“Health literacy is a state of knowledge and comfort that allows you to navigate the world and achieve wellbeing,” Danielle Brooks, director of quality health equity at AmeriHealth Caritas, told Home Health Care News. “It is critical to navigating, supporting and advocating for yourself when experiencing a medical or health-related need.”

AmeriHealth Caritas, based in Newtown Square, Pennsylvania, is a national managed care solution provider.

Limited health literacy significantly impacts Medicaid members, with 60% having basic or below-basic literacy, compared to only 24% of those with employer-sponsored coverage, according to the Center for Health Care Strategies. This demographic includes people aged 65 and older, individuals with lower incomes, those with lower education levels, people with limited English proficiency and minorities.

Furthermore, low health literacy rates lead to higher hospital use, higher mortality rates and higher health care costs. Improving rates could prevent one million hospital visits and save over $25 billion annually, according to the Centers for Disease Control and Prevention (CDC). Health literacy is essential in home care because it can affect a patient’s ability to understand and follow their treatment plan.

Oftentimes, patients also don’t realize that home health care or home care are options available to them.

“The complexity of the health care system and health concerns like COVID-19 require strong literacy skills to find, understand, evaluate and use health information to make informed decisions,” Sabrina Kurtz-Rossi, assistant professor at Boston’s Tufts University School of Medicine, told HHCN. “Compelling sources of health information, including inaccurate information on social media and the internet, intensify the need for improved health literacy for all.”

The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) have listed improved health literacy as organizational priorities. Specifically, HHS has included it in its Healthy People 2030 initiative.

Organizations and professionals can enhance their health literacy by implementing proven strategies. These include addressing questions in simple, non-medical language and creating and testing written materials for the intended audience, as per the HHS.

It’s important to consider that any patient may face challenges in understanding health information. Adults with limited literacy often feel ashamed of their abilities and may conceal their difficulties. Conducting informal client assessments can help identify individuals with limited literacy skills.

“Organizations should start by asking themselves this question,” Brooks said. “What do we need to do to reach our clients in a way they understand and that speaks to them? Materials and messaging need to be presented in a way that is most easily understood by clients and resonates with them. Employees must learn how to incorporate health literacy into their work every day.”

State contracts often require insurers serving Medicaid enrollees to have materials available in multiple languages, written at a sixth-grade reading level or lower, and have member-facing staff who can speak languages other than English.

“It is important to have data on how your current and potential clients understand and process information,” Brooks said. “This includes not only what languages they speak but also factors like age, education level, gender identity, sexual orientation and family structure. This information provides important insights into their needs. It is about communicating to members in a way that is most easily understood and actionable.”

The CDC recommends asking patients how often they need help reading written material from their doctors or pharmacies and asking them to explain instructions in their own words to show that they understand. Use videos, models and pictures to help clients learn. Listen to concerns without interrupting and consider clients’ cultural and linguistic norms when developing messages. Use certified translators and interpreters to adapt to language preferences.

“There are validated tools for analyzing written health information for reading ease and accessibility,” Kurtz-Rossi said. “These include the Patient Education Materials Assessment Tool, the CDC Clear Communication Index, and the Readability, Understanding and Actionability of Key Information on Informed Consent Forms (RUAKI) Indicator. Readability formulas can tell you the reading grade level at which a material is written but do not assess layout and design, cultural relevance or other features that help make information accessible.”

Active engagement is also vital to improving clients’ health literacy and ensuring they receive the best care. Engaged clients are more likely to follow treatment plans and work with their caregivers to make informed decisions.

Caregivers should encourage questions, ask clients to express concerns, and readily offer information during visits. Open communication helps build relationships between clients and caregivers and may make clients feel more comfortable asking questions about their conditions.

“The ten attributes of literate health care organizations provide a framework for how organizations can ensure clear communication and understanding,” Kurtz-Rossi explained. “Health-literate organizations strive to provide equitable and understandable information and services using evidence-based health literacy interventions, including plain language in written and oral communication and teach back to confirm understanding. Other health literacy tools and resources can help organizations engage leadership, prepare the workforce, create a shame-free environment and use plain language print materials and websites.”

Caregiver literacy is also a concern

It is important to note that caregivers also have a range of health literacy skills.

“Health literacy is a multifaceted concept which reflects not only individual-level skills but also the unnecessary burden placed on clients and caregivers by an overly complex health system,” Rachel O’Conor, assistant professor at the Center for Applied Health Research on Aging at Chicago’s Northwestern University, told HHCN. “Thinking about health literacy as both an individual skill, but also an organizational trait, can be helpful for agencies to consider as they seek to promote health literacy among their caregivers.”

A recent study showed that 44% of caregivers demonstrated adequate knowledge, 36% demonstrated marginal knowledge and 20% had low health literacy skills. In adjusted analyses, caregivers with marginal and low health literacy demonstrated worse overall performance on health tasks and poorer interpretation of health information presented on print documents and recall of spoken communication. As a result, these caregivers demonstrated poor performance on everyday health tasks with which they commonly assist older adults. The application of health literacy best practices to support better training and capacity-building for caregivers was found to be warranted.

Researchers suggested online training modules to promote caregiver communication with health care clinicians. Following health literacy best practices, these modules should be developed using plain language and cultural inclusion.

“To ensure caregivers are equipped to provide a high level of care, agencies should provide skills-based training on how to assist with health-related tasks,” O’Conor said. “The training could incorporate health literacy best practices in order to promote comprehension and application of the information.”

O’Conor said that she has found that the inclusion of both spoken and print information can promote recall, as well as breaking the information into manageable pieces for better comprehension.

“All corresponding information needs to be easy to understand,” she said. “Passing a simple test demonstrating competency may be reasonable to ensure proficiency in these skills. This act of demonstrating proficiency is in essence the application of teach-to-goal procedures, which is a common health literacy best practice to promote comprehension of health information.”

Home-based care agencies that prioritize personal and organizational health literacy can benefit from multiple positive outcomes. Expanded literacy can improve client health outcomes, decrease emergency department visits by ensuring clients seek preventative care, reduce the number of dosing errors, help clients manage chronic conditions and increase satisfaction.

