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The Long Haul Ahead: A Penn Nursing Investigation of Home Healthcare for COVID Survivors in the Community

To examine the characteristics and outcomes of COVID survivors recovering at home after hospitalization, Kathryn H. Bowles, BSN, MSN, PhD, and colleagues at the Penn Nursing School and Villanova University performed a retrospective study of more than 1400 patients in the New York area.

COVID-19 isn’t like other infectious diseases. Most infectious diseases are traditionally defined by five distinct stages or phases—incubation, prodrome, illness, decline and convalescence, with each identified with a pathogen presence and severity of signs and symptoms that typically follow concordantparallel paths. In persons with COVID-19, though, pathogen load has been shown to decline as symptom severity escalates, and the equation between infection and symptoms can be nonexistent.

The convalescent phase has been up-ended, as well, with evidence now suggesting that the post-COVID experience resembles that of sepsis rather than that of most respiratory illnesses, which resolve predictably over time. This is because, like sepsis, a systemic response to infection, COVID-19 causes deleterious effects throughout the body. According a report from Italy of COVID-19 survivors evaluated two months after hospital discharge, the most prominent lingering symptom was fatigue, followed by dyspnea, joint and chest pain. Other reports and studies suggest the potential for persistent cardiovascular, rheumatoid and neurological consequences.

The significance of these effects is not yet known, but data from previous coronavirus epidemics suggests that long-term complications will occur in between 20% and 40% of persons in recovery from COVID infection. Patients still reporting symptoms 30 to 40 days from onset have been described as “long-haulers” since at least June 2020—a term that has entered the clinical lexicon.

Visiting Nurse with Patient in home

COVID-19 Survivors: From Hospital to Home Healthcare

From almost the beginning of the pandemic, professional care of COVID survivors in the community following hospitalization has fallen largely upon nurses and primary care physicians. However, the idiosyncrasies of the disease and the relatively short time span since the pandemic arrived have limited what’s known about the effects of SARS-CoV-2 post-COVID, or the needs of COVID survivors.

An authority in the transition from hospital to home healthcare, Dr. Bowles has investigated the factors involved in hospital discharge decision making and planning for more than two decades. Presciently, Dr. Bowles was an advocate for  "tele-homecare" as early as 2001.

Surviving COVID-19 After Hospital Discharge: Symptom, Functional, and Adverse Outcomes of Home Health Recipients

The investigation of COVID-19 patients that Dr. Bowles led earlier this year involved referrals from 64 hospitals over a six-month period in the five boroughs surrounding New York City. Patients were cared for by the Visiting Nurse Service of New York.

“The vast majority of studies about COVID-19 take place in the hospital setting, but we were curious to study what happens longer term to these patients who recover in their homes,” Dr. Bowles explains in a video she recorded to accompany her report. “Ours is the largest study of COVID-19 survivors to report home health outcomes weeks and months after hospital discharge,” she continued.

Study Population Characteristics

The average age of the study population was 67, but 53% of patients were younger than 65 years. The cohort was representative of a diverse population and almost exactly split between genders (51%/49%).

The patients were considered quite ill, Dr. Bowles reports. Hypertension, diabetes, and chronic pulmonary disease were the most common comorbidities, and pain, dyspnea and anxiety and/or confusion were common in the population. Most were dependent on assistance with the activities of daily living, including management of oral medications. Patients received home healthcare for an average of 32 days, with each patients visited ~11 times, and were evaluated following discharge from home healthcare.

“We’re happy to say they did quite well,” Dr. Bowles continued. "Whereas prior to home healthcare care patents required assistance with 6 of 9 activities of daily living, the average following comprehensive home healthcare was one, and many symptoms, including dyspnea and anxiety, improved significantly for the majority of patients." Eighty-seven percent left HHC without adverse events (rehospitalization or death).

The significance of these findings is compounded when considering the dearth of home healthcare services available to COVID patients nationally.

Citing a Medicare report that only 11% of COVID survivors in the United States have received home healthcare, Dr. Bowles urged providers during the current surge to better identify patients who can benefit from home healthcare, and increase referrals accordingly as a safe haven for COVID-19 recovery.

Surviving COVID-19 After Hospital Discharge: Symptom, Functional, and Adverse Outcomes of Home Health Recipients is available in the November 24 edition of the Annals of Internal Medicine.

 

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The Penn Physician Blog is a resource for health care professionals featuring Penn Medicine physicians and their research, innovations, programs and events. 

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