On a typical workday, Johns Hopkins nurse practitioner Amy Kilen visits five to six patients in their homes. She performs comprehensive exams; makes sure they have the right medications and are using them properly; talks with caregivers and family members; and gets a general sense of how her patients are doing by examining them in person.
The COVID-19 crisis, however, has brought an end to her routine. On April 6, a day when there were more than two dozen deaths from the highly contagious coronavirus in Maryland, Kilen performed three of her usual checkups by phone. She visited only one home, where two of her patients live together.
A staff member of Johns Hopkins Home-Based Medicine (JHOME), Kilen delivers primary care to patients age 65 and older who have trouble leaving their home due to chronic conditions such as arthritis, heart failure and dementia.
She says the pandemic has brought difficult challenges. “It has changed everything. Generally, what we do is very personal: We’re able to see the whole world of the patients. Limiting that contact really changes the whole feel of the practice.”
Mattan Schuchman, JHOME’s medical director, says that monitoring the health of these vulnerable, chronically ill patients remotely has become an essential part of minimizing their exposure to the new disease. “We expect that if they did contract the coronavirus, the mortality rate in our patient population would be upwards of 20%,” he explains.
These days, Kilen and one other JHOME practitioner usually visit no more than one patient a day. Reasons include complex health issues, a lack of caregiver or social support, unstable heart failure and a history of regular hospitalization. A new or complicated wound, acute illness or flare-up can also prompt an in-person visit.
For most patients, checkups are now conducted by phone or video. Although JHOME patients and providers were initially hesitant, most embrace the new normal — and even look forward to aspects of it, Kilen says.
“Seeing your older patients on FaceTime is a neat intergenerational connection,” she says. “I’ve actually been pleasantly surprised with how well they’ve adapted to the technology.”
So far, clinicians at JHOME, which is part of the Johns Hopkins Health System’s Home & Community-Based Services division, has one patient who contracted COVID-19. The Johns Hopkins Home Care Group — part of the same division — can test JHOME patients who have potential symptoms.
A Difficult Discussion
Kilen says that many of her patients want to discuss coronavirus, a topic that leads to some tough conversations about their end-of-life wishes. Even patients on the younger side of JHOME’s 65 and older age range who have advanced chronic diseases are more likely to die from COVID-19 — whether or not they are put on ventilators.
“A lot of them, of course, don’t want to hear it,” she says. “Having that conversation [about coronavirus] is a little bit difficult to do.”
Schuchman says many patients express the desire to stay home with palliative, nonaggressive care if they were to get coronavirus.
“They wouldn’t want to come into the hospital knowing the risk of mortality is so high for them,” he says. “They would prefer to be at home, where they’re comfortable.”
During home visits, patients are screened for COVID-19 symptoms, and practitioners wear a face mask, face shield, gloves and a gown. Whereas Kilen used to bring in a backpack, she calls her “ambulatory office” that holds everything she might need for a full day of exams, she now carries a smaller bag, containing only what she needs for that visit.
On April 6, her only in-home checkup was to examine two women who live together. One suffers from heart failure and heart disease; the other has advanced cancer and memory issues related to it. Because the women had been confused about their medications on her previous visits, Kilen wanted to make sure they had the right ones and were taking them correctly.
“Exposing them to just me, rather than to the entire hospital system if they get their medications wrong, is lower-risk,” she says.
At the visit, she brought trash bags to place medical supplies on and to use as a seat cover, if necessary. The nurse practitioner tries to avoid sitting down, maintains distance when possible and keeps her exams short. She says her face mask poses a challenge to her patients: Those who are hard of hearing have more difficulty understanding Kilen, and dementia patients may not even recognize her.
Telemedicine doesn’t require her to wear any special gear. While some patients have learned and embraced video conferencing, Kilen’s remote checkups on April 6 were conducted by phone. She relied on caregivers and family members to tell her how patients were doing and to read off medications they have in the home — something she would normally check in person.
“I’m getting more comfortable with telephone and video visits,” Kilen says. “My anxiety about the change has been alleviated just with the experience of doing it.”