“Caregivers have a unique role to play when it comes to tailoring and communicating treatment plans to meet the unique needs of individual clients,” Kurtz-Rossi said. “Doctors are one important point of content, but it takes a health care team – including family members – and each member of the team needs to listen to client concerns and communicate plans and services clearly. Clear communication builds trust. When a client is engaged with and trusts their caregivers, they are more likely to follow recommendations.”

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Specifically, the study took into account the status of family caregivers, and how that changed from 2015–2016 to 2021–2022. One in five adult Americans provides care support to a friend or family member, according to the CDC.

The CDC recognizes this sect of the population as critically important, given that the loved ones they care for may otherwise be in a brick-and-mortar care facility. Like home care providers, these family caregivers allow seniors to age in what is oftentimes the preferable setting – the home.

Over that stretch of time – from 2015-2016 to 2021-2022 – the percentage of caregivers aged 60 years and older increased from 28% to 35.4%, which outpaced the general population.

The prevalence of frequent mental distress also increased during that time period by 2.3%. In general, caregivers are more susceptible to mental distress and depression than their non-caregiver counterparts.

Out of 19 health indicators, 13 were more unfavorable for caregivers than non-caregivers. Obesity, asthma, chronic obstructive pulmonary disease and arthritis especially hinders caregivers. Caregivers were also more likely to report “inability to see a doctor due to cost during both periods.”

But four measures did improve in 2021-2022, including the prevalence of current smoking, physical inactivity, no health coverage and inability to see a doctor due to cost.

These caregivers, in some cases, are likely candidates for support under self-directed programs. The Biden Administration has attempted to better support this group of individuals over the last few years.

“The National Strategy to Support Family Caregivers has raised awareness of the need to support the health of caregivers nationwide,” the study authors wrote. “Goals outlined in the strategy include strengthening services and supports for family caregivers and expanding data, research, and evidence-based practices. Providing relief from caregiving tasks, broadly known as “respite care,” was identified as a priority. Availability of such services can be optimized through public policies and community collaboration, resulting in high-quality, affordable and flexible care. Additional strategies to ensure financial and workplace security for caregivers have been implemented in some states and include enhancement of paid family leave and antidiscrimination laws.”

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Late Friday, the Centers for Disease Control and Prevention (CDC) issued guidance that ended a blanket indoor mask requirement that had been in effect for the last two and a half years.

The guidance was part of the CDC’s revisions to the agency’s COVID-19 recommendations, one of the final sets of changes that began in August.

The CDC recently reported that just over 73% of counties in the U.S. have “high” COVID transmission levels. About 27% of counties meet the substantial, moderate or low categories.

Since early in the pandemic, the CDC has urged people in the U.S. to wear masks – what the agency calls “source control” – while in health care settings.

The new guidelines apply to nursing homes, home health facilities and hospitals. The guidelines do not apply to restaurants and other non-health care environments.

“Updates were made to reflect the high levels of vaccine- and infection-induced immunity and the availability of effective treatments and prevention tools,” the CDC’s new guidance reads.

Even though masks are no longer required in facilities where transmission is not high, the CDC still recommends they be worn:

– If someone has a suspected or confirmed COVID-19 or other respiratory infection
– If someone has close contact or a higher-risk exposure with someone who had COVID-19 for 10 days after their exposure
– If someone lives or works somewhere that is experiencing a COVID-19 outbreak (in this case, universal mask wearing can stop once no new cases have been identified for 14 days)
– If mask wearing is recommended by local public health authorities

Last week, President Joe Biden made waves by saying “the pandemic is over” during his appearance on CBS’ “60 Minutes.”

In an interview with ABC News after receiving her bivalent COVID-19 booster shot, CDC Director Rochelle Walensky didn’t directly agree with the President but said the country “is in a different place.”

“I think if we look at the big picture, things are very different,” Walensky said. “We’re in a different place. Schools are open and businesses are open. We have a lot of population immunity out there right now.”

The updated guidelines come almost exactly a year after President Biden unveiled a six-pronged national COVID-19 strategy where home health agencies were explicitly mentioned in the plan.

At the time, the Biden administration pushed American workers to get vaccinated and called for an increase in testing and masking among health care workers.

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Up until now, health care providers in many states have been left to develop their own in-house vaccination policies for workers. In some instances, however, health care providers across the continuum of care have had to adhere to state-mandated vaccine policies.

Wednesday’s announcement from CMS was made in collaboration with the U.S. Centers for Disease Control and Prevention (CDC). No other health care settings serving older adults, including home health care, were mentioned.

“Keeping nursing home residents and staff safe is our priority,” CMS Administrator Chiquita Brooks-LaSure said in the announcement. “The data are clear that higher levels of staff vaccination are linked to fewer outbreaks among residents, many of whom are at an increased risk of infection, hospitalization or death.”

Overall, there are more than 15,000 nursing homes that participate in the Medicare and Medicaid programs. Effectively, making COVID-19 vaccinations a requirement suggests nursing homes could be cut off from reimbursement within those two channels if they do not comply.

“If you visit, live or work in a nursing home, you should not be at a high risk for contracting COVID from unvaccinated employees,” President Joe Biden said in a White House address.

So far, different health care settings have seen varying vaccination rates, with home health care often being cited among the least vaccinated sub-sectors. As with the general population, all corners of the health care world have seen a small portion of the workforce firmly against getting vaccinated.

If nursing homes are pressured into implementing mandatory vaccination policies, operators may ultimately see their vaccine holdouts leave for other health care jobs, industry insiders fear.

“Focusing only on nursing homes will cause vaccine hesitant workers to flee to other health care providers and leave many centers without adequate staff to care for residents,” Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), said in a statement. “It will make an already difficult workforce shortage even worse. The net effect of this action will be the opposite of its intent and will affect the ability to provide quality care to our residents.”

Leaders from LeadingAge similarly noted that vaccinations should be required for health care workers in all settings.

“[To] penalize nursing homes by withholding or withdrawing funding is not the right way to increase vaccination rates,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement. “Without Medicaid and Medicare funding, nursing homes cannot provide the quality care that our nation’s most vulnerable older adults need.”

As of Aug. 8, about 62% of nursing home staff were vaccinated, with vaccination rates ranging from a high of 88% in some states to a low of 44%.

