AFD - Pandemic Issues For Home Health Providers

[sharon sanders]

Pandemic Issues For Home Health Providers - Pt 1




# 2133



http://afludiary.blogspot.com/2008_07_01_archive.html

Note: This is the first of a multi-part series I'll be doing on the HHS's recent report on the home health care industry during a pandemic.
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The recently released HHS document - Home Health Care During An Influenza Pandemic : Issues and Resources - brings to light a number of difficulties that the home health care industry will face during a severe pandemic.


With more than 17,000 home health care agencies operating in the United States, ranging from small volunteer or non-profit outfits to larger commercial agencies, the scope of their problems and the resources they will have available to solve them are going to vary considerably.


This document therefore must be viewed more as a springboard for discussion than as an actual roadmap for agencies to follow to become pandemic ready - a point that is made early on in the document:

`This report serves as a discussion piece for home health care agencies and others to consider; this is not a Department of Health and Human Services (HHS) guidance.'
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For anyone anticipating that home health care services would be commandeered to care for the general public at home during a pandemic, the report states:

In the event of an influenza pandemic, because of anticipated shortages of health care professionals and widespread implementation of social distancing techniques, it is expected that the large majority of individuals infected with the influenza virus will be cared for in the home by family members, friends, and other members of the community � not by trained health care professionals.
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In other words, the home health care industry lacks the capacity to provide medical care in the home to the vast majority of pandemic flu victims.

You should therefore dispense with any notion that a home health care nurse is likely to visit you to wipe your fevered brow during a pandemic.
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In fact, this report identifies two primary receivers of home health care during a pandemic.

Those medical and surgical patients, not hospitalized because of the pandemic, who are well enough to be discharged early from hospitals to free up hospital beds for more severely ill patients.
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Patients who become or already are dependent on home health care services (predominantly elderly persons with chronic disease) and will continue to need in-home care during the influenza pandemic whether or not they become infected with the influenza virus.
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Accordingly, the home health care industry will be asked to handle their current patient load, plus the addition of surgical and medical patients discharged early in order to free up hospital beds during a crisis.

This at a time when their own ranks may be severely depleted due to absenteeism.

I'll have more on that, in a future blog.





Since 90% of home health care providers are non-governmental, and this document is not considered `official HHS guidance', much of this report reads like an overly polite to-do list.


You see genteel phrases like "agencies need to ensure' or `Measures that home care agencies can take' littered throughout the document.


While couched in diplomatic language, and at times almost apologetic in tone, the unmistakable message here is that private agencies are going to be expected do a great deal in order to prepare for a pandemic.

These are not mandates, of course.

More like, "They're only suggestions. . .but let's not forget who's making them. "
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Sometimes, though, the tortuous diplomatic tip-toeing through the preparedness minefield in this document borders on the absurd. In regards to agencies having adequate resources on hand, the following advice is given:

The HHS Home Health Care Services Pandemic Influenza Planning Checklist recommends that agencies think about whether plans should include at least a week's supply of resources when there is evidence that the potential for pandemic influenza has reached the United States.

This will provide a base until the agency is able to receive direction from its local, State, and Federal government agencies on how and where to access necessary supplies.
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This rather tepid advice - that agencies should `think about whether plans should include' - illustrates the difficult position that the HHS, and the authors of this document, are in.

They want to motivate agencies, not frighten them. They want to cajole the industry, not bully it.
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They are walking a fine line.

They obviously want agencies to do more than just `think about' these issues, they want them to act. And I'd venture they'd like to see agencies prepared for far longer than a week.


But attempts to mandate specific preparations, particularly before a pandemic erupts, would likely lead to a firestorm of industry protests and a prolonged fight with lobbyists and congress.


As long as they remain `suggestions' instead of regulations, and `advice' rather than mandates, they can be openly discussed by government agencies.


But of course, it remains up to the individual health care agency (or any other private enterprise) to decide whether to prepare for a pandemic, and to what extent.

Perhaps this will ultimately prove to be the true Achilles' Heel of our privatized health care system.

Our dependence upon the willingness (or ability) of profit driven (or worse, non-profit volunteer) private enterprise to absorb the costs of preparing for an extraordinary incident like a pandemic.
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I'll have more from this document over the next couple of days, including a look at anticipated absenteeism among home health care workers during a pandemic.

In the meantime, this HHS document is well worth your time to review.


