key: cord-0827125-pbsmvgz6
authors: Brocard, Eva; Antoine, Pierre; Mélihan-Cheinin, Pascal; Rusch, Emmanuel
title: COVID-19′s impact on home health services, caregivers and patients: lessons from the French experience
date: 2021-08-18
journal: Lancet Reg Health Eur
DOI: 10.1016/j.lanepe.2021.100197
sha: 9dd79517c1a4d6e3cc6eb05997497b7719327deb
doc_id: 827125
cord_uid: pbsmvgz6

nan

The changing needs of citizens (longer life expectancy, an ageing population, as well as a desire to stay at home as long as possible) impelled an "ambulatory shift" seen in French health care services reform [1] , involving both hospital reform, as well as organizational structure design. In France, homebased care is provided either in the context of hospitals who employ healthcare professionals in the home, independent nurses, both providing healthcare services, or domestic help personnel and informal caregivers who are paid directly by their client patients.This ambulatory shift has also taken place to offer alternatives to patients in a time of health crisis, when the health care system faces bed and medical staff shortages. Since the beginning of the Covid-19 pandemic, home-based care has been unprecedently solicited to relieve the pressure on hospitals, enabling patients with chronic conditions or suffering from non-severe Covid-19, to be taken care of and monitored at home [2] .

While invaluable evidence has been accumulated about the impact of Covid-19 on the French healthcare system and the strains the pandemic imposed on it, our knowledge of the challenges faced by the home-based care sector during this pandemic has been very limited. To remediate this paucity of knowledge, the French Health National Conference (CNS), a consultative body gathering the widest range of stakeholders from the health and social sectors, surveyed its members to collect information on the rights and access to care of home-based patients during the Covid-19 pandemic [3] . Building on 20 written contributions shared by the CNS' members, this paper discusses the impacts of Covid-19 on home-based care services, homecare givers, and patients in France, and offer policy recommendations to strengthen access and quality of care delivered in the home.

Covid-19 has heightened the challenges already faced by the home care sector before the outbreak (long work hours, low minimum wage and limited opportunities for career advancement leading to staff shortages) [4] and exposed their lack of knowledge by public authorities and a large number of health professionals. Homebased care providers not employed by a hospital, were at an even lower priority than hospitals and nursing home professionals for the alreadyinsufficient PPE supplies. They did not only received minimal guidance early in the outbreak but also were provided significantly less facemasks, or none for informal care providers, than any other health professional, exacerbating the inequities they face as a marginalised workforce. It also translated into a misconception of the application of patients' rights, such as the right to clear and fair information, or about medical secrecy leading to situations where healthcare professionals would deny home-based care providers access to patient medical information, ignoring the regulatory changes in the 2016 health law [5] .

In addition to these difficulties, other factors participated in a decline of visits by care providers to patients at home, especially during the first wave of the pandemic. Similar to findings observed in the United States [6] , the main reasons behind this reduction are the concerns from families or care providers about bringing or getting Covid-19 in the home, home aides needing to care for their own children due to school closures, or providers being forced to remain in quarantine because they were diagnosed positive to Covid-19. The reduction of home care services has imposed a substantial additional burden on informal caregivers. Findings of an online survey showed that in April 2020, family caregivers in France [7] , similar to unpaid home carers in the United Kingdom [8] , provided more care, surveillance, emotional support, and assistance (bathing, grooming, etc.) than prepandemic. The crisis has also shown the lack of surveillance/monitoring tools collecting epidemiological data on home-based care workers and patients suspected, infected with, or deceased from Covid-19. The first provisional mortality data for patients deceased from Covid-19 at home were provided only in August 2020. The numbers are nevertheless likely to be underestimations as they rely on the study of transmitted paper death certificates [9] , and not recorded in databases as it is for hospital and nursing homes deaths.

Despite these hurdles, the pandemic also helped to transform healthcare delivery at home and enabled the implementation of innovative experiments to slow Covid-19 transmission. For example, the COVISAN [10] experiment developed in the Greater Paris Metropolitan area consists of mobile health units providing Covid-19 home testing, education on preventative measures for patients and their relatives as well as solutions for isolation of positive cases in hotels if necessary. The pandemic has led to an unprecedented reliance on hospitalization at home for patients with chronic diseases and patients suffering from non-severe Covid-19. The National Federation of Hospitalization at Home (FNEHAD) [11] reported 4000 patients with Covid-19 who were hospitalized at home between March and June 2020, which represented 4% of the total of hospitalizations, the double of prepandemic (2% before . Finally, in the use of digital health technologies increased in order to monitor both Covid-19 positive patients, with for example the COVIDOM telemonitoring platform [10] , as well as patients suffering from chronic diseases or a disability. Remote consultations by phone or video call emerged as an alternative to offer a safe continuity of care for non-Covid patients unable to make a physical visit to their doctors [12] .

