational cohort follows 1614 HHC patients with a COVID‐19 diagnosis and compares an “Early Cohort” between March 31 and May 31, 2020 to a “Late Cohort” between June 1 and December 31, 2020 for differences in: (1) sociodemographic and clinical characteristics (2) health care utilization, and (3) outcomes. Early patients were younger, more likely to be a minority, referred from hospitals or directly from emergency departments, started their care with greater independence in functional abilities, and had fewer comorbidities. Early patients were more likely to have COVID‐19 as their primary diagnosis (88.5% vs. 79.4%, p < 0.001), and were assessed as having more severe COVID‐19 symptoms. Early and Late Cohorts were assessed similarly for dyspnea at the start of care. COVID‐19 patients in the Early Cohort were more likely to have their vital signs monitored remotely (7.3% vs. 1.4%; p < 0.001), have received oxygen in their home (27.8% vs. 15.3%; p < 0.001), and received more virtual care than patients in the Late Cohort (2.04 visits vs. 0.86 visits; p < 0.001), although they had approximately two fewer total visits (12.48 vs. 14.45; p < 0.001). Patients in both cohorts had substantial improvement in dyspnea and functional ability during the course of HHC.

State of New Jersey Department of Health, n.d.). Hospitalization, intensive care unit admission, and mortality within acute care settings became established benchmarks. Interactive websites and open data sources allowed researchers and laymen alike to explore patient populations in hospital settings. The Centers for Disease Control and Prevention provided access to six hospital-centered data sets (Centers for Disease Control and Prevention, n.d.-b) .

A panicked population, differential infection rates, lack of knowledge about the course of illness, rapidly changing best practices for treatment, restrictions prohibiting hospital discharges from being denied admission to nursing homes, and vast numbers of primary care physicians opting not to treat COVID-19 patients or having insufficient PPE supplies all influenced substantial selection effects on how patients flowed through various health systems (Boehmer et al., 2020; Centers for Disease Control and Prevention n.d.-c, n.d.-d; Johns Hopkins Coronavirus Resource Center, n.d. ) . Two years into the pandemic, there is a solid understanding of patient populations flowing through hospital systems seeking health care for COVID-19.

With hospitals giving priority to the most critical patients, the hospital census early in the pandemic overrepresented the elderly and patients with multiple comorbidities (Centers for Disease Control and Prevention, n.d.-d). However, as the pandemic evolved, hospital admissions transitioned to a younger population with fewer comorbidities .

In the initial surge, as hospitals approached maximum capacity, they needed contingency plans for patients in excess of their facility capabilities. Home Health Care (HHC) became an important source of care for COVID-19 patients as hospital beds were restricted to the most severely ill patients, and less severely ill, stable patients were referred to HHC. Yet, there are no published studies on patient overflow from hospitals into other care settings. One noteworthy exception is the documented excessive mortality among residents discharged from hospitals to nursing homes and longer-term care facilities, as well as infection rates among staff in these facilities (Kosar et al., 2021) . Unlike the wildfire contagion witnessed in congregate care facilities, home health patients are safe from contagion from other patients, and research indicates home health clinicians experienced low rates of work-related infections while delivering care to COVID-19 patients 

This retrospective, observational, cohort study used data from one of New Jersey's largest providers of HHC, The Visiting Nurse Association Health Group (VNAHG), to examine admissions of patients diagnosed with COVID-19 in 2020. New Jersey is a suitable geographic region to explore early cases in the pandemic, as its proximity to New York City made it an epicenter of early COVID-19 cases. By June 1, 2020, New Jersey was surpassed only by New York State in the incidence of COVID-19 cases (Statista, n.d.) . At the start of the pandemic, anticipating surge capacity, the VNAHG made arrangements with local hospitals to take COVID-19 positive patients onto HHC service when there were not enough hospital beds for admission. The sample was limited to patients with a COVID-19 diagnosis who began their HHC between March 31 and December 31, 2020 (n = 1614). This study received approval from the VNAHG Institutional Review Board. Assessments are required at the start of care (SOC), transfer to inpatient facility, resumption of care, and discharge.

The OASIS contains 10 items assessing patient functional abilities (eating, oral hygiene, toilet hygiene, shower/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, roll left to right, sit to lying, and lying to sitting on side of bed).

At SOC, and discharge, patients are asked to perform these activities, while clinicians rate their performance. Response categories range from 1 (helper does all the effort to complete the activity) to 6 (patient completes the activity by themselves with no assistance from a helper). A small number of assessments (n = 7) indicated the activity was not attempted because the patient did not perform this activity before the current illness. These responses were recoded as dependent (=1) for that activity. An aggregate measure was created summing these 10 items with scores that ranged from 10 (total dependence) to 60 (total independence).

In addition to assessments of functional abilities, the OASIS contains four questions on patients' usual ability with everyday activities before the current illness (selfcare, ambulation, stairs, and functional cognition).