The new emergency regulation for Medicare and Medicaid nursing homes comes as the Delta variant spreads, leading to a rise in COVID-19 cases among nursing home residents. Nursing home cases have jumped from a low of 319 on June 27 to nearly 2,700 cases on Aug 8, according to CMS.

“As we advance these new requirements, we’ll work with nursing homes to address staff and resident concerns with compassion and by following the science,” Brooks-LaSure added.

While home health providers weren’t part of the CMS announcement, it could produce a trickle-down effect on the referral front as well.

Since the pandemic started, many facilities have been reluctant to open their doors to outside staff. Linking vaccination status to reimbursement is likely to exacerbate those anxieties, especially for home health providers with poor vaccination rates among workers.

As of last week, nearly one-quarter of all U.S. hospitals required staffers to get a COVID-19 vaccine.

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Since the onset of the COVID-19 emergency in early 2020, home-based care providers have had to navigate seemingly countless challenges around keeping both patients and staff safe. Providers are now gearing up to face a new and more aggressive strain of the coronavirus: the Delta variant.

Among its major distinctions, the Delta variant is more transmissible than previous strains of coronavirus. The CDC, in fact, has classified the Delta variant as more transmissible than the common cold, influenza and the viruses that cause smallpox or Ebola.

The Delta variant has been the most dominant strain of the COVID-19 virus in India and Great Britain for some time. By the end of July, Delta cases made up more than 80% of new COVID-19 cases in the U.S., according to CDC estimates.

For home health providers, especially those in states with lower vaccination rates, all this has meant a renewed focus on infection control and staff education. Many are working tirelessly to ensure that their staff members are fully vaccinated, something that has been a challenge in the home health space, past surveys have suggested.

“We are doubling down on vaccination efforts for staff,” Brent Korte, chief home care officer at EvergreenHealth Home Care, told Home Health Care News. “We’re somewhere north of 90% for employees, including all clinicians and support staff. And we’re doubling down on this idea that we won’t rest till we get to 100%.”

Kirkland, Washington-based EvergreenHealth Home Care, a part of EvergreenHealth, is one of the largest home health and hospice providers in the Pacific Northwest. The company has a staff of roughly 600 members that manage more than 11,000 episodes of care each year.

With more than 90% of its staff vaccinated, Evergreen is in a presumably better position than its industry peers, many of which are in the midst of debating mandatory-vaccination policies.

Generally, mandatory-vaccination stances haven’t been extremely common in home health care, at least compared to other settings.

As of Tuesday, nearly one-quarter of all U.S. hospitals required staffers to get a COVID-19 vaccine. Some of the nation’s largest operators of skilled nursing facilities (SNFs) have taken that route as well, including Genesis HealthCare, which implemented a “universal” COVID-19 vaccination requirement for its employees, care partners and onsite vendors at the state of August.

“It’s a very delicate conversation — the justification and the strength behind getting vaccinated,” Korte said. “We’re at the level now where we hone in on the last maybe 8% or so of staff that can get vaccinated.”

Planning ahead

In order to address vaccine hesitancy, Korte has offered to listen to the concerns of every employee who has reservations. He recommended that other home health leaders do the same.

“No judgment whatsoever,” Korte said. “I can at least hear out and learn why they don’t want to be vaccinated, then maybe that can help me change my approach as the executive overseeing all of our work.”

In the early period of the public health emergency, Evergreen was one of the first providers in the country to treat COVID-19 patients. Being on the front line of care early has prepared Evergreen for this next phase of the pandemic, Korte explained.

“Being the first in the United States was super difficult,” he said. “The silver lining is that it forced us to prepare, it forced us to figure out personal protective equipment (PPE). It forced us to figure out proper PPE rationing. We didn’t really choose to be the tip of the spear, but it helped us not become the epicenter because we were able to take quick action. We’re using that same mentality with the Delta variant.”

In addition to Evergreen’s vaccination efforts, the company hasn’t let up on its PPE standards, still working overtime to keep its staff educated and protected. The company’s infectious disease physician, Dr. Frank Riedo, has played an integral role.

“We not so jokingly call him the Fauci of Washington State because he was the doctor that identified the first U.S. [COVID-19] patient,” Korte said. “We’re sharing his feedback. We’re super lucky as a system-based provider to have that resource. I recommend that any of the thousands of agencies out there lean on whoever that most respected, most neutral voice is.”

Another home-based care organization that is navigating the Delta variant is New York’s VNA of Albany.

VNA of Albany is a nonprofit that is affiliated with Albany Medical Center, Saratoga Hospital, Glens Falls Hospital and Columbia Memorial Hospital. As an organization, VNA of Albany offers home health and private-duty care, serving 11 counties in New York state.

Similar to Evergreen, VNA of Albany has maintained its staff PPE requirements. Keeping staff educated has also been important, as COVID-19 cases continue to rise, Holly Chaffee, VNA of Albany’s vice president and COO, told HHCN.

“It’s been educating staff that the variant is out there, encouraging them to be vigilant about hand washing, about PPE and about educating their patients,” Chaffee said. “Just because you’re vaccinated doesn’t mean this is over.”

Constant communication

Among the steps it’s taking to battle the Delta variant, VNA of Albany conducts weekly team meetings with its clinicians to keep them up to date. Ensuring that VNA of Albany’s staff has been vaccinated is one of the organization’s main strategies against this latest phase of the public health emergency.

Overall, 92% of the organization’s field staff is fully vaccinated, according to Chaffee.

And while providers have mostly bounced back, many saw patient-volume decreases in the earlier part of the COVID-19 emergency. Chaffee said she doesn’t believe the Delta variant will trigger this kind of impact.

“I think it may lead to an increased volume in home health because in the skilled facilities, people were unable to visit with their family members,” she said. “Whereas, if they’re at home, they can see their family members. The isolation for patients has led to more comorbidities, loneliness and isolation, on top of other illnesses.”

Chaffee noted that a potential increase in home health volumes could result in staffing pressures on an industry that is already struggling to recruit and retain workers.

In the past week, a number of home health providers have also taken the time to address the Delta variant, with publicly traded companies doing so during their second quarter earnings calls.