Anyone reading it will, no doubt, come away with the inescapable conclusion that home health care agencies have a tremendous job ahead of them to prepare.


The big unanswered question is: Will the Industry rise to the challenge?

posted by FLA_MEDIC @ 8:25 AM

 

[sharon sanders]

Re: Pandemic Issues For Home Health Providers

Re: Pandemic Issues For Home Health Providers

Saturday, July 12, 2008

<!-- Begin .post --> Pandemic Issues For Home Health Providers - Pt 2



# 2137

Note: This is the second of a multi-part series I'll be doing on the HHS's recent report on the home health care industry during a pandemic.
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The recently released HHS document - Home Health Care During An Influenza Pandemic : Issues and Resources - brings to light a number of difficulties that the home health care industry will face during a severe pandemic, not the least of which will be the acquisition of patient supplies, PPE's, and antivirals during a pandemic.


As the report states, this may prove difficult. (Reparagraphing & Highlighting mine)

Supplies and Equipment.

Maintaining a flow of supplies sufficient to continue operations, protect healthcare workers, and meet patient needs throughout a pandemic is an obvious necessity and a complicated issue for the home health care agency.

Normal supply sources may be overwhelmed or disrupted, resulting in supply shortages.
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This report goes on to recommend that home healthcare agencies anticipate their role in the distribution of . . .

`.... supplies specifically needed for surge patients and supplies for surge and existing patients that are not usually provided, such as food, water, or medications.'
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Finally, agencies need to ensure that their workforce has the essential protective equipment needed to safely care for patients, including NIOSH-certified N-95 filtering face-pieces or higher rated respirators as feasible.

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With the exception of the weasel wording at the end, this sounds like a pretty strong call to arms.

The `as feasible' at the end, does give me some pause. Who decides what is feasible, and by what criteria?

"Sorry, we would have liked to have bought N95 masks for our employees, but it just wasn't feasible."
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OSHA (Occupational Safety & Health Administration) recently released estimates on what quantity of PPE's healthcare workers would need over the period of a 12-week pandemic wave.

While dealing with masks, HCWs (Health Care Workers) would also need gloves, gowns, face shields or goggles, along with other infection control supplies.

While none of these `guidance documents' carry the force of law, it would be difficult for any agency to argue that they weren't adequately informed of the pandemic threat, and of the need to prepare.

Not to put too fine a point on all of this, but it would seem likely that any agency that fails to take reasonable steps to protect their employees during a pandemic could be called upon to defend their actions at some point.

I'm not a legal expert, but it would seem prudent to me that agencies gather the pertinent HHS, CDC, and OSHA guidelines and have a long discussion with legal counsel over potential liability issues.
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Similarly, the CDC recently released proposed guidelines on the stockpiling of antivirals for Very high and High Risk Employees. Home health care workers, by definition, will almost all fall into the `HIGH RISK' category according to this OSHA graphic.



Occupational Risk Pyramid for Pandemic Influenza

As this HHS document states, Home Health Care workers will be at a heightened risk for contracting pandemic flu.

An obvious factor in the ability of the workforce to work during a pandemic is infection. A significant share of the home health care workforce likely will become infected with the influenza virus and be unable to report to work.

Estimates based on past pandemics suggest that at least 25 percent of the workforce overall will become infected.²⁰ Today these estimates likely would be mitigated in the event of a pandemic by government use of antivirals.
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I will break in at this point to ask exactly how the `government use of antivirals', which has already been stated to be reserved for treatment only, not prophylaxis, will mitigate the percentage of healthcare workers infected?


Unless I'm missing something, this seems to be a rather optimistic assumption. But I digress.

An HHS proposed guidance as of June 2008 (not an agency determination or policy), recommends that healthcare workers who have direct high-risk exposures to pandemic influenza patients as well as front-line emergency services (e.g., law enforcement, fire, and emergency medical services personnel) receive pre-exposure prophylactic antivirals.
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The burden of providing this antiviral outbreak prophylaxis falls on the employer, and reportedly will not come from the National Strategic Stockpile. A 12 week pandemic wave would require roughly 80 Tamiflu per HCW (Health Care Worker), at a cost of approximately $500.


While the initial cost is an inhibiting factor, getting prescriptions for all employees (who, frankly, tend to change jobs a lot), storing the meds, and distributing them are all obstacles that need to be addressed as well.

