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Don Knox, executive director of  the Home Care & Hospice Association of Colorado, wrote a letter to Gov. Jared Polis on Dec. 7 supporting top priority status in COVID-19 vaccine access for home health care and hospice providers.

These providers “are on the frontlines of the pandemic caring for over 12 million of the nation’s most at-risk individuals annually through over 3.5 million dedicated caregivers,” Knox wrote.

In Colorado, they include physicians, nurses, therapists, home health aides, hospice aides, personal care aides, home care workers and direct support professionals — and more than 60 percent of them report having cared for COVID-infected patients.

The Home Care & Hospice Association of Colorado, based in Aurora, represents about 130 of the 200 or so agencies in the state that provide home health services.

Many of these agencies saw referrals slow at the beginning of the pandemic, Knox told the Business Journal.

“People were hesitant to let caregivers into their house, so that reduced the demand,” Knox said. “And similarly, some nurses and caregivers didn’t want to provide home care because of the fear of COVID.”

Early on, home health providers also had to cope with the same shortage of personal protective equipment that affected all health care facilities.

“It was really shockingly bad how little PPE was available to home care,” Knox said.

The PPE supply now has improved, and after a few months, the demand for home health care picked up again.

With the current surge in COVID-19 cases, Knox expects an increase in the demand for home health services.

“The increasing COVID hospitalizations are concerning,” he said, “and some of those patients will be discharged to home care when they leave the hospital. My understanding is that home care is

prepared to take care of them.”

Some local agencies say, however, that while they are currently keeping up with the demand for home health care, they are concerned about being able to hire enough providers if there’s a big increase in the number of people who need their services.

POST-HOSPITAL CARE

Patients with COVID-19 are being hospitalized in both El Paso County and the state at a sharply increased rate. 

According to El Paso County Public Health, as of Dec. 7, 259 confirmed cases of COVID-19 were being treated at regional hospitals and 14 potential cases were under investigation, for a total of 273 COVID-related hospitalizations.

Just a month ago, on Nov. 7, 89 people with confirmed COVID-19 were hospitalized and 13 cases were being investigated, for a total of 102 COVID-related hospitalizations.

As these patients are discharged from the hospital, some will return to skilled nursing and assisted living facilities, and some who return to their homes will require skilled home care.

“Everybody needs to be prepared to take these patients when they come out,” Knox said.

Medicare patients who are discharged from the hospital can receive home care coverage if they’re considered homebound and can’t travel to get care, Knox said. Medicaid patients qualify for home care coverage whether they are homebound or not.

Private insurance plans also cover home care in certain circumstances, and the Department of Veterans Affairs is another important referral source for home care, especially in Colorado Springs, Knox said.

Post-hospitalization COVID patients may need physical, occupational, respiratory or speech therapy, as well as continued nursing for people who have lingering after-effects.

“Home care’s ability to take those patients sooner frees up hospital beds,” Knox said.

While acutely ill patients generally need to remain hospitalized, “home care is increasingly being asked to take on more acute patients at home,” he said. “I think there is a place for that kind of care.”

As of Dec. 7, more than 14,900 COVID-19 patients have been hospitalized across the state, according to the state Department of Public Health and Environment. 

Although he does not have data to put a number on it, Knox thinks that thousands of those patients have received home care.

Even with the increasing numbers, those patients do not represent the majority of patients home health care providers see, he said. For the most part, they are people with conditions such as chronic obstructive pulmonary disease, asthma, multiple sclerosis, cardiac conditions, cancer and other ailments, as well as people who need continued rehabilitation for joint replacements, other surgeries or injuries. For these people, home care bridges the gap between hospitalization and outpatient clinics.

Knox thinks home care will continue to see an increasing number of these patients as well as its share of COVID patients.

“The demographic trends are just overwhelming,” he said. “As our population ages, home care will be increasingly utilized because it’s typically where patients prefer to be treated. Secondly, it’s relatively low cost — it costs big money to build big facilities.”

PROVIDER SHORTAGE

Centura Health at Home, an agency affiliated with Penrose-St. Francis Health Services, is seeing an increase in demand for home health care services.

