The Impact of the COVID-19 Pandemic on Disabled and Hospice Home Care Patients.

As of March 29, 2020, there have been over 634,835 confirmed cases of coronavirus disease 2019 (COVID-19) infection and 29,957 resultant deaths (1). News reported that older patients were abandoned suspected to be linked to COVID-19 (2). As a family physician, home care nurse, and caregiver performing home care services, we have encountered many challenges and dilemmas in the face of the COVID-19 outbreak.

Disabled and hospice home care patients generally suffer from chronic illnesses or critical conditions, which make them vulnerable to COVID-19. In 2019, 325,558 disabled patients in Taiwan required basic home care services, such as bathing, food delivery, and companionship (3). In addition, 222 home care teams in Taiwan provided high-tech home care to 58,958 patients (4). Similarly, estimated prevalence of 437,822 patients requires home enteral nutrition in the United States (5). These patients regularly received invasive procedures, such as nasogastric tubes, Foley catheters, and tracheotomy tube replacements, and even infusion therapy, ventilator support, and hospice care. Therefore, infection surveillance, prevention, and control in home care are further challenged by the COVID-19 pandemic.

A significant proportion of disabled patients will need to be intubated and use ventilators if diagnosed with COVID-19. Judging by the contemporary situation in many countries, ventilators are becoming an increasingly important and scarce medical resource; so, we should try to prevent the use of ventilators. Therefore, we propose the following policy suggestions on top of existing protocols (6):

First, we propose that disabled home care patients should be treated as people who require home isolation. It is better for them to have independent space and minimize the number of carers in contact with them. At present, the Taiwan Center for Disease Control recommends that if the family members of disabled patients need home quarantine, a medical team should not go to the patient’s home to provide services. However, we should approach this issue in a different way. We believe that if there is a disabled patient in a family, when their family members or caregivers are suspected to be infected by COVID-19 and need to be quarantined at home, they should not live together, and a quarantine hotel or another alternate space should be arranged.

Second, carers should also engage in basic daily observation and enhance their personal hygiene, particularly by wearing a mask and washing their hands. In Taiwan, many families employ carers from Indonesia, Vietnam, and the Philippines to assist in daily care. Sometimes, a communication gap can result in a gap in infection surveillance, prevention, and control. Therefore, the government should prepare multilingual manuals for COVID-19 infection prevention. Most importantly, we need to give more support to carers to reduce the pressure on them.

Third, because the medical staff performing home medical care will visit several patients, each of them should measure their body temperature and be vigilant of any COVID-19-related symptoms and signs. When performing invasive treatments such as the replacement of tracheostomy or nasogastric tubes, we recommend wearing a face mask and a protective gown to avoid being splattered by secretions. Moreover, at present, Taiwan is promoting mutual support among home care facilities. Once any member in any specific facility displays a high risk of COVID-19 infection, another home care team can quickly take over their services, reducing the risk of patients returning to the hospital for treatment.

Finally, disabled and terminal cancer patients have a relatively high infection rate (7). The dilemma is that many of them often have respiratory symptoms, fever, and a differential diagnosis in a home care setting is quite difficult at this time (8). We recommend that if we could exclude them from possessing significant history of exposure to COVID-19, medical treatment should be provided for them at home as much as possible. At this time, the intervention of hospice home care is also important. In addition, we believe that the quantity and integration of primary care at this time must be heightened. If these patients can be taken care of in the community and their need for hospitalization can be reduced, the burden on the emergency and critical care units in the hospital can be greatly eased.

In addition to actively looking for possible treatments of COVID-19, we believe that we also should prevent another tragedy of the older patients. We hope that in the face of the COVID-19 pandemic, all governments should coordinate the functioning of their primary care system and hospitals to implement an efficient hierarchy of medical care and overcome the COVID-19 pandemic.

Author Contributions

Study concept: T.-G.T. and C.-J.T.; Data collection: H.-L.W., H.-C.K., and C.-J.T.; Literature search: H.-L.W. and H.-C.K.; Drafting the manuscript: T.-G.T. and C.-J.T.; Critical manuscript revisions: H.-L.W., H.-C.K., and C.-J.T.