Leaders from Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED), for example, said the aging-in-place giant hasn’t seen volume disruption yet, though it is seeing more staff members enter quarantine. That’s partly due to vaccine hesitancy among a relatively small portion of its workforce.

“I think the Delta variant has got people’s attention,” President and COO Chris Gerard said during a Thursday conference call. “When we do a polling of our internal staff, it’s a pretty stark line — around 20% — that are pretty opposed to taking the vaccine for various reasons.”

“Our goal is to make sure that we continue to educate and stress the importance of this,” Gerard added.

Additionally, Amedisys is watching for the potential impact the Delta variant may have on the occupancy rates at senior living facilities — a major referral source for the company. In total, senior living facilities account for about one-quarter of Amedisys referrals.

“Occupancy pressures continue to be a headwind we are fighting today, especially with the Delta variant surging and pointing to a higher probability of occupancy being significantly lower throughout the remainder of 2021,” Gerard said.

So far, the Delta variant has not impacted hiring or revenues at Frisco, Texas-based Addus HomeCare Corporation (Nasdaq: ADUS), but the company is still working to increase its staff vaccination rate, which currently sits at 60% for home health and hospice.

On the personal care side, the staff vaccination rate for Addus checks in at almost 40%.

“We’re continuing our efforts to educate our caregivers on the benefits of being vaccinated,” Bradley Bickham, executive vice president and chief operating officer of the company, said on a Q2 earnings call Tuesday. “But this is an ongoing process and certainly more challenging with a personal care workforce that is largely, part-time workers.”

Elective surgeries paused

Home health providers are hunkering down for another possible wave linked to the Delta variant by hammering home the importance of the vaccine, but they aren’t panicking from a business perspective.

Monday did bring a troubling sign of what the future may hold, however, as Texas Gov. Greg Abbott asked hospitals to voluntarily postpone elective surgeries due to a spike in COVID-19 cases.

“The state of Texas is taking action to combat the recent rise in COVID-19 cases and ensure that our hospitals and communities have the resources and support they need to mitigate the virus,” Abbott said.

Other states experiencing similar spikes — Arkansas, Louisiana, Florida and others — may be forced to announce similar precautions in days to come.

That could hit home health providers hard, as most saw a sharp decrease in patient volumes during the first round of elective-surgery delays.

“There’s fear in the home health community — and in the health care community, at large — that things could get tough again,” EvergreenHealth Home Care’s Korte said. “It was terrifying, what Washington state went through in March and April [2020], what New York went through a few months later and what the entire nation ended up going through. No one wants to experience that again.”

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The letter was born out of a collaboration between seven organizations, including the Home Care Association of America (HCAOA), the National Association for Home Care & Hospice (NAHC), the Partnership for Medicaid Home-Based Care (PMHC) and the Partnership for Quality Home Healthcare (PQHH).

“I’m really thrilled that all of the home care associations got together and are speaking in one voice on such an important issue as vaccines,” Vicki Hoak, executive director of HCAOA, told Home Health Care News.

Last week, ACIP specified which groups should be granted priority access for Phase 1 of vaccine distribution.

ACIP determined that health care workers and residents of nursing homes should be on the list. The CDC committee also said that essential workers, older adults and individuals with underlying medical conditions should also be granted priority access to a vaccine.

During a Tuesday meeting, ACIP voted 13 to 1 in favor of those recommendations.

Vaccine distribution has garnered national attention since last month’s news that COVID-19 vaccine manufacturers Pfizer and Moderna filed for emergency use authorization with the Food and Drug Administration (FDA). Oxford and AstraZeneca are also close to rolling out a vaccine.

In their letter, the national home-based care advocacy organizations commended ACIP’s recommendations but urged the committee to be specific in its definition of health care workers in order to ensure that all caregivers are included. That includes home health aides, hospice aides, personal care aides, home care workers, direct support professionals and others.

“Our concern is that under the most recent CDC COVID-19 Vaccination Program Interim Playbook for COVID-19 Vaccination Program Jurisdiction Operations, home care workers, specifically personal care aides and home health aides, are not explicitly mentioned as Phase 1 or Phase 1A critical populations for vaccinations,” PMHC Chairman David Totaro told HHCN in an email.

The distinction is important because caregivers working on the non-medical side of home-based care are sometimes overlooked when it comes to federal policy, according to Hoak.

“Sometimes when you think of COVID, you think ‘medical,’ and a personal care aide helping people with activities of daily living doesn’t always come to mind,” she said. “But they are just as critical, especially during this pandemic.”

In the letter, the group also stated that the home care population should be afforded high-priority status for access to the vaccine.

The letter also stressed the importance of the adoption of these recommendations at the state and local levels. ACIP recommendations will serve as a guideline, but ultimately the decisions happen at a state level.

In Massachusetts, for example, physicians and community leaders on the Massachusetts COVID-19 Vaccine Advisory Group have expressed that front-line workers such as caregivers should be early recipients of the vaccine.

Texas has also placed home health workers in its “Tier 1” prioritization category, along with hospice staff.

“What we’re doing next is encouraging all of our members to send letters to their various state officials who are developing these plans,” Hoak said. “Now that we have tried to encourage the federal agency to adopt our recommendations — making sure that they’re all-inclusive — the next step is to advocate at the state levels to make sure that same message is carried forward.”

In addition to the previously mentioned organizations, the American Network of Community Options and Resources; the Council of State Home Care & Hospice Associations; and the National Hospice and Palliative Care Organization also signed the letter.

Combined, the seven organizations represent in-home care providers caring for over 12 million individuals annually. Collectively, those home-based care providers have served “tens of thousands of patients with active COVID-19 infections,” according to the letter.

Over 60% of home care and hospice providers are currently reporting COVID-19-infected patients on service, with many of those patients often living in facility-based settings.

“We want to emphasize that the individuals we serve often have complex service needs and are

at high risk for COVID-19,” The letter reads. “While we recognize the need for vaccinations for those that live in long-term care facilities, it is important to remember that our workforce, on a daily basis, frequently goes to multiple homes. They also provide care in other health care settings, including nursing homes, assisted living facilities and in-patient hospice facilities. The greater protection that both the workforce and individuals receive, the less likely there will be a community spread of the virus.”