Responses ranged from 1 (a helper completed the activities for the patient) to 3 (independent, no assistance needed). We summed responses to these four questions to form a single measure of pre-COVID-19 functional abilities, ranging from 4 (dependent on a helper for all activities)

to 12 (complete independence). While not directly comparable to the measure of functional ability, it provides a gauge of independence in functional abilities before COVID-19 infection.

Measured characteristics at admission included: sex, age, and race and ethnicity, living situation, and referral source.

Clinicians determined a primary diagnosis, and up to five other diagnoses for which the patient was receiving HHC. The degree of symptom control for each of the patient's diagnoses at SOC was assessed on a scale that ranges from 0 (asymptomatic, no treatment needed at this time) to 4 (symptoms poorly controlled). COVID-19 designation was determined by an ICD-10 code of U07.1 at the SOC OASIS assessment.

Severe acute respiratory syndrome coronavirus 2 is the virus that can lead to COVID-19. Dyspnea, or shortness of breath, is a common clinical symptom of COVID-19, and is frequently used as an indicator of respiratory symptoms (Simonelli et al., 2021) . Dyspnea was measured using the OASIS measure of dyspnea with response categories that range from 0 (patient not short of breath) to 4 (short of breath at rest). Clinicians rated patients' dyspnea at SOC and again at discharge. Table 1 ). A total of 218 (13.5%) patients were transferred to an inpatient facility and 11 (<1%) expired during the course of their care and were not included in analysis because of lack of outcome measures. Patients discharged from HHC included in the analyses numbered 1385 (85.8% of the original sample). There were no significant cohort differences in the percentage of patients whose care ended in discharge ( The majority of patients in the Early Cohort (68.3%) were referred from hospitals. While hospitals remained the largest referral category in the Late Cohort (59.1%), the proportion was smaller (p < 0.001), and there were greater proportions of referrals from SN facilities (10%−15%;

p < 0.01) and other facilities (6.8%−9.8%; p > 0.05).

Patients in the Early Cohort were also significantly more likely to come directly to HHC from hospital emergency departments (ED) and

were not admitted to an inpatient bed at the hospital (2.8% vs. 0.1%; p < 0.001). Analyses examining patients coming directly from the ED indicated they were, on average, 10 years younger (57 vs. 67 years old; p < 0.001) and had substantially fewer comorbidities ( At the start of the pandemic, age was strongly associated with mortality, with increases in age associated with exponentially higher mortality (Biswas et al., 2021; Caramelo et al., 2020; Center for Disease Control & Prevention, n.d.-d; Hussain et al., 2020) . High mortality among the elderly during the initial phase of the pandemic not only changed the demography of the US population, but also the potential pool of HHC patients. Shifts to a more aged HHC patient population in the Late Cohort, as well as greater referrals from SN and other facilities, likely signal improvements in acute treatment and stabilization of COVID-19 patients as the pandemic progressed Kosar et al., 2021; Seligman et al., 2021) .

The COVID-19 pandemic radically transformed health care delivery, with massive increases in telehealth and remote services (Jonnagaddala et al., 2021; Raffan et al., 2021; Slomski, 2020) . Early reports suggested that blood-oxygen saturation was an important, but silent, clinical warning sign of deterioration among COVID-19 patients (Shah et al., 2020) . The organization was able to seamlessly enroll COVID-19 patients into their existing remote monitoring program, allowing clinical surveillance of this at-risk population and early intervention if necessary. Rapid uptake of remote monitoring early in the pandemic may have allowed clinicians to avert unnecessary hospitalization among a more acutely ill patient population in the Early Cohort. Patients in the Early Cohort were also significantly more likely to receive oxygen in the home. There were no differences in the rate of hospitalization between the Early and Late Cohort (Early 12.7%, Late 14.4%; p = 0.342). These findings suggest that increased interventions (oxygen in the home and monitoring) may have kept Early Cohort patients from deteriorating and cycling back to the hospital.

During the pandemic there was a greater demand for virtual care.

In HHC, payment parity between telemedicine and in-person services was low before the pandemic. An alternative explanation is that differences in dyspnea at discharge represent differences between the cohorts that predate COVID-19

infection.

The vital role of role of HHC in treating COVID-19 patients, has been absent from public discourse and minimally included in the published literature. Early in the pandemic, HHC readily took overflow patients from hospitals, often directly from the ED, and provided care to a new patient population in a heavily strained health care system. As the pandemic progressed, acute care settings underwent a transition from older patients with greater comorbidities, to a younger patient population with fewer comorbidities. In contrast, HHC served a substantially younger population with fewer comorbidities at the start of the pandemic and trended to older patients with more comorbidities later in the pandemic. Care of COVID-19 HHC patients also shifted significantly as the pandemic progressed; Early Cohort HHC patients were significantly more likely to receive remote monitoring, oxygen in the home, and have remote check-ins compared to the Late Cohort. These findings highlight the changing function of HHC in the pandemic; from accepting overflow from acute care (e.g., directly from EDs), to a growing subpopulation from long term care facilities. 

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The authors declare no conflicts of interest.

Authors elect to not share data.

http://orcid.org/0000-0002-2425-8570