By Christopher Cheney
A Denver-based health system has used remote monitoring to care for coronavirus disease 2019 (COVID-19) patients who do not require hospitalization.
Although there are therapeutics for treating seriously ill COVID-19 patients in the inpatient setting—remdesivir and dexamethasone—there are no therapeutics that have been found effective in treating coronavirus patients in the outpatient setting. Given that limitation, monitoring low-acuity COVID-19 patients at home is a viable option.
Denver Health created its Virtual Hospital at Home (VHH) program to care for COVID-19 patients who do not require inpatient care. “A remote home monitoring program can provide a safe care mechanism for