Admittedly, all of this places a heavy burden on home health care providers, many of which are either small entities operating on a shoestring budget, or in some cases, non-profit outfits. Whether they are capable of meeting these challenges is unknown.
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While directed primarily at the home health care industry, the challenges listed in this document are largely shared by all health care providers, along with many first-responders.


The assumption that during a pandemic, supply lines will continue as normal, is seriously in dispute. There are good reasons to believe we could see prolonged shortages of many goods, including disposable PPE's such as masks, gloves, and gowns.


Agencies and facilities that fail to prepare, in advance, for a pandemic are likely to find their ability to provide life-saving and mission critical services may be severely compromised.


It would seem in the interest of individual communities, and our nation as a whole, to find ways to support these home health care agencies before and during a crisis.

Outreach to local businesses, civic groups, and religious groups would be one way to achieve this. In the past we've seen private fund raisers to purchase bullet proof vests for police officers in many communities.


Perhaps this is a model that we can use to help purchase antivirals and PPE's for nurses and first responders before the next pandemic.
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Tomorrow, in Part 3, I'll look at absenteeism among home health care workers during a pandemic.

posted by FLA_MEDIC @ 10:07 AM

 

[sharon sanders]

Re: Pandemic Issues For Home Health Providers

Re: Pandemic Issues For Home Health Providers

Pandemic Issues For Home Health Providers - Pt 3



# 2138

Note: This is the Third of a multi-part series on the HHS's recent report on the home health care industry during a pandemic. Here are links to Part 1 and Part 2.
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The recently released HHS document - Home Health Care During An Influenza Pandemic : Issues and Resources - covers a good many issues important to the Home Health Care sector, but none so important as anticipated employee absenteeism during a pandemic.

While this report is home health care provider centric, much of what is contained in it would apply to any health care delivery system, including hospitals, EMS, and long-term care facilities.
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This is a subject I've covered numerous times, following the ongoing poll on allnurses.com (see here, here, here, and here) over HCW (health care workers) willingness to work during a pandemic.

While the polling question asked is whether nurses would work `during a severe pandemic with a shortage of PPE's', it is quite obvious from the responses that many nurses would be reluctant to work even with protective gear.
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There are now more than 320 comments, and over 1100 respondents to this poll. As you will see, the results of the allnurses poll (currently 47% willing to work in a pandemic) closely match the results of polling referenced in this HHS document.
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The HHS document looks at three different causes of employee absenteeism during a pandemic.

• Employees sickened and unable to work
• Employees unable to work
• Employees unwilling to work in a pandemic

The first category, employees sickened and unable to work, is addressed this way:

An obvious factor in the ability of the workforce to work during a pandemic is infection. A significant share of the home health care workforce likely will become infected with the influenza virus and be unable to report to work.

Estimates based on past pandemics suggest that at least 25 percent of the workforce overall will become infected.²⁰ Today these estimates likely would be mitigated in the event of a pandemic by government use of antivirals.
​

As I pointed out in Part 2 of this series, the suggestion that infection rates among HCWs would be reduced by government use of antivirals is a curious statement.

The stated policy, so far, has been to use government stockpiled antivirals for treatment only, not for prophylaxis.

Since no one can know, in advance, what the attack rate would be of the next pandemic it is impossible to accurately judge the percentage of HCW's that would be affected by the virus.

The 25% number provided could be reasonable, or it could be far afield.


The second category, employees unable to work, anticipates that during a pandemic there may significant obstacles preventing many HCWs from being able to report to work.

School and daycare closures, a shutdown of public transportation, and even fuel shortages are mentioned as possible factors.

(The excerpts provided are reparagraphed for easier reading, and the highlights are mine)

The survey presented participants with a series of disaster scenarios. More than 80 percent of respondents indicated they would be able to report to work in the event of a mass casualty incident.


(The scenario presented was that of an explosion in Yankee Stadium with 2,000 seriously injured people transported to hospitals.) (See Figure 1).19

In contrast, less than two-thirds (63.5 percent) of survey respondents indicated that they would be able to report to work in the event of an infectious disease outbreak such as SARS.19 Similar �able to report� response rates were given for smallpox (68.6 percent) and radiation (63.8 percent) scenarios.19


Figure 1. Health Care Workers� Ability to Report to Work, by Disaster Scenario

N = 6,428 health care workers in 47 facilities
Source: Qureshi K, Gershon RRM, Sherman MF, Straub T, Gebbie E, McCollum M, Erwin MJ, Morse SS. Health care workers� ability and willingness to report to duty during catastrophic disasters. Journal of Urban Health. 2005;82(3):378�388.