“Our volume has been very, very strong — even higher than normal,” Director Cassandra Pratt said. “Since March, we’ve seen an increase by 20 percent for home health referrals. … We are actively looking for staff, we’re so busy.”

Pratt said Centura Health at Home has added three staff members, and “we would love it if that was three times the amount.”

Despite big sign-on bonuses — RNs receive a $15,000 bonus with a two-year commitment, high salaries and strong benefits packages to attract top talent — the agency is having trouble finding more associates, she said.

“Before the pandemic, I used to get maybe 10 applicants a week for our open positions,” she said. “Now I’m getting maybe one to two a week.”

Pratt isn’t sure why this is the case but theorizes that many of the people who normally would apply are choosing to stay at home because of their family situations.

“I think a lot of folks have to be at home with e-learning,” she said. “Maybe their spouse’s situation has changed at work. … It just seems like folks are maybe not actively pursuing those roles right now.”

The shortage of applicants isn’t just in home care.

“Our inpatient areas also have the same trouble,” she said. “It’s definitely nursing shortages but also [physical therapists] and [occupational therapists].”

At the same time, Centura Health at Home is seeing an increase in demand for services for COVID-19 patients. 

“In March, we had a total of about 30 that we serviced, and that’s been double in just the past month,” Pratt said. “I think across the state, they’re going home a little bit faster than they used to.”

These patients require home health services for longer now than at the beginning of the pandemic, she said.

“Typically, it goes about 45 days,” Pratt said. “Before, we would definitely discharge by day 30.”

Another factor is that many skilled nursing facilities that used to take post-hospitalization patients are not accepting them now.

“Toward the end of October, we started noticing that some skilled nursing facilities have told us, ‘Sorry, we just had an outbreak and can’t take any patients,’” she said.

Centura Health at Home’s COVID-19 patients require a lot of rehab services to help them regain their strength.

“A lot of them need some medication management, maybe some nebulizers or inhalers,” she said. 

HOSPICE CARE

Referrals to the hospice program at Pikes Peak Hospice and Palliative Care have remained steady, but “there have been some times of ups and downs,” President Dawn Darvalics said.

Patients are referred to hospice when they are terminally ill and have a prognosis of six months or less if the disease or condition runs its normal course. Referrals come from physicians in hospitals, skilled nursing facilities and in private practice. 

The vast majority have diagnoses such as dementia, cancer, cardiac conditions such as congestive heart failure, COPD and others. A very small number of referrals are patients with a terminal diagnosis of COVID-19, but some with other conditions are COVID-positive or have been exposed, Darvalics said.

Nonetheless, the pandemic has had profound effects on the way the organization operates.

One of the biggest changes since March has been in the way it communicates with partner organizations, such as nursing homes, hospitals and assisted living facilities, she said. Staff members are no longer able to freely walk into facilities, especially when they have an outbreak or lockdown.

The agency offers options for social worker and chaplain visits by video conference or telephone calls, but certified nursing assistants provide personal care services that have to be delivered in person.

“We would always follow the direction of the patient and family, if they didn’t feel comfortable letting us into their home,” she said. “But for the most part the nursing services and CNA services are welcomed. We take precautions; we always make sure that we are following strict infection control procedures.”

Darvalics said Pikes Peak Hospice has not been experiencing any additional hiring issues that weren’t present before COVID-19. 

“The positions that are hard to fill are always the positions that are hard to fill — your nighttime shifts,” she said.

“What has been a challenge at times is the number of staff you have out on quarantine, because we take a very conservative approach to making sure that everyone is safe,” Darvalics added. “We look to our current employee base, and we have reached out to staffing agencies … a few times.”

Darvalics said that while staff members are used to being on the road, they miss coming into the office for interdisciplinary group meetings and events.

“Those really gave them that human connection with team members that they don’t necessarily get every day because of the nature of the work that we do,” she said. “So we’ve gotten creative in how we can safely still connect our staff. During virtual meetings, we dedicate time to making sure that they talk about things like, ‘How was your weekend?’

“I can tell they’re just really looking forward to the day when we’ll go back to being the way that it was.”