U.S. nursing homes are experiencing the worst outbreak of weekly new COVID-19 cases since last spring due to community spread among the general population, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) announced on Tuesday.

Nursing home cases have officially surpassed the previous peaks since the Centers for Medicare & Medicaid Services (CMS) started tracking cases in nursing homes.

“Our worst fears have come true, as COVID runs rampant among the general population and long-term care facilities are powerless to fully prevent it from entering due to its asymptomatic and pre-symptomatic spread,” Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement.

Additional reporting by Tim Regan.

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In September, the American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) urged state leaders to prioritize nursing homes and assisted living communities for vaccine distribution, pointing to the tragic deaths among both residents and staff. In-home care advocates and other aging services stakeholders have made similar overtures.

Early policies out of Texas suggest those outreach efforts are paying off.

Workers in long-term care settings serving high-risk, vulnerable populations should be part of the first group to receive COVID-19 vaccines, according to new recommendations from Texas’ COVID-19 Expert Vaccine Allocation Panel. That includes home health workers.

“These guiding principles established by the Expert Vaccine Allocation Panel will ensure that the State of Texas swiftly distributes the COVID-19 vaccine to Texans who voluntarily choose to be immunized,” Governor Greg Abbott, a Republican, said in a statement.

In addition to long-term care workers, hospital staff members and emergency medical responders directly caring for COVID-19 patients will likewise receive early access to a vaccine.

Specifically, home health workers are included in Texas’ “Tier 1” prioritization category, along with hospice staff. “Tier 2” includes outpatient settings where health care providers are treating patients exhibiting COVID-19 symptoms.

Nearly 3,700 health care providers and institutions in Texas have signed up to receive vaccine shipments, The Dallas Morning News reported, attributing the information to a spokesman from the Department of State Health Services.

“This foundation for the allocation process will help us mitigate the spread of COVID-19 in our communities, protect the most vulnerable Texans, and safeguard crucial state resources,” Abbott’s statement continued.

While Texas is one of the only states so far to directly call out home health workers, others have broadly identified “health care workers” as early vaccine recipients.

In California’s framework unveiled Monday, for example, state officials said the goal is to first vaccinate the state’s 2.4 million health care workers, including first responders and those who work in congregate care settings.

Full Phase 1 distribution recommendation will be ready by Dec. 1, according to Democratic Governor Gavin Newsom, who recently had to quarantine with his family after his children were exposed to the coronavirus.

“The first tranche of vaccinations will be extraordinarily limited,” Newsom clarified.

Considering the developments in Texas, it’s likely that even more states will focus on in-home care workers in days to come. Doing so certainly makes sense from a numbers standpoint, as home health and hospice agencies employ millions of workers who deliver care to even more high-risk individuals each year.

In 2018, the country’s network of roughly 11,500 home health agencies cared to 3.4 million Medicare beneficiaries, according to the Medicare Payment Advisory Commission (MedPAC). In doing so, they delivered roughly 6.3 million visits.

Most of those beneficiaries suffered from multiple chronic conditions and had trouble eating, bathing or dressing.

In 2019, home health agencies employed an estimated 1.5 million workers, according to the Alliance for Home Health Quality and Innovation’s 2020 Chartbook, produced in conjunction with Avalere Health.

While Texas is clearly prioritizing home health and hospice workers, it is unclear whether “health care workers” also includes front-line professionals in the non-medical home care field.

How government officials define “home care” has been an issue throughout the COVID-19 pandemic, especially in regard to paid-leave rules outlined in the Families First Coronavirus Relief Act (FFCRA).

Even if states prioritize home health and home care agencies for a COVID-19 vaccine, it’s not a guarantee that workers will opt for one, especially with all the unknowns and potentially unpleasant side effects.

Participants in Moderna and Pfizer’s coronavirus vaccine trials told CNBC in September, for instance, that they experienced “high fever, body aches, bad headaches, daylong exhaustion and other symptoms” after receiving the shots.

For the 2019-2020 flu, vaccination coverage among health care personnel was 80.6%, according to the U.S. Centers for Disease Control and Prevention (CDC). By occupation, flu vaccination coverage was highest among physicians, nurses, pharmacists, nurse practitioners and physician assistants.

Flu vaccination coverage was lowest among health care aides and non-clinical personnel, the CDC notes.

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The unique stops along O’Donoghue’s professional path — training as a certified nursing assistant (CNA) and a brief go at a law career — have made building a successful business in just a few years much easier to navigate, she told Home Health Care News. Those experiences have also assisted with recent events, namely the COVID-19 crisis.

After losing her father, a physician, to early-onset dementia at a young age, O’Donoghue tried her hand at being an attorney. It was quickly evident that it was the wrong career choice, and she was lured back to her father’s line of work in health care.

“I did the typical millennial thing,” O’Donoghue said. “[I said], ‘I’m just gonna start a company.’”

That was in 2016. Now, Corewood Care is a thriving private-pay home care and care management provider with three locations in Virginia, Maryland and Washington, D.C.

O’Donoghue recently shared with HHCN how she has been so successful in building Corewood from the ground up.

A company of one

At its outset, Corewood started and ended with O’Donoghue.

Still, her industry research, CNA training and impromptu visits to any and all home care conferences made her feel comfortable enough to steer the ship by herself.

“I went to association conferences and met with competitors — at least those who would meet with me. I would even lie about my age. I would just learn everything that I could,” O’Donoghue said. “I even got my CNA — I wanted to know how I could do the care and do it properly. So once I got my license, I was the first caregiver at Corewood, and I provided care for our first client.”

Business started through building relationships with family members who thought their loved ones needed assistance.

Instead of immediately sending a professional caregiver or aide from her agency into potential clients’ homes, O’Donoghue took a different, more subtle approach. She began first by working with local schools to recruit younger adults with a passion for senior care. Those college- and high school-aged students would then provide light assistance and companionship for Corewood’s clients who were not quite ready for a full-blown caregiver.

“Once that individual started showing signs of decline in terms of their physical or mental abilities, that’s when we would do a transition over to personal care,” O’Donoghue said. “And it was a nice transition because the person was already used to receiving care in place and having someone there that they were familiar with and enjoyed.”

