As 2021 draws to a close, many countries are working through what it means to live with SARs-CoV2 virus, Delta and its newest sibling Omicron. This pandemic is not over as an increasing number of northern hemisphere countries face a fresh wave of significant community outbreaks. Balancing between preventing fresh community outbreaks and the safe opening of their economy and society is anything but straightforward. Vaccination is the main lever for re-opening but has become a polarising issue and a source of tension at the individual, family, community, and societal levels.
For countries adopting an endemic approach to Covid-19, the home recovery model (HRM) plays an increasingly prominent role in managing community infections. The HRM allows asymptomatic people or with mild illness to serve their mandatory quarantine period at home. It is a sensible approach, without which the alternative is to send all positive cases to a managed quarantine or health facilities. Like most countermeasures against Covid 19, implementation is anything but smooth.
Countries like Singapore and New Zealand have had to put HRM in place swiftly. Teething problems have surfaced. Various media platforms have reported delays, confusion, and frustrations of those adversely affected, sometimes with deadly consequences, as in New Zealand recently. No system is perfect, but vital lessons from Singapore and New Zealand require prompt remedial actions as the HRM is here to stay in short to medium term.
Fear, stigma, anxiety, and uncertainty
There is still a lot of “fear” and stigma for someone when told they have Covid-19. For an increasing number of positive cases having to recover from home, there is added anxiety and uncertainty for themselves and their families living in the same household. Delay and gaps in communication add an unquantifiable level of stress and have long shadows that linger long after their home isolation is over.
Decision-makers responsible for HRM can minimize anxiety and frustrations for affected individuals and their families by making sure that: 1. Policies including should be appropriate, clear, and timely 2. The design of related processes should be flexible to cope with diverse person's health needs, family circumstances, and home environments. 3. Implementation and communication should be responsive, timely, with a high degree of coordination and an abundance of patience and empathy. 4. There is adequate, appropriate and timely: a. Professional health, social and welfare support, and b. Material support of health (for example, PPEs, rapid antigen tests kits, pulse oximeters, etc) and non- health resources (for example food and basic household items) for the entire household, not just the affected individual.
There are multiple factors for a fit-for- purpose HRM. Even with advanced planning, implementing all these different elements in an “integrated system” will still be challenging (case in point, the Singapore experience 1, 2 ). A worst case scenarios is the combination of inadequate planning coupled with a rushed, non- integrated, and siloed implementation. In that case, HRM can become another source of transmission amongst household members, provides fertile grounds for confusion, frustration and could result in death 3 (case in point, the New Zealand experience).
The basic elements of a fit for purpose HRM involve the following: 1. Criteria for eligibility 2. Initial assessment 3. Home care support resources (medical and non-medical) 4. Daily baseline reporting of health and other indicators 5. Daily contact of health and non-health support staff (virtual or physical) 6. Clear escalation process for adverse changes in circumstances 7. A clear process for a successful conclusion of home recovery
Criteria for eligibility
Setting clear eligibility criteria for home recovery is important. Key considerations should include those living in the same household, the household environment, their support network, and the health status of everyone in the household.
Initial assessment
Once a person is informed of a positive result, getting the first assessment for eligibility is the next crucial step. This assessment has to consider both health and non-health factors (for example, household living environment ). Ideally, the person's GP is the most appropriate person for this task, but the overriding consideration is the timing of getting the first assessment completed comprehensively.
If the person does not have a GP, an appropriate health professional should still do the initial assessment.
The timing for this first assessment should be no later than twenty-four hours after notification of positive test result.
Home care support resources
An initial home care support kit should ideally be delivered to the HRM person's accommodation within twelve hours after being notified of the positive test result. The content should have the health monitoring tools (for example, pulseoximeter, temperature, and blood pressure monitor) and basic food supply for 24 hours.
Some people may not be familiar with using some of the health devices. During the first assessment, the health professional should ensure that the person knows how to use these devices.
Daily baseline reporting of health and other indicators
Daily assessment of a person's well-being requires both health and non-health indicators. Basic health indicators would include oxygen saturation level, temperature, heart rate, and blood pressure. Non-health indicators would include sleeping patterns, nutrition, any living arrangement issues.
Daily information should be recorded digitally as official documentation and a copy provided to the person at the end of the HR program.
Daily contact with health and non-health staff
Daily contact with health and non-health staff for people in home recovery is a fundamental essential lifeline. There will inevitably be an endless list of questions that needs answers. While a standard Q&A sheet can be provided, having someone to talk through can be the difference between coping and not coping mentally during isolation at home. Having a separate non- health daily contact person will free up health support staff to concentrate on health-related issues. Non-health-related issues could include paying household bills, employment, transport, children's education, and relationship with neighbors.
Clear escalation for adverse changes in circumstances
Some people starting out on HRM may not be able to continue due to adverse changing circumstances. These circumstances can be health or non-health- related. When that happens, the process for escalation and change to be clear, seamless, and without delay. Delay in escalation and change can be fatal, especially when faced with significant and sudden deteriorating health conditions.
The HRM escalation criteria and process should operate on the principle of "if in doubt, implement the escalation protocol."There have been three deaths in New Zealand of people under its HRM and is the subject of coroner inquest. Separate from any recommendations from the coroner inquest (which can take some time), two immediate steps are taken by those running the system in New Zealand. First, there should be a rapid assessment that no others in their HRM are at risk. Second, review and tighten up the existing escalation protocol.
A clear process for a successful conclusion of the HR stay
The process to formally “discharge” a person at the end of a home recovery stay clear and reassuring for the individual and their families. There should be formal documentation and an opportunity to discuss a final discharge involving the person, their families, and the discharging health professional. The person should receive a copy of this discharge documentation —another copy sent to their GP where applicable.
If wearable devices or apps indicate a person's home isolation status, these should be updated by the health professional conducting the discharge discussion.
Final word
Hopefully, the time will come when getting Covid 19 will be like getting the flu, where most of us can recover from home without the current HRM's bureaucratic process. Until then, those responsible for the HRM have an unenviable assignment despite their best intention and dedication. There should be a requirement that every team involved in every stage of HRM should have a person who has gone through HRM. It will go some way to putting themselves in the shoes of those that find themselves isolated in an HRM.
CHUAH Jin Chai 蔡 仁材 Wellington, NEW ZEALAND 23rd November 2021
Note 1. https://www.straitstimes.com/singapore/home-recovery-the-default-covid-19-care-arrangement-for-everyone-from-sunday 2. https://www.youtube.com/watch?v=hfjr5AQQ978 3. https://www.nzherald.co.nz/nz/covid-19-delta-outbreak-home-isolation-deaths-a-moral-and-legal-failure-ron-paterson/O6CQT57RPNH5FLXATI6JYBSJYI/