In July 2020, in the midst of the pandemic, the French Government publicly acknowledged the value of professional home caregivers and expressed its support to make these professions more attractive in the future. The Government has committed to the payment of a premium of up to 1000 euros for the 320 000 home caregivers who maintained their visits during lockdowns, a pay rise of between 13% and 15%, and more recently announced free of charge Covid-19 self-testing for home care providers. However, necessary steps forward are still needed to strengthen the home-based care sector in France post-pandemic. The experiences and hardships observed during the outbreak are providing an exceptional platform to build on the inspiring solutions and cooperation implemented this past year. Therefore, capitalizing on innovative coordination and experiments implemented during the pandemic, the CNS urges public authorities to better integrate homecare services with all the actors of the health care system by encouraging the participation of home caregivers (professionals and informal ones) and patients to the decision-making process affecting them and the organization of their sector. Furthermore, the rapid uptake of digital health technologies by the healthcare system, combined with the ease of telemedicine practices rules in France during the pandemic provides the unique opportunity to embrace the transformational benefits offered by these technologies. However, the CNS stresses once more [13] on the importance of digital upskilling and equipment of home caregivers and their patients to ensure a better and equitable access to care in the home. Finally, the development of a centralized database on homecare, similar to HomeCareData [14] in Switzerland or the Home Care Reporting System database in Canada [15] , appears more than ever essential to gather robust data on home-based care and inform decisionmaking for the patient, and at the policy level.

The increasing demand for home-based care and the lived experiences during Covid-19 provide a unique window of opportunity to invest in home-based care providers and services, which will translate into better access and continuity of care in a resources constraints context.

Health inequalities and France's national health strategy

Covid-19: quel suivi pour les patients Covid+ en ambulatoire ? Communiqu e de presse. Haute Autorit e de Sant e (HAS). 13 avril 2021

Health democracy in time of COVID-19: a perspective from France

Observatoire OpinionWay pour UNA

D ecret n°2016-994 du 20 juillet 2016 relatif aux conditions d' echange et de partage d'informations entre professionnels de sant e et autres professionnels des champs social et m edico-social et a l'acc es aux informations de sant e a caract ere personnel

Impacts of the COVID-19 pandemic on home health and home care agency managers, clients, and aides: a cross-sectional survey

Impact du confinement: une charge suppl ementaire pour les aidants

Caring behind closed doors: six months on. The continued impact of the coronavirus (COVID-19) pandemic on unpaid carers

Visualisation des donn ees du centre d' epid emiologie sur les causes m edicales de d ec es de l'Inserm sur la Covid-19

response to the COVID-19 pandemic. Lancet

F ed eration nationale des etablissements d'hospitalisation a domicile, L'HAD, un partenaire pr esent, r eactif et adaptable

Keeping what works: remote consultations during the COVID-19 pandemic

« Faire en sorte que les Applications et Objets Connect es en sant e b en eficient a tous » Avis de la Conf erence Nationale de sant e du 8 f evrier 2018

Soins a domicile: de nouvelles donn ees. Bulletin of August 18th, 2020 of the Swiss Health Observatory (Obsan

Canadian Institute for Health Information

The Lancet Regional Health

We would like to thank all the members of the French Health National Conference, as well as its associate members, for their written contributions on the topic of home-based care during the Covid-19 pandemic who provided invaluable information for the conception of this comment. We would like to thank them, as well as the General Directorate of Health of the Ministry of Health and Solidarity for their support in the development of this document.

The study conception and design was conducted by all of the authors: Eva Brocard, Pierre Antoine, Pascal M elihan-Cheinin and Emmanuel Rusch.The data analysis and original draft manuscript preparation was made by the corresponding author Eva Brocard and Pierre Antoine.The writing, review and editing of the final manuscript draft was conducted by all the authors: Eva Brocard, Pierre Antoine, Pascal M elihan-Cheinin and Emmanuel Rusch.All authors reviewed the results and approved the final version of the manuscript. E. R is the elected President of the French Health National Conference and receives no salary for his role.