Bringing an extra worker into the equation, then, felt more like a companion — plus a friend — than it felt like an unwanted upgrade in care.

Through word of month, among other light marketing tools, Corewood began to receive more and more requests for care. Just a year and a half in, the company was hiring new workers and recommending care solutions to dozens of families.

“One care manager I was working with, she asked me, ‘Have you ever thought about care management?’ And it made sense,” O’Donoghue said. “So we started doing care management as well and things just took off. It was just so unique to the industry in the area because [not a lot of people] do it.”

Some of O’Donoghue’s colleagues thought it was a poor business decision, worrying that other care managers would stop referring clients to her. But that wasn’t the case.

“In the beginning, people were worried about that, but it actually worked in our favor,” she said. “Care managers are usually nurses or social workers. And at the end of the day, it’s about finding the best solution for the client. So if another care manager may have the tools and resources at their disposal, great. We’re all here to work together. Even though we have a care management team, for instance, we refer cases out to other care managers, and they refer to us. We even work with other home care agencies.”

The collaborative approach bought Corewood credibility from competitors and other health care operators in the area. Similarly, O’Donoghue was gaining credibility with her current and future workers as she built out a diverse-minded staff.

A well-rounded team

Off the bat, Corewood’s caregivers respected O’Donoghue because she acted and felt like she was one of them.

After all, she was her own company’s first caregiver. Her CNA training helped her with caregiver relationships. Even her fluency in french, oddly enough, helped her gain equity with workers who originally were from the French-speaking countries of West Africa.

The benefits, like 401k offerings, for instance, have helped too. In Corewood’s experience, the happier the caregivers are, the better business is.

“That’s the biggest impact for Corewood,” O’Donoghue said. “It resonates with clients when they hear from the workers that they love working with us. And then, they make referrals to their friends.”

Caregivers aside, Corewood’s hiring practices have been especially beneficial over the last few months as the COVID-19 virus has taken a stranglehold on the industry.

The company’s CFO grew up in Hong Kong and lived there during the SARS outbreak — another illness caused by a coronavirus. Early in the year, before the global pandemic was referred to as such, he urged Corewood to get its ducks in a row.

“The moment he heard that COVID-19 was on its way out, he said, ‘Guys, we’ve got to prep. And we’ve got to start now,’” O’Donoghue said.

That preparedness has kept Corewood from running into a lot of the issues that agencies across the country have.

Its personal protective equipment (PPE) stock is intact, its cleaning supplies are far from running out and its caregivers aren’t as struck by the sudden fear that has plagued so much of the workforce over the past month.

The correct messaging was easy to communicate — thanks to a former CDC worker on Corewood’s staff. She’s a physician and still approved by the CDC as a trainer.

The company also leveraged her knowledge early on.

“We asked her, ‘Can you give our caregivers the right information?’ Because the scariest thing about an epidemic or pandemic like this is the lack of information,” O’Donoghue said. “So she came into the office and we brought small groups of caregivers in to hear from her first hand.”

Corewood’s staff — probably by virtue of its leader’s age — also skews younger. That has manifested itself in good technology infrastructure, which enabled the majority of the team to begin working remotely at a moment’s notice in March.

Despite being relatively new to the home care world, Corewood feels like they’re ahead of it, O’Donoghue said.

“We were already kind of ahead of the game,” she added. “That’s because we’ve been in tune with it and we can see where the industry is going.”

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As of April 9, over 9,000 health care workers had contracted the COVID-19 virus in the United States, according to the Centers for Disease Control and Prevention (CDC). The actual number is undoubtedly much higher — and it’s likely impossible to know how many in-home care workers have been affected due to testing challenges and an overall lack of support for non-facility-based caregivers.

The SEIU represents 2 million workers in health care, the public sector and property services across the country. On the call, home care workers shared emotional testimonies, detailing workplace difficulties that included a severe lack of personal protective equipment (PPE), no sick leave and low wages, among other undesirable conditions.

“I work in home care because it’s a gift from God. I have to do this job because someone needs me to care for them,” a Memphis, Tennessee home care worker said. “But despite the crucial role we have in keeping our clients safe from the coronavirus, this is the most inhumane, unsafe and unappreciated line of work.”

More so than attacking their provider organizations, the home care workers spoke out to advocate for additional governmental support.

During the virtual event, one worker said that her colleagues had been making protective masks out of paper towels. Another said she had been making her own hand sanitizer with a mixture of ingredients she bought at the store — paying for supplies herself.

“We have no voice, especially during this crisis,” the worker said. “I have no paid sick time days through the home care agency or my other job. My agency has tried to provide the resources for us as far as PPE, but they can’t seem to obtain any. We have no shields, no gowns, no sanitizers — we don’t even have masks.”

No paid sick leave

In addition to personal hardships, the virtual press conference also highlighted general challenges facing all in-home care providers, including clients refusing visits.

For example, one home care worker described a time when she went into work and her patient told her she shouldn’t be there. She was sick, and the patient could tell.

Even so, the worker felt obligated to go work to take care of her client — and to make enough money to survive.

Along those lines, one of SEIU’s demands was removing the exemption that the Department of Labor (DOL) placed on home care workers, which keeps them from receiving additional workplace benefits included in the Families First Coronavirus Response Act (FFCRA).

Broadly, the FFCRA grants paid family and sick leave for workers during the coronavirus crisis in the U.S.

Home care industry advocates had vied for agencies that employed either home care or home health workers to be exempt from the act’s benefits in order to ensure that they had enough workers to deploy on a day-to-day basis. If the DOL hadn’t included those workers, there was also concern that smaller, cash-strapped agencies would go under if forced to pay for extra leave.

But that exception backfired for some front-line workers, according to SEIU.

“It’s hard. I wish that they would give us paid sick days, but we don’t get them. We get no time off,” one worker from Richmond, Virginia, said. “And it’s a choice you have to make to live and survive. … We get sick just like everyone else. And home care workers, we take care of seniors and others with disabilities, and we are in high demand, but yet you don’t want to give us anything for what we do? I don’t understand why they forget about us.”