The survey indicated that the two most significant structural barriers to workers� ability to report to work in a catastrophic emergency situation were transportation issues (33.4 percent) and child care (29.1 percent).19
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The report goes on to list some of the steps agencies can take to try to remove barriers preventing employees from being able to work:

• • Community planning groups may need to formulate contingency plans for providing health care providers, including home care providers, transportation during an emergency.

• • The home health care agency should be aware of how many of its employees use public transportation and should share those numbers with local planners.

• • In addition, the agency may want to make arrangements for the transport of its own workers. For example, agencies could consider approaching local schools to see if, in the event of a pandemic severe enough for school closures, school buses might be redeployed to transport home health care workers to their jobs while schools are closed.

• • On the other hand, if schools and daycare centers are closed or children need to stay home because of influenza infection, either case could result in some home health care workers needing to stay home with children.

• • Another issue related to workers� ability to work is the possibility that some may be employed by other health care facilities as well. The other employer may have a need for them during a pandemic that conflicts with that of the home health care agency.

Willingness to work during a pandemic is another issue altogether. Health care workers would not only be risking their own health, and lives, to treat patients they could potentially bring the infection home to their families.

Willingness of Health Care Workers to Report to Work During a Pandemic


Research indicates a distinct difference between the concepts of ability to work and willingness to work, with the first referring to a worker's capability and the latter referring to a worker's attitudes and intentions regarding reporting to work.19

Surveys indicate that a significant number of health care workers may be unwilling to report to work during an infectious disease-related emergency.

The New York City survey cited above indicated that less than half (48 percent) of the workers would be willing to report to work during an infectious disease outbreak (see Figure 2).19

The most commonly cited reasons that workers gave for not being willing to respond to an emergency included fear and concern for their own and their families' health and well-being (31.1 percent and 47.1 percent respectively).19

Figure 2. New York City Health Care Workers� Willingness to Report to Work, by Scenario

N = 6,428 health care workers in 47 facilities.


Source: Qureshi K, Gershon RRM, Sherman MF, Straub T, Gebbie E, McCollum M, Erwin MJ, Morse SS. Health care workers� ability and willingness to report to duty during catastrophic disasters. Journal of Urban Health. 2005;82(3):378�388.


Individuals are willing to put themselves at risk. We see it in every disaster and emergency. What they're not willing to do is carry that risk back home to their families.
Joseph Cappiello, M.A.
The Joint Commission


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Other studies are cited, all providing similar results. Those interested should definitely read the entire document.

Measures that home care agencies can take to increase workers' willingness to report to work include:

• Ensuring that workers have appropriate personal protective equipment and providing training on its appropriate use, including fit testing. Knowing how and when to use such equipment may lessen some of the workers' concerns, thus increasing their willingness to report to work in a public health emergency.²³

• Helping employees identify backup informal child-care and adult-care arrangements in the event of school and day care center closures.10

• Providing psychological support during a pandemic, including incorporating psychological support of health care workers into pandemic planning, reinforcing to workers their value and importance to the community; possibly extending resources to cover workers' families, and offering psychological resources to workers for an extended time after the pandemic subsides.²⁴

Not listed at this point is the recent recommendation that employers of High and Very High risk employees (mostly health care workers and first responders) provide outbreak prophylaxis for the duration of a pandemic wave. I'm unsure why this was excluded in this summary since it is mentioned elsewhere in the document.
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The results of these surveys show that many HCWs harbor deep concerns over working during a pandemic. Based on these results, a 50% (or greater) reduction of the workforce would not be unexpected.


Agencies, and health care facilities, need to take a serious look at how they can restore faith among their employees that their health and safety, and that of their families, will be the primary concern during a pandemic.


After the debacle of the SARS experience in Canada, where nurses weren't told early on just how infectious the disease really was, and sometimes weren't provided the most efficient PPEs, there remains a climate of mistrust regarding infectious diseases among many HCWs.

Openly, and aggressively, planning for a pandemic is one way to alleviate some of these concerns. Actively encouraging employee input and participation in these plans is essential to build trust. Pandemic planning should not take place behind closed doors.
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The issues addressed in Home Health Care During An Influenza Pandemic : Issues and Resources go far beyond what I've covered in these three blogs. The document deserves a thorough reading by all health care providers.

posted by FLA_MEDIC @ 9:44 AM