Ruth Caballero paused outside an unfamiliar apartment door, preparing to meet her new patient.
She covered the knob with a plastic bag. Put on a surgical gown, then a heavy-duty N95 mask, a lighter surgical mask on top. Cap, face shield, shoe covers. Hand sanitizer between each step of the process. Finally, the nurse donned two sets of gloves and knocked on the door with her elbow, ready to care for her first coronavirus patient.
After about three weeks in a hospital, the man was home in his New York apartment but still so weak that sitting up in bed took some persuading.
"You made it out of the hospital, so you are a miracle," Caballero told him. "Now let’s keep you out of the hospital."
Home health care is becoming a new front in the national fight against COVID-19 as some patients come back from hospitals and others strive to stay out of them.
Home care nurses, aides and attendants — who normally help an estimated 12 million Americans with everything from bathing to IV medications — are now taking on the difficult and potentially dangerous task of caring for coronavirus patients.
How Coronavirus Has Grown in Each State — in 1 Chart
New York has quickly become the epicenter of the American coronavirus outbreak. This chart shows the cumulative number of cases per state by number of days since the 10th case.
Source: Johns Hopkins University
Credit: Amy O’Kruk/NBC
While Americans are being told to keep to themselves, home health providers and their clients still largely have to engage in person, often intimately. Many agencies are ramping up phone or video visits but can’t always get paid for them, and even the smartest phone can’t physically dress a wound or get someone to the bathroom.
Like their colleagues in hospitals and nursing homes, home care workers have faced a scarcity of protective equipment, but with a lower public profile. Some agencies have scoured for masks at nail salons, auto body shops and tattoo parlors, said William Dombi, president of the National Association for Home Care and Hospice, an industry group.
The crisis is testing the industry, but it’s also a moment of pride for workers who have often felt under-recognized.
"It is a challenge to keep the business operational, but it’s an opportunity," Dombi said. "We’re getting a chance to establish what can be done."
Coronavirus care at home has expanded rapidly in the last few weeks. At least some agencies in most states are now taking COVID-19 patients referred after hospitalization or nursing home care or as an alternative to them, Dombi said.
Coronavirus Pandemic Coverage
Still, some patients have struggled to get care. After being diagnosed with coronavirus-related pneumonia late last month, Penny Wittbrodt contacted multiple agencies around her home in Winchester, Kentucky. None was then accepting COVID-19 patients, she said, though her doctor was able to arrange home oxygen. Wittbrodt, who has asthma and a history of respiratory hospitalizations, is still not well, though she's had some relief at times.
A retired home health nurse, Wittbrodt feels such care is especially valuable in the pandemic.
"Home health would expose far less people to COVID than hospitalization," she said.
New York-based Americare Inc. has taken about 100 COVID-19 patients released from hospitals, and over 200 of the agency's other patients also have tested positive or shown symptoms, VP Bridget Gallagher said.
Every corporate staffer including the CEO is calling protective gear suppliers, but the agency still counts its stock of N95 masks every day.
"We’re doing what we can, but I have to be honest: None of it feels like enough," said Gallagher, who's also on the board of the Home Care Association of New York State.
For many agencies, chronic staff shortages are amplified by absences due to illness or quarantine. And workers are grappling with patients’ fears while reckoning with their own risk.
The surgical mask and gloves that Washington home health aide Adassa Clarke now wears rattle her patient, who has Alzheimer’s disease and relies on a wheelchair. The patient doesn’t have COVID-19 but can't retain what she’s been told about an illness going around.
"What’s going on? Do I have a germ? Am I dying?" she asks, according to Clarke. Sometimes, the patient breaks into tears.
At 65, Clarke herself is in an age group at higher risk of severe cases of COVID-19, and she’s trying to stay home as much as she can.
But patients "come first," said Clarke, a certified nursing assistant.
"I just feel like the more I help, the more I keep going," she said.
A home health nurse with Chicago-area patients with COVID-19, Vanessa Pepino-Adraneda is extra-vigilant about protective gear and other precautions. Pepino-Adraneda also girds herself by focusing on caring for her patients and allowing herself moments of sadness, frustration or exhaustion.
"I try my best to protect my sanity amidst all this chaos," she said.
For some people, especially older adults and people with existing health problems, the virus can cause severe illness or be fatal. For most people, it carries mild symptoms or none at all, meaning some patients could have the virus and not know it.
The Visiting Nurse Service of New York, one of the nation’s largest home health agencies, currently has nearly 400 COVID-19 patients, and another nearly 300 referrals await, Executive Vice President Dan Savitt said. Separately, about 80 confirmed and presumed coronavirus patients are getting hospice care.
As an industry, "I do feel like we’ve risen to the challenge," he said.
When the agency first told Caballero and other nurses in late March that COVID-19 patients were coming, "I won’t say that I wasn’t nervous," Caballero says.
She was relieved, though, to see the protective equipment the agency issued. And her first visit, to the man in the apartment, went well. When she called later that night, he was not only sitting up but had gotten into a chair.
The person who would have been her next coronavirus patient died before visits began.
Caballero is now caring for several COVID-19 patients. They came home debilitated and fearful, afraid that hospitals "sent them home to die," she says.
She encourages them to take step after small step: to sit on the side of the bed, to walk to the bathroom, to have a meal at the kitchen table.
"It is a challenge. This disease has taken so many lives," she says, but "I’m so blessed and so honored and so grateful that these patients are coming home."
"Think about it -- there but for the grace. It could be I."
Associated Press Video Journalist Ted Shaffrey contributed to this report.