Although they may have an exemption under FFCRA, many home-based care providers have voluntarily implemented comprehensive paid sick leave and emergency leave policies. Others have also launched initiatives that provide bonus pay to workers caring for COVID-19 patients during the public health emergency.

A worker’s point of view

The potential effects of paid leave requirements bestowed upon agencies during the pandemic is a reasonable point of concern. But the workers on the front line — the ones risking their health for the patients — also have reason to feel left behind. 

The press conference was led by SEIU President Mary Kay Henry and National Employment Law Project (NELP) staff attorney Nzingha Hooker. It’s goal: to give a voice to those on the front line who feel like their worries have been back-burnered, they said.

Many of those worries were addressed by the home care workers who spoke Wednesday morning.

Apart from working without adequate PPE, highlighted concerns included an inability to collect hazard pay and a universal lack of COVID-19 testing.

“It’s time to bring home care workers in from outside of the laws, protections and shadows,” Henry said. “[We need] to truly value these health care heroes for the valuable role they play in getting everybody the care they need with dignity and respect in the home.”

Home health and home care agencies need to juggle keeping their businesses above water and keeping their workers feeling safe and valued.

The current circumstances make that juggle increasingly harder.

“It’s a very dangerous job,” a worker said. “I’ve said it is my gift from God to do this work, but I still deserve to be respected.”

The post ‘I Deserve to Be Respected’: Home Care Workers Make Emotional Plea for Better Treatment appeared first on Home Health Care News.

What you need to know from Friday through Sunday (March 20-22)

— CMS announced Sunday it is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs.

— CMS officials spoke to thousands of home health providers during a Friday morning phone conference, offering clarity on telehealth rules and face-to-face requirements.

— Various state governors have voiced concerns about health care workers’ access to PPE, at times clashing with the Trump administration.

— Doctors in Italy — the country hit hardest by the spread of coronavirus — are urging their peers around the world to care for patients in the home setting.

— Congressional leaders on Sunday afternoon failed to reach agreement on another major economic stimulus bill that includes additional funds for public health needs.

Doctors in Italy: Treat more patients at home

The death toll in Italy jumped by 793 to 4,825 on Saturday, with some ICUs in the country reportedly on the “brink of collapse.” Prior to Saturday, Italy had already surpassed China as the country with the most COVID-19-related fatalities.

A new paper suggests hospitals may be the main source of spreading the virus, as was the case with SARS years ago. Additionally, doctors in Italy are urging their peers around the world to avoid centralized care and shift the delivery of health care into the home.

The message underscores what home health providers have been saying for weeks.

“Managing patients at home is a brilliant thing,” Maurizio Cereda, co-director of the surgical ICU at Penn Medicine and a co-author of the paper, told STAT. “Bring them nutrition, measure their oxygen levels, even bring them oxygen, and you can probably keep many of them at home. This is what we mean by moving from patient-centered medicine: Of course you still care for and care about the patient, but you also think about the population as a whole. That change would decrease transmission and protect other patients as well as health care workers.”

What you need to know from Thursday (March 20)

— CMS approved the state of Washington’s request for an 1135 Medicaid waiver.

— Supply shortages appear to be worsening.

— At a White House Task Force press briefing, CMS asked that all elective surgeries, non-essential medical, surgical and dental procedures be delayed during the novel coronavirus outbreak.

— Millions of people in California have been ordered to stay at home except for when it is absolutely necessary for at least one month to slow the spread of COVID-19.

— As hospital capacity tightens, some patients may be diverted to skilled nursing facilities — not home.

Cutting elective surgeries could strain home health providers

To save supplies and human resources, CMS recommended on Thursday that all elective surgeries be halted.

“The reality is clear and the stakes are high: We need to preserve personal protective equipment for those on the front lines of this fight,” CMS Administrator Seema Verma said in a statement.

That could lead to uncertainty for some home health providers, especially those who specialize in post-surgical rehab.

“Knee replacement surgeries are likely to go down in frequency,” VNA Health Group President and CEO Dr. Steven Landers recently told HHCN. “Providing a high-value, post-acute service for joint replacement recipients is a big part of what home health agencies do.”

What you need to know from Wednesday (March 18)

— The Senate voted 90-8 in support of a COVID-18 relief package that includes federally mandated paid sick leave; President Trump then approved the package Wednesday evening.

— In a letter sent to Ohio Governor Mike DeWine, the Ohio Home Care & Hospice Association warned that hundreds of home care and hospice providers in the state are immediately in need of “additional assistance.”

— Stocks again tumbled on Wednesday, triggering another 15-minute trading halt and erasing the Dow’s gains since January 2017.

— Nonprofit newsroom ProPublica released an in-depth report showing how hospitals can be quickly overwhelmed by COVID-19, information that reinforces the efforts of home-based providers and hospital-at-home programs.

— President Trump invoked the Defense Production Act, a move that lets the federal government order American companies to produce necessary medical equipment.

Senate, Trump approve emergency measures

Voting 90-8, the Senate approved a relief package that includes paid sick leave, unemployment benefits, free coronavirus testing and other measures. The president then gave his signature to the package Wednesday evening.

Specifically, the package offers two weeks of paid sick and family leave to certain workers who are under quarantine, who are helping family or who have children home from closed schools. The package also includes an additional 12 weeks of paid leave due to prolonged circumstances.

Two-weeks paid sick leave will be compensated at 100% normal salary. The 12-week measure will be compensated at 67% normal salary.

Without added financial support under Medicaid and Medicare, the move could prove costly for many U.S. home-based care agencies. The package does include a tax credit, however.

New York home care advocates call for support

New York Governor Andrew Cuomo announced Wednesday that there were 1,008 new confirmed cases of COVID-19 in his state. New York’s case total is now more than 2,380, making it the most exposed state in the nation — by far.

Of the more than 2,380 confirmed cases, at least 549 have required hospitalization.

While the ongoing pandemic has placed extreme pressure on New York’s hospital system, home-based care providers are beginning to see disruption as well. New York’s home-based care providers serve more than 900,000 individuals annually.

To support providers, the Home Care Association of New York State (HCA-NYS) is asking health care officials for supply reinforcements and expanded flexibility when it comes to normal requirements.

