Home Care as a safe alternative during the COVID-19 crisis

COVID-19 among residents homes. part of post-acute chronic (HC). OBJECTIVE: This study aims to evaluate the incidence of COVID-19 in Home Care patients and the clinical outcomes of these patients; it also aims to assess the impact of the epidemic on the number of patients, new admissions, and hospitalizations. METHODS: A descriptive study of the COVID-19 cases that affected the population in care by Home Doctor (a private company of Home Care), between the months of March 2020 and May 2020 and analysis of the total number of patients, the hospitalization and death rate in the period compared to the pre-epidemic period. RESULTS: There were 31 confirmed cases of COVID-19, 21 of which were male, mean age 73 years. All patients had multiple comorbidities, the most prevalent were: Systemic Arterial Hypertension (54%) and Stroke (35%). The incidence of COVID-19 was 1% in the studied population. There were 10 hospitalizations with 5 hospital deaths and one case of home death (lethality 19%). Safe care was maintained, with a low death rate (0.6%) and hospitalization (6.1%). CONCLUSION: Home Care is able to maintain safe care during the pandemic due to COVID-19, with a low incidence of COVID-19, low hospitalization rate, and low mortality when compared to nursing homes institutions.


INTRODUCTION
The World Health Organization (WHO) received, in December 2019, the first reports of cases of pneumonia of unknown etiology in the city of Wuhan (Hubei province, China), subsequently attributed to infections by the new betacoronavírus called SARS-CoV-2, Severe the epidemic (1QTREPI), reporting the incidence of COVID-19 cases in this population and analyzing the clinical data and outcomes of these patients.
We analyzed the total number of patients undergoing care, the number of new cases (related and unrelated to , as well as the rate of hospitalization and death in the 1QTREPI in comparison to January/2020, using as a reference the period pre-epidemic (REFPRE).
The data were retrieved from the electronic medical records system of the company and presented as absolute numbers (N), frequency (%), and mean when appropriate.

RESULTS
In the 1QTREPI, 2931 patients were treated in all home care programs. The company recorded over this period 31 confirmed COVID-19 cases, 10 of them in females and 21 in males, with a mean age of 73 years (21-95 years). All patients presented multiple comorbidities, and the most prevalent were: Systemic Arterial Hypertension in 17 cases (54%) and sequelae from strokes in 11 cases (35%). The incidence of COVID-19 was 1% in the population studied. There were 10 hospitalizations with 5 in-hospital deaths and one case of death at home, a patient undergoing exclusive palliative care, which represents a mortality rate of 19% (Table 1).
The geographical distribution of confirmed COVID-19 cases was disclosed on a daily basis for the entire care team through a case map, and data relating to 31/05 are presented in Figure 1.
Virtual consultations have been made available with doctors, nurses, nutritionists, psychologists and social workers since April/2020 aiming to reduce the commuting of professionals to patient homes and, consequently, reduce patient exposure (54% of medical visits and 44% of nurse visits were replaced by telehealth consultations). Physiotherapy and speech therapy sessions were maintained in-person due to the profile of the need of the population. A satisfaction survey was applied in patients treated through this modality using the Net Promoter Score (NPS), with a result of 54% (zone of quality).
Patients undergoing home care received safe and quality care, with their clinical stability maintained, which can be evidenced by a low mortality rate and a low and declining rate of hospitalization in the 1QTREPI (Table 2). other countries, mainly in Europe, in the United States (USA), in Canada, and in Brasil. On 11 March 2020, the WHO characterized COVID-19 as a pandemic.
In Brasil, the first confirmed case of COVID-19 occurred on 26 February. On 20 March, the Ministry of Health acknowledged, through Decree No 454, the status of community transmission of COVID-19 throughout the national territory. Since then, the number of cases has grown exponentially, and currently, despite the known underreporting, the country holds the second position worldwide among countries with the greatest number of cases and deaths due to  There are various reports worldwide on the high mortality related to COVID-19 among the residents of Nursing Homes, which correspond to 25% of all deaths related to COVID-19 in the United States, and even larger percentages in some North American states and European countries (such as France and Ireland) 2 . The worldwide concern regarding the safety of patients and professionals in these institutions is entirely appropriate.
In Brasil, unlike the scenario of other countries such as the USA, a large part of post-acute care, rehabilitation and care of chronic patients are performed at home, through the home care (HC), instead of in nursing homes, both in the public sector and in complementary health. This modality includes the administration of medicines, enteral nutrition, wound dressing, rehabilitation therapies, oxygen therapy, and even more complex therapies such as parenteral nutrition and invasive and non-invasive mechanical ventilation.

