It is heartbreaking to see our elders suffer the most during this global pandemic. Faced with the highest mortality rate, increased risk of isolation and lack of adequate care, the sufferings of this vulnerable group have multiplied over the past year. Nurse leaders around the country have, however, recognized their plight and banded together to advocate for elders’ right to life and health, building the case for home and community care.

In a recent research paper, Lessons on COVID-19 from Home and Community: Perspectives of Nursing Leaders at All Levels, Nurse Leaders in Canada discuss their learnings from the pandemic and emphasize how tailored care in home and community settings can ensure that the pain and suffering inflicted by this pandemic are never repeated. 

Homecare: Undervalued and Underutilized

Since the beginning of this crisis, the primary response strategy was to build hospital capacity. However, only 13% to 14% of confirmed COVID-19 cases were hospitalized, according to statistics published by the Government of Canada. The remaining majority stayed home and either looked after themselves or were supported through virtual and in-person health services by formal and informal caregivers. Despite the largest proportion of COVID-19 cases being treated at home, the quality and quantity of homecare fell short of ideal; primarily due to the three reasons below:

• Fear of the unknown:  The uncertainty about the nature of the virus, along with a lack of clear and consistent information, created significant confusion and panic. With the stay-at-home orders in place, homecare patients and their families became anxious about nurses and personal support workers conducting home visits. Thus, patients ended up declining homecare services even when these were essential for their wellbeing. 

• Homecare service reductions: The experiences of European countries, where hospitals were overwhelmed with COVID-19 patients, influenced countries like Canada to focus on increasing hospital capacity. As a result, hospital-based treatments and surgeries were cancelled, while in Ontario, 2,200 older adults occupying hospital beds were transferred to long-term care.
• Non-essential services: Like the US, in Ontario most of homecare service was deemed non-essential, leading to large-scale cancellations. Moreover, initially PPE (Personal Protective Equipment) was prioritized for acute care settings, which created significant challenges in providing safe services elsewhere.

Therefore, this deprioritization of homecare resulted in 20% to 60% reduction of various homecare services, creating workforce destabilization in the sector. Staff did not have adequate hours of work or had to commit to working only in one setting or sector. In some cases, they saw opportunities to work elsewhere, with higher pay and predictable work. Many also went on leave of absence and applied to receive government aid. Overall, this caused a significant decline in homecare workforce capacity.

In essence, the COVID-19 crisis provided an opportunity for nurse leaders to identify three key insights, each of which strives to use the pandemic as a ‘catalyst’ to ensure positive future change, while surmounting the challenges of the past. These include:

1. The pandemic exposed the pre-existing biases and barriers, especially impacting older individuals:

These biases can briefly be characterized into three categories:

• Preference for hospital-based and curative models of healthcare delivery, while underutilizing primary care, home care and technology-based solutions:

As soon as the global pandemic was officially declared, policy makers swiftly sought to build hospital capacity, in the fear of hospitals ‘getting overwhelmed with sick patients’. However, by prioritizing hospitals in the pandemic response strategy, home and community care support services were deprioritized or cancelled. This yielded immense impact on the provision of personalized care, monitoring physical and mental health as well as medication, tackling social isolation and ensuring timely medical interventions. 

Thus, to counter these challenges, nurse leaders in the home and community sector had to “band together” and advocate for the vast population that receives care beyond hospital settings. This proactive stance ensured that more people received palliative care at home and legitimized the use of virtual care options where appropriate.

• Systemic bias to adopt short-term crisis management frameworks: 

Not having faced a crisis of this magnitude in recent history, there is a systemic bias to gravitate towards short-term crisis management frameworks. These have been previously adopted in crises such as inclement weather, small-scale viral outbreaks and labor strikes etc. Protocols for such events include use of emergency response levels (ERL) codes that prioritize or cancel services automatically, without individual assessments made in collaboration with patients and families.

Thus, nurse leaders immediately established that this model of emergency assessment was unsuitable in the current circumstances. This especially rings true with regards to vulnerable adults requiring care at home, and their family which is likely suffering from ‘caregiver stress and burnout’. 

• Ageism:

Even in pre-pandemic years, older adults have been vulnerable in terms of ‘life and death, mental health, economic well-being, abuse and neglect and potential loss of shelter or housing’. Adding fuel to fire, the pandemic planning did not effectively assess the impact of COVID-19 on this already risk-prone group. Consequently, many older, frail adults experienced loneliness, fear as well as physical and mental health decline. Furthermore, faced with reduced resources and support, informal caregivers also, suffered exhaustion.

Given the magnitude of these negative implications, the United Nations put out a policy brief on the impact of COVID-19 on older adults. This identified four key priorities:

1. Ensure healthcare decisions affecting older people are guided by dignity and right to health.
2. Ensure essential “physical distancing,” accompanied by social support measures and targeted care e.g.  improving access to digital technologies.
3. Holistic focus on older persons within the socio-economic and humanitarian pandemic response.
4. Improve older adult participation, in collaboration with civil society to address ageism.

