A reconsideration of the healthcare provider in the age of COVID-19.

Lately there have been a number of discussions about protecting healthcare workers, bolstering the ranks with volunteerism and about alternative care sites and providers. There have been call-ups of retired clinicians of all stripes, field promotions of health sciences students, and alternative venues for care like telemedicine.

Those efforts are all quite noble and intelligent, but the one group that doesn’t seem as considered or fully addressed is that of home health workers. While they are often tangentially referenced in healthcare environment conversations, this unique, variable, and incompletely accounted landscape is potentially an area of increased risk for providers, patients, public spread and mortality.

In most of the discussions, publications, and public call-outs by leadership, public health and others, this quiet and large workforce is generally not mentioned. There are specific instructions for some cohorts of care-provision such as EMS https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.htmlor the hospital setting writ large https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.htmland while there is a a long term care and nursing home guidance https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.htmland home healthcare is called out https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.htmlit appears to distinguish arbitrarily between certain considerations of infection potential, and the protection requirements of said personnel.

The guidance appears to assume that PPE requirements will differ from the other settings, when in fact, a patient receiving home care may actually be capable of aerosol-generation in close approximation to the care giver.

This healthcare subenvironment is at risk for not being fully and properly captured in terms of data collection, in part because the participants in home healthcare often vary substantially in training, credentialing and advocacy at public health strategic levels. Considerations and assumptions of patient contact and a lack of inherent engineering and infection controls, make this a potentially devastating vulnerability for all parties concerned and could be a hidden vulnerability in the overall healthcare strategy. In fact, in assessments performed in 2016, https://acl.gov/aging-and-disability-in-america/data-and-research/profile-older-americans distinct state requirements of accountability for “who is providing home care” and the potential effects listed a cohort of personnel that includes Community Attendant Services (CAS), Registered Nurses (RN) and Licensed Vocational Nurses(LVN), Home Health Aides (HHA), Personal Care Assistants (PCA), dialysis technicians and medical equipment suppliers among others. This is a large and stratified group with significant risk profiles who deserve more attention in terms of PPE guidance and inclusion in the “healthcare system” universe.

In terms of consideration, most of these settings are not mentioned or included in terms of PPE requests and priority, even as those personnel are being asked in many states to engage in the healthcare setting as part of surge. One might consider that they are already engaged. Additionally, they are not part of the PPE prioritization. In a time of shortage, of course the first consideration should go to the high aerosol generating and proximal areas such as critical care, respiratory therapy, and the interventional theater. Admonition, however, for all who may be at risk should not be overlooked.

In some guidance, the home health setting calls out masks distinct from N95 protections. What might serve better would be additional guidance for an assessment of the risk factors in terms of procedures, aerosol generation, distance, barriers and more as well as the allowance of the more sophisticated respiratory and other barrier provisions.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html

The healthcare system is, after all, a much broader universe in the 21st century.

Matthew Minson, MD is a physician and has served as a senior health official at the local, state and federal level. He is the author of a series of books championing individual health and social advocacy published by Texas A&M University Press. He has appeared on and contributed to C-Span, PBS and NPR among others.