OBJECTIVE
The present study aims to evaluate the incidence of COVID-19 in patients undergoing home care and the clinical outcomes of these patients; in addition, we aim to assess the impact of the epidemic on the numbers of total patients, new admissions, and hospitalizations during the initial period of the pandemic.

METHODS
This is a descriptive study that included the collection, tabulation and analysis of data on COVID-19 cases that affected a population undergoing care by Home Doctor (a private home care company), between March 2020 and May 2020, i.e., the 1 st quarter of   From January to May, we observed an increase of 305 patients/month in home care, which represented an increase of 15% in cases treated (Table 2). This increase in patients can be attributed to: I -Hospital discharge of COVID-19 patients, either in an active stable phase of the disease or in the rehabilitation phase During the 1QTREPI, a total of 35 patients were admitted into home care, from a hospital, with a diagnosis of COVID-19, 11 (32%) of them still in the active acute phase of the disease, and 24 (68%) for rehabilitation therapy and treatment of complications.
II -Hospital discharge of with diagnoses unrelated to  During the 1QTREPI, 1137 patients were admitted to home care from hospitals. The main reasons for home care were the need for end of treatment with intravenous, intramuscular or subcutaneous medication, oxygen therapy, dressings, nutritional support, and rehabilitation therapies.
III-To avoid hospitalization of suspected or confirmed non-critical cases of COVID-19, through home monitoring of oximetry, oxygen supplementation, medical follow-up at home, daily medical telephone monitoring, and emergency medical center available 24/7.
In the 1QTREPI, a total of 76 patients were monitored with confirmed or suspected COVID-19, with 10 hospitalizations (13%).

DISCUSSION
The home care sector grew exponentially in recent decades. Currently, it is estimated that approximately 1 million patients start home treatment yearly in Brasil, including the public and private sectors 3.4 . Thus, this segment is responsible for reducing the demand for hospital beds and the overload of the hospital sector, something that becomes even more important in the context of the COVID-19 epidemic.
Advanced age and the presence of comorbidities are associated with increased mortality in the pandemic caused by the novel coronavirus. The high prevalence of this combination, associated with physical environments that provide inadequate barriers for infection control, puts nursing home patients at great risk, and studies have shown that once a first case occurs in these institutions, the ability of the infection to spread to other patients is quite high 5,6,7 . The world literature reveals alarming numbers regarding these institutions, with 2/3 of patients affected in a period of 3 weeks and mortality rates reaching values as high as 72% 8 .
Home care, which is classically recognized by the social benefits it provides, such as patient participation in family life and society and consequent improvement in the quality of life, presents a unique advantage in terms of patient safety and infection control. The patient is naturally maintained in home isolation, assisted by a team of professionals trained to meet the special need of their care. This, in association with the correct use of individual protection equipment (IPE) and incorporation of innovations in the sector (such as the use of telehealth) are key points for safe healthcare in the context of the epidemic 9,10,11 .
The study population consisted primarily of elderly patients with comorbidities, and in this known risk group, the incidence of COVID-19 was of only 1%. The subgroup of patients affected by COVID-19 was 80% comprised of elderly individuals, all of them with comorbidities, and the mortality of 19% observed is quite lower than that reported worldwide in nursing homes.
The epidemic drove the rapid incorporation of telehealth in the context of home care, with patient satisfaction within the quality level set by the NPS. Learning about this technology, its risks and benefits, will be essential so that professional councils and societies can define the role of this tool in the future.
Home care, like all health sectors in Brasil and worldwide, faced difficulties with the emergence of the epidemic regarding the supply chain (with scarcity and overpricin), interruption or reduction of public transport that hindered the commuting of professionals, increased rate of absenteeism, need for collaborator leaves, among others. However, it showed great plasticity and the ability to adapt, quickly and effectively re-structuring itself and being able to keep patients safe in their homes while actively contributing to keeping hospital beds available.

CONCLUSION
Home care has proven to be able to treat patients of different complexities in their home environment safely during the COVID-19 pandemic, with a low incidence of COVID-19, low hospitalization rates, and low mortality when compared to nursing homes.
Home care, in addition to maintaining patients safely in their households, is capable of increasing its capacity rapidly, admitting patients from hospital environments and contributing to improve the availability of hospital beds.
The current pandemic has led to great considerations on how to provide the best health care and create safe treatment options beyond the hospital environment. The migration of post-acute and chronic care to the home environment with the use of technology seems to be an important piece to solve this complex puzzle.