“While hospital surge capacity concerns are, of course, extremely vital in this massive public health crisis, essential access to supplies, regulatory flexibility and emergency aid are needed for home care providers … ,” HCA-NYS President and CEO Al Cardillo said in a statement. “A great many of these individuals are at risk and require vital services to protect their health and safety.”

HCA-NYS is a statewide health organization of nearly 400 member providers and organizations.

HCA-NYS is calling on state officials to make available immediate financial aid for home care’s COVID-19 response, in addition to waivers of certain regulations to relieve workforce pressures.

“These waivers would provide immediate relief,” Cardillo said. “Certain services or procedures can be done remotely, using telehealth or other technologies. Other procedures, such as timeframes for completing in-home assessments, can be relaxed. This regulatory flexibility helps reduce the exposure of patients and staff, allowing for deployment of resources proportionate to risk and preventing further stresses on hospitals as cases continue to rise.”

Ohio providers face dire situation

In a letter to Ohio Governor Mike DeWine, the Ohio Council for Home Care & Hospice called for additional assistance to help manage their COVID-19 response. The Council represents about 600 home care and hospice providers in the state.

“These health care at home agencies are on the front lines fighting this pandemic and are at a critical place,” Joe Russell, executive director of the Ohio Council for Home Care & Hospice, said in the letter. “The COVID-19 pandemic is stressing home care and hospice agencies to a breaking point.”

Specifically, Russell called for more personal protective equipment, coronavirus testing, telemedicine flexibility, reimbursement support and other measures.

“Most agencies will struggle to stay in operation if three is not additional flexibility to assist them with resource management,” Russell said.

Established in 1965, the Ohio Council for Home Care & Hospice is a nonprofit association that represents the interests of health care at home providers in Ohio.

“Unfortunately, without additional resources to support health care at home agencies with [PPE] needs, additional flexibility to manage agency workforce and plans of care, and having additional reimbursement flexibility, we are afraid the Medicaid home care program will begin to collapse,” Russell wrote.

What you need to know from Tuesday (March 17)

— The Trump Administration announced another round of telehealth expansions aimed at reducing person-to-person interaction during the COVID-19 crisis.

— Florida landed an 1135 waiver from CMS, with other states likely to follow suit to support Medicaid-reimbursed home-based care providers.

— CMS issued new COVID-19 guidance for Programs of All-Inclusive Care for the Elderly (PACE) organizations.

— The Pentagon announced it will provide up to 5 million N95 masks to the Department of Health and Human Services to help protect health workers.

— The first cases of coronavirus in senior living were reported in the state of Georgia.

Partnership outlines priorities

On Tuesday, the Partnership for Quality Home Healthcare (PQHH) released a list of strategic policy and regulatory relief suggestions aimed at improving access to home health, ensuring patient safety and eliminating barriers during the ongoing COVID-19 emergency.

Among its suggestions, PQHH called for dedicated and clear telehealth capabilities for home health providers, including the use of phone-based visits.

“This will go far in containing the virus, in assisting patients in quarantine, in monitoring existing Medicare home health patients to ensure they will continue to stay in their homes and not seek hospital or physician care,” PQHH stated. “In addition, the telehealth rules should be modified to allow home health clinicians to bill directly for services provided.”

PQHH also called for clarity around Medicare’s homebound requirements and asked that policymakers ensure home health providers’ access to personal protective equipment (PPE).

“PPE supplies are running low but are critical to preventing exposure during home health visits of COVID-19 positive or quarantined patients that could harm home health workers or spread the virus to other homebound patients,” PQHH noted.

What you need to know from Monday (March 16):

— New York Governor Andrew Cuomo called attention to the likely capacity challenges U.S. hospitals will face moving forward; hospital-at-home models could be key to boosting capacity.

— Stocks plunged once again, With the Dow dropping 2,997 points and trading paused for 15 minutes after rapid selloffs.

— On Sunday, The U.S. Centers for Disease Control and Prevention (CDC) recommended that no gatherings of 50 or more people take place over the next several weeks.

— Also over the weekend, the U.S. Centers for Medicare & Medicaid Services (CMS) issued an 1135 waiver to relax certain rules and Conditions of Participation (CoPs) for certain Medicare health care providers.

— The cost of in-patient admissions for COVID-19 treatment could top $20,000, a price tag that places a premium on preventative home health and hospital-at-home treatment.

Read: “Hospital-at-Home Programs Ready to Play Critical Role as Coronavirus Cases Spike”

CMS provides home health relief

CMS provided relief to home health agencies, specifically creating flexibilities around timeframes related to OASIS transmission. CMS also announced that it is allowing Medicare administrative contractors (MACs) to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs) during emergencies.

“It remains vital that our health care system be equipped to respond effectively to the additional [COVID-19] cases that do arise, that federal requirements designed for periods of relative calm do not hinder measures needed in an emergency,” CMS Administrator Seema Verma said in a statement. “These temporary blanket waivers – offered to providers and clinicians across the country – are reserved for the rarest of situations. They represent a massive mobilization of our country’s resources to combat this terrible virus. In a time of emergency, the health system needs maximum flexibility to respond appropriately.”

House passes coronavirus relief package

On Saturday, the U.S. House of Representatives passed bipartisan legislation in response to the spread of coronavirus.

Among its provisions, the relief package would provide paid emergency leave with two weeks of paid sick leave, in addition to up to three months of paid family and medical leave, according to House Speaker Nancy Pelosi (D-Calif.).

The Senate is in the process of reviewing the legislation, with some hinting that substantive changes will be needed for it to pass.

Home health legal experts previously told HHCN that a federally mandated sick leave policy would be devastating for some in-home care agencies.

“We are already seeing market consolidation as a result of PDGM and certain regulatory burdens that make it challenging for a smaller provider to keep up, and I fear this would add more fuel to the fire,” Angelo Spinola, an attorney and shareholder at San Francisco-based Littler Mendelson, said. “If these agencies are over-regulated to the point of going out of business, our seniors and their families may be forced to the grey market of less qualified, unsupervised caregivers.”

HHCN encourages you to reach out to us individually or at Editor@HomeHealthCareNews.com for story ideas, tips or general feedback.

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