As a hospice nurse in Seattle, Diane Speer said giving out hugs to patients and family members was a routine part of home visits. But in the midst of the coronavirus pandemic, she now tells family members to keep their distance. “There’s no touching hands or handshakes,” said Speer, who works for Renton, Washington-based Providence St. Joseph Health. It’s “time for a virtual hug.” Hundreds of thousands of health care workers like Speer go into homes around the country to provide vital services for seniors and disabled people. But with rising concerns about the coronavirus and the particular danger it poses for older adults, those workers could be endangering their patients and themselves. “There is the knowledge that these are health workers who have skills that can benefit you, but the fear is the health care worker: Who is the last person they saw and where have they been lately and are they bringing something into my home?” said Dr. Thomas Schaaf, chief medical officer for Providence St. Joseph’s Home and Community Care division. Hospice and home health nurses, home care aides and temporary nurses are stepping up protective measures. These include calling patients at home before they visit to see if they or anyone in the household have a fever or other symptoms of COVID-19, the disease caused by the virus. They’re also washing hands in front of patients and wearing masks and other protective gear to reduce infections and to make patients more comfortable about their precautions. Still, home health providers say they’re seeing some patients turn them away for fear of getting the virus. “It’s been quite a challenge — we’ve had patients discharged from the hospital for a home health referral who have refused to have our caregivers come in,” Schaaf said. Providence nurses visit patients at home, nursing homes and assisted living facilities. Visits are often critical for wound care, to ensure patients are taking their medications and to assess if a patient’s housing is safe to minimize falls and other dangers. He said his large health system has been trying to move care visits — such as those done by social workers or chaplains ? to phone or video conferences. “We are trying to balance the clinical needs of the patient with the need to limit contact as much as possible,” Schaaf said. ‘Flying By The Seat Of Our Pants’ Marie Grosh, a nurse practitioner in Cleveland who calls on elderly patients at home, said she has shifted her schedule so that she now sees patients with communicable diseases at the end of her shift to reduce infection risks to others. She’s also stopped visiting patients who need only a checkup and don’t have immediate acute issues. When visiting patients, she no longer sits down or puts down her bag of medical supplies to reduce the risk of coming in contact with germs or spreading infection. “I am going from home to home. If I get sick, I can get over it, but I can’t risk taking anything from one home to the next home I am going to,” Grosh said. “We are all trying and flying by the seat of our pants,” she said of trying to find the best way to keep seeing patients while reducing infection risk. To alleviate patients’ anxieties, Schaaf said, nurses wash their hands in the home instead of using hand sanitizer in their car. They are also calling patients ahead to see if they have any possible COVID-19 symptoms, such as fever, and, if present, they wear masks and gloves. Dr. Amy Moss, a senior vice president at Baton Rouge, Louisiana-based-Amedisys, a large home health, hospice and personal care chain, said it is imperative for employees to be using standard infection-control protocols such as hand-washing to protect staff and patients. “Health care workers prepare for this scenario from Day One of their careers,” she said. Payment methods vary for health aides. Most insurers cover home health and hospice, although patients may have a copay. If the visit is not made, the provider can’t bill for the service. Training Temporary Workers As hospitals gear up for a surge in patients, staffing companies that employ temporary nurses say they are seeing an uptick in demand. But having nurses rotate out of various health facilities could increase the infection risk, said Saskia Popescu, a senior infection prevention specialist at HonorHealth, a large health system in Phoenix. “The more people you are exposed to in the hospital, the higher the risk,” she said. But she added that the risk is mitigated when hospital staffers make sure temporary workers follow the hospital’s infection-control rules. “When you are using contracted staff, you are dependent on that staff member having the right education and training,” she said. The problem for services providing nurses in patients’ homes or facilities using temporary nurses is these workers may not have the same infection-control training as nurses in higher-risk areas, such as hospital emergency rooms, she said. “I don’t feel like we give them as much attention when it comes to infection control,” Popescu said. “And they may not know where the risks are.” Lynne Gross, president of RNnetwork, a nursing temp agency based in Boca Raton, Florida, said her nurses have to fill out a survey and attest that they are in good health and have not knowingly been exposed to the coronavirus before starting a new assignment. “If they have any flu-like symptoms, they have to wait out a two-week quarantine period,” Gross said. Personal aides who help patients at home with nonmedical needs, such as preparing meals and dressing, are also taking new precautions. “Our staff is doing a lot more cleaning and wiping down of surfaces in homes, with disinfectant,” said Lawrence Meigs, CEO of Visiting Angels, a Bryn Mawr, Pennsylvania-based company that provides home care and has about 600 franchises across the country. He said the aides are still making visits. “We consider our caregivers essential personnel,” he said. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.