For the last six months, most of us have been spending a lot more time at home, thanks to stay-at-home orders and the continued recommendations for safety to minimize COVID-19 exposure in the community. For some Penn Medicine clinicians, patients’ homes are where they’ve always worked — and their ranks have grown dramatically during this time.
Indeed, when the pandemic hit the area, Penn Medicine at Home, which provides a variety of clinical care services in the home setting, saw their patient numbers skyrocket. But thanks to a solid infrastructure, a new program and technology, they hit the ground running. And, now that outpatient and elective care are back up and running, the growth of home care as a convenient option for many patients is likely to last, too.
Delivering Home Care Safely
While keeping patients safe — especially those battling life-threatening disease — was essential, an equally significant concern was ensuring the safety of Penn Medicine’s field clinicians. Unlike in hospitals, which were able to restrict visitors and implement careful isolation and cleaning procedures appropriate to each space, “we had no control over a patient’s home environment,” said Sandra Jost, PhD, RN, chief nursing officer & associate executive director of Penn Medicine at Home. “When our clinicians go into a home, they’re typically only directly assessing the patient, but there are often many more people living there who enter and leave the home. And you didn’t always know who was COVID positive and who wasn’t. This pandemic has caused us to have to assess the home more comprehensively.”
Field clinicians were educated on the use of PPE (personal protective equipment) and soon donning and doffing PPE became a part of many visits. But repeating this process — putting equipment on, treating a patient, removing PPE safely (usually by the trunk of their car), and heading on to the next patient — over the course of multiple visits each day was exhausting.
Penn Medicine Home Health leaders came up with an ingenious solution: traveling vans. During the peak of the COVID surge, a van — fully stocked with PPE and necessary care supplies for the day’s visits — would meet the field clinician at a patient’s home. In addition to shoring up supplies, an additional clinician rode in the van and would assist in putting on and removing the necessary PPE in the van. Over the course of three months, the five rented vans made more than 850 visits to patient homes — seven days a week.
Arranging these trips was not easy. Think in terms of putting together a complicated puzzle, with the pieces changing daily. Maria Buccafuri, MSPT, knew this firsthand; she oversaw the entire process. Based on the daily referrals she received, Buccafuri created routes each day for each van, matching stops that were within a specific region. She notified the drivers and “traveling” clinicians as well as the field clinicians making the home care visits. She also made sure the van had the correct supplies and equipment (including PPE) for each of the visits.
Not surprisingly, the “Bucca” vans (as they were sometimes affectionately called, after Buccafuri) were an immediate success. “We made sure our clinicians were well taken care of.”
Virtual Care: A Lifeline
Telehealth was well established at Penn Care at Home prior to the pandemic but when COVID-19 hit the region, the number of patients requiring virtual monitoring tripled, from 300 to 900. Many were COVID-positive patients — or those who had been exposed. Others were in fragile physical states or immunocompromised.
Penn Care at Home met these challenges head on. They had already provided many home health patients with tools to monitor vital signs (i.e., blood pressure cuff and pulse ox) and electronic tablets, not only to report the numbers and respond to survey questions but also enable virtual visits. These visits gave home care clinicians the ability to speak to — and more importantly, observe — patients. They were also a way to demonstrate to family members how to do simple care tasks, such a changing a dressing or flushing an IV line.
When the surge came, Penn Medicine at Home provided several hundred additional tablets but also initiated “Bring Your Own Device,” which allowed patients to use their own phones or other electronic device, simply by downloading an app. “An additional 150-200 patients brought their own,” said Danielle Flynn, MSN, director of Penn Medicine Home Health, “but this initiative allowed us to monitor up to an additional 900 patients, if necessary.”
Once the technology was in place, the challenge was finding additional clinical staff to virtually monitor patients. They reached out to clinic-based nurses who normally worked in outpatient facilities that, at the time, had limited elective procedures. “They knew nothing about home health but had great knowledge and skills in specialty areas,” Flynn said. “It was a huge undertaking but it shows how we can break down silos and start to collaborate in ways we hadn’t before — across entities.”
Telehealth also proved to be an excellent way for rehab specialists to keep their patients exercising and help them with day-to-day activities. To keep patients engaged, they customized approaches based on patient needs. “We wanted to make it more patient centered and patient driven,” said Scott Rushanan, MS, OTR/L, MBA, director of Rehabilitation Services for Penn Medicine at Home.
Some patients, though, needed a little more motivation to get them moving. Occupational therapist Katherine Scheponik was having trouble with one of her patients. “She was trying to make the activities more fun but the patient displayed decreased interest and was having difficulty engaging,” Rushanan said. But she knew the patient enjoyed watching cooking shows.
In a stroke of genius, Scheponik asked for the patient’s virtual help in making a cake for her daughter, using a cooking show format. It was a turning point. Not only did the patient enjoy this exercise — which engaged her physically, emotionally and cognitively — but her attitude did a 180-degree turn. After that, she was totally engaged, in exercising and learning strategies for personal care tasks.
Timing is Everything
In February the Penn Center for Cancer Care Innovation at the Abramson Cancer Center (ACC) launched Cancer Care at Home. The new program, an interdepartmental collaboration, significantly expanded the number of cancer drugs Penn Home Infusion Therapy (PHIT) could administer in the home setting. “We were looking for the safest chemo regimens we could do at home, ones that didn’t need continuous monitoring in a clinic,” Jost said. “We wanted to create a continuum of cancer care.”
Within a month of the launch, the pandemic arrived and PHIT’s patient population exploded. Indeed, there was a 63 percent increase overall in cancer patients alone. At the time, PHIT clinicians were fully trained in administering other chemo regimens in the home as well as supportive care, such as hydration and therapy to help prevent nausea and vomiting. But the tremendous surge in patients required more nurses to complete the home visits. PHIT leaders reached out to those who already had the knowledge: nurses who normally provided chemo infusions in the outpatient setting. Several jumped at the opportunity to redeploy to field work to handle the sudden influx. One was Stefanie Reilly, RN.
Because Reilly, who works on the infusion units at the Perelman Center, had previously worked for PHIT, she was no stranger to giving home infusions and served as a resource to other new-to-home care nurses. She loved the one-on-one care of home visits. “One patient told me I was the first person he’d let in his house,” she said. After a four-hour infusion, another said, “You’re so comforting. I couldn’t have asked for a better experience.”
Jacqueline Hedrick, BSN, was another. Normally working in the ACC at Chester County Hospital, she too wanted to help out in the home setting. Her visits sometimes brought her to patients that she knew from her work in the infusion clinic. “That was fantastic. I already had a relationship with them,” she said. “You get to see a different side of patients than in clinic. I got to meet one patient’s granddaughter and son who he had talked about in the clinic. This makes it extra personal.”
While infusions at home have decreased from their highs during the COVID surge, “we anticipate that the vast majority of the patient volume moved to home will continue after COVID, with some exceptions,” Jost said.
And for many patients, this is great news. Not only do home visits keep them safe, but this may eliminate the need to travel up to an hour — or more — to receive treatments in clinics, which are sometimes a short infusion, lab draw, injection, or dressing change.
“Some patients are really sick. For them to go in for something like simple hydration, it’s hard,” Hedrick said. “What could be better than receiving treatment in the comfort of your own home?”