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Background/Objectives: COVID‐19 required rapid innovation throughout the healthcare system. Home‐based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands‐on, model of care to accommodate restrictions on in‐person contact. Our aim was to determine strategies used by New York City (NYC)‐area HBPC practices to provide patient care during the first wave of the COVID‐19 pandemic with the goal of informing planning and preparation for home‐based practices nationwide. Design: Cross‐sectional qualitative design using semi‐structured interviews. Setting: HBPC practices in the NYC metro area during spring 2020. Participants: HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC‐area practices. Measurements: Semi‐structured interviews explored HBPC practices' COVID‐19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end‐of‐life care, telehealth, community‐based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. Results: Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID‐19, such as patient outreach and telehealth. HBPC‐specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in‐person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long‐standing patients. Conclusion: NYC‐area HBPC providers adapted care delivery and operations rapidly during the height of the COVID‐19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges. [ABSTRACT FROM AUTHOR]

1. Characterize patients in a home-based primary and palliative care (HBMC) practice who died during the spring 2020 COVID-19 surge in New York City 2. Identify multiple levels of disruption that occurred during the COVID-19 surge 3. Describe three ways that home-based medical and palliative care practices are positioned to support end-of-life care for homebound older adults during emergencies COVID-19 end-of-life research has focused primarily on patients who died in hospitals and nursing homes. Less is known about homebound patients receiving home-based primary and palliative care (HBMC) in the community. To describe characteristics and end-of-life care experiences of patients in an HBMC practice who died during New York City's initial 2020 COVID-19 surge. Mixed-methods, retrospective quantitative and narrative analysis of demographic, clinical, and end-of-life data from unstructured electronic medical record notes for all patients who died between March 1 and June 30, 2020. 112 (9%) of the practice's 1,300 patients died during this period, with the average monthly mortality rate doubling in April 2020, the peak of the NYC surge. Thirty-four (30.4%) had confirmed or probable COVID-19. 58 (52%) were referred to hospice, and 50 enrolled. Eighty-two patients (73%) died at home. Our qualitative analysis found that COVID-19 disrupted regular caregiving routines, often requiring new or inexperienced caregivers to step in; rapidly evolving COVID-19 knowledge and protocols complicated access to services (e.g., requiring patients to present a negative COVID-19 test to begin hospice despite testing shortages); avoiding hospitals and emergency departments became an urgent concern due to visitor restrictions and families' fears of loved ones dying alone; and COVID-19 complicated ongoing care for complex conditions (e.g., continuing dialysis for COVID+ patients). Throughout the surge, the HBMC team drew on their collaborative practice and longstanding relationships with patients, families, and hospice and home care providers to navigate service disruptions and provide comfort and emotional support. Overall, COVID-19 created severe disruptions and barriers to necessary care, further complicating care for this very high-risk, high-needs population. HBMC played an integral role in supporting patients and their families through the pandemic surge. As a model focused on interdisciplinary, whole-person care for medically complex patients, HBMC may be uniquely positioned to support homebound patients at the end of life, both during emergencies and beyond. [ABSTRACT FROM AUTHOR]

1. Characterize patients in a home-based medical care (HBMC) practice who died during the spring 2020 COVID-19 surge in New York City 2. Identify health service and caregiving disruptions that occurred during the COVID-19 surge 3. Identify home-based primary and palliative care practice adaptations to maintain care for homebound patients during the COVID-19 surge Much COVID-19 research focuses on care in institutional settings, but less is known about the care experiences of homebound patients receiving home-based primary and palliative care in the community. Before COVID-19, these patients faced high symptom burden, multiple comorbidities, and high mortality. To describe characteristics and care experiences of patients in a home-based medical care (HBMC) practice who died during New York City's (NYC) spring COVID-19 surge through a mixed-methods, retrospective electronic medical record (EMR) review. We analyzed EMRs for all HBMC patients who died in the initial COVID-19 wave in NYC (March 1-June 30, 2020). We developed an abstraction tool to collect service-related measures (eg, phone calls, televisits), household and clinical characteristics (eg, dementia status), and clinical notes on key disruptions including those related to family caregiving, paid caregiving, medical supplies, and hospice. During the study period 112 patients died, twice the practice's usual monthly deaths. Thirty percent died from confirmed or suspected COVID-19, 73% died at home, and 46% were enrolled in hospice. Medical and service disruptions included medication shortages, delayed hospice enrollment, and suspension of nursing and hospice visits due to personal protective equipment and staff shortages. Caregivers experienced difficulties with long-distance care and frustration over service disruptions. HBMC providers adapted by conducting outreach via phone and telehealth and leveraging relationships with partners such as hospice and medical equipment vendors. Hospital restrictions and fear of infection increased caregivers' and providers' commitment to keeping patients at home at the end of life. Disruptions in family caregiving and health services such as hospice during COVID-19 complicated the dying experience. HBMC providers were an important bridge between caregivers and supportive community and medical resources. The COVID-19 pandemic exemplified how home-based primary and palliative care can be an important resource at the end of life. Targeted resources are needed to support families in managing end-of-life care. [ABSTRACT FROM AUTHOR]

1. Illustrate the role of home care workers (HCWs) in caring for homebound older adults during COVID-19 2. Characterize disruptions in HCW services in the setting of COVID-19 and how these impacted the ability of patients to stay safely at home 3. Identify the impact of HCW services on patients and their family and other unpaid caregivers The devastating impact of the COVID-19 pandemic has made the need for quality home-based care for homebound older adults with serious illness clear. Home care workers (HCWs) played a critical role in keeping homebound older adults safely at home during COVID-19, yet their essential work is often undervalued and understudied. To illustrate the roles of HCWs during COVID-19 and how HCW service disruptions impacted patients and their caregivers. We collected demographic and clinical data and performed a thematic analysis of medical records from 53 patients with HCWs in a home-based primary and palliative care practice in New York City. We abstracted unstructured clinical notes between 12/1/2019 and 12/31/2020 into a priori and emergent categories and identified core themes via discussion in team meetings. Of the 53 patients, 24.5% died during the initial COVID surge, 34% lived alone, and 41.5% had 24-hour HCWs. The following five themes emerged: Changes to HCW roles included taking on new medical tasks and increased intensity of existing tasks (e.g., managing progressing dementia behaviors); delays in staffing contributed to changes in HCW hours and continuity, including unexpected loss of services; disruptions in HCW services put patients at risk of hospitalization and nursing home placement due to safety concerns; payment structure and patient preferences made it challenging to get sufficient hours of paid care; and lack of adequate and high-quality HCW services created additional caregiver responsibilities and caregiver burden. During COVID-19, HCWs were essential to keeping homebound older adults safely at home. Inadequate HCW services, including unstable schedules and inadequate hours of paid care, became particularly disruptive, leading to risk of hospitalization and prolonged length of stay. This analysis can inform policies encouraging better integration of HCWs on medical teams and addressing workforce shortages to expand access to adequate HCW services for homebound older adults and their caregivers to manage serious illness and end-of-life care. [ABSTRACT FROM AUTHOR]