1. Nurse Leaders had to Address Panic in their Patient and Staff circles:

Confronted with unprecedented fear and anxiety, front-line homecare nurses addressed the wave of panic by using ‘science-based decision making, compassion and an orientation to action’. They provided the much-needed connection between family members and primary care doctors and nurses. Following are some strategies employed by nurse leaders to build structure, provide consistency, and raise confidence:

• Ensured uniform decision making by incorporating the perspectives from patients, providers, and the environment.
• Employed professional practice priorities framework that ensured science and evidence-based decision making, developed client and employee screening, and established digital and virtual care etc.
• Adopted a patient and family-centric care approach by allowing patients full control in terms of who can come to their house and when they can come. Through use of automated calls to identify patients’ preference for an in-home visit, virtual visit, a patio or curbside visit, technology is being employed innovatively to customize the care experience.
• Leveraged the full scope of nursing care by coaching, addressing queries, and directly communicating with patients and caregivers, in cases where in-person visits were inappropriate.
• Active advocacy by nurse leaders, across various forums, ensured the prioritization and distribution of resources, reimbursement for virtual care services, provision of pandemic pay for front-line home and community staff etc. 

•  Learning, Innovation and Capacity Development Opportunity 

The pandemic has provided two key areas in home and community care where nurse leaders have demonstrated effective innovation, design, and execution. These include:

1. Recognizing the importance of homecare: 

All around the world, homecare is being hailed as the gamechanger in the provision of care. Augmenting the learnings from the pandemic, several homecare models have been developed and deployed to integrate the disparate healthcare services by using virtual platforms, complimented by visits from in-home caregivers. “Primary care@home” is one such model, whereby homecare providers collaborate with primary care providers to meet patient’s care needs. Another is the “LTC@home” model, where patients waiting for a place in long-term care receive safe, continuous monitoring at home, with a combination of ‘in-person care, technology-assisted care and family caregivers’.

1. Legitimizing the criticality of the virtual care model:

As soon as the pandemic was officially declared, the administrative staff in healthcare settings instantaneously transitioned to remote work. This was, however, not immediately possible in the case of clinical care, which was largely provided using in-person channels. As soon as virtual care compensation was approved, urgent focus was placed on deploying and scaling virtual care by developing tools, skills and employing change management strategies. 

Conclusion

The pandemic undoubtedly is a health calamity with enormous social, economic, and political repercussions. However, it does provide an unprecedented opportunity to evaluate our failings and cement the faults that already plague our system. There is no doubt that close collaboration is sought between health and social care sectors, with a keen focus on home and community care. The research paper concludes by identifying the way forward, through the following interventions:

• While promoting public health measures, attention must be paid to health needs of older adults, especially those with chronic illnesses. 
• A holistic approach is recommended, where personal, social, health, resources and local domains of well-being are incorporated in the healthcare planning and delivery. 
• Focus on providing personalized care by building systems that yield greater autonomy to front-line healthcare providers. This can be done by equipping these providers with the flexibility and tools to deploy a blended model of care (in-home visits, virtual care, and remote consultations) that best meets the needs of the patients at home.
• An immediate focus on workforce stabilization through effective human resource planning, including the hiring of full-time positions at competitive salaries and benefits.

How Can We Make a Difference?

We at LocateMotion Inc. have developed SenSights.AI, an easy-to-use mental health & well-being intelligence platform for elders & caregivers. It aims to help older adults ‘age in place’ by tracking the progress of early cognitive decline by capturing vitals, daily notes, medication effects, feelings, behavior, and finally assessing virtual interventions based on risk-levels. 

Offering 24/7 remote monitoring, personal emergency interventions, access to physicians and data collection, increases patient and caregiver engagement and knowledge about mental health (especially during the decline stage) and related modifiable factors, improving healthy living behaviors and potentially delaying dementia progression in high-risk populations. 

Additionally, SenSights.AI offers telehealth services that help at-risk providers, home health, skilled nursing, long term entities increase their capacity by complimenting virtual care with a physical visit, reduce readmission rates and avoid wandering and fall episodes by offering proactive monitoring and risk profiles along with smart alerts.

Our holistic approach to continuous patient monitoring, caretaker engagement and building capacity of personal care workers will ensure that home care reclaims its value for elders, their families, and health care providers, COVID-19 and beyond!

Book a demo today to learn more about LocateMotion (SenSights.ai) and how our proactive monitoring solutions can work for you at Sensights.ai/demo

Follow us on LinkedIn at @LocateMotion for more updates.

Contributors: Mariam Javed, Nauman Jaffar