Lessons in resilience: Home-based primary care during COVID-19

The COVID-19 pandemic fundamentally changed how we care for frail older adults, accelerating the shift from hospital to community care and focusing attention on existing and novel models that provide care in the home. A systematic review of home-based primary care (HBPC) conducted by our group just prior to the onset of the pandemic concluded that new care models and evidence would likely emerge to increase home-based care delivery.1 After 3 years of a public health emergency, we reassessed the effects of COVID-19 on HBPC. We conducted a systematic search of peer-reviewed literature in February 2023, querying Medline and adapting search terms for Cumulative Index to Nursing and Allied Health (CINAHL), Embase, Web of Science, Cochrane, and Scopus libraries.1 We included articles describing longitudinal primary care provision in the home as related to COVID-19. All authors reviewed included articles and elicited themes for synthesis. Eighteen articles were included (Figure 1). Researchers identified five overarching themes: practice challenges and adaptations, telehealth, changes in healthcare utilization, vaccination, and provider strain. Table S1 lists the included article citations and provides information about each study. Table S2 describes the identified themes, synthesizes study findings, and identifies research gaps. Each theme reinforced the resilience of HBPC in balancing patient-centered care with safety for the frailest and most vulnerable patients. HBPC adapted quickly to provide care throughout the pandemic. As healthcare provision outside of traditional facilities accelerates, lessons can be learned from HBPC. Our review revealed three knowledge gaps that have implications for the future of primary care broadly as more care shifts into the home. First, we need evidence to understand how hybrid (virtual/in-person) HBPC models impacted the provision and quality of care. While increased telehealth uptake was not a “silver bullet” to eliminating barriers to primary care, telehealth likely facilitated access to some previously unobtainable care, such as visits with specialty providers, who do not traditionally make house calls. However, none of the included studies measured delayed or deferred primary care among homebound patients during the pandemic (e.g., cancer screenings). Perhaps the strongest support for HBPC's efficacy during COVID comes from the Center for Medicare and Medicaid Innovation's Independence at Home (IAH) demonstration. In 2020–2021, HBPC recipients had three times as many primary care visits as matched controls. The Center for Medicare & Medicaid Services (CMS) found “frequent primary care visits may have been more valuable for attending to health needs during the pandemic,” while also driving cost savings ($5508 per beneficiary annually).2 Second, important adaptations to HBPC may now be indispensable and require policy codification. Several telehealth accommodations have been extended through December 2024, including the allowance of telehealth for many routinely billed Medicare services, including primary care. Permanent approval has been given for virtual behavioral and mental health care. Whether telehealth deployment in primary care should be similarly codified is currently before Congress. Third, it is unknown how much HBPC must grow to meet the needs of an aging society. In 2020, the prevalence of homebound older adults grew by 220%.3 This rise was unequal across racial and ethnic groups, highlighting COVID-19's disparate impact on older adults. Whether the prevalence of homeboundedness returns to pre-pandemic levels and which groups are the most impacted remains to be seen. The rise in homebound older adults, however, exacerbates a preexisting condition of our healthcare system: the supply of clinicians with aging expertise is outstripped by demand.4 Novel solutions are needed to deliver high-quality home-based care at scale. This will likely include technology integration and dissemination of geriatric principles to other healthcare professionals to deliver specialized community-based care. The COVID-19 pandemic demonstrated that HBPC is adaptable and resilient to unprecedented challenges. Further research must focus on these knowledge gaps to inform the ongoing expansion of home-based medical care for homebound and non-homebound patients alike. Robert M. Zimbroff: Study concept and design, analysis and interpretation; manuscript drafting and revision. Katherine A. Ornstein: Study concept and design, analysis and interpretation; manuscript drafting and revision. Orla C. Sheehan: Study concept and design, analysis and interpretation; manuscript drafting and revision. The authors declare no conflicts of interest. There is no sponsor for this research. Table S1. Systematic review included articles. Table S2. Thematic categories, research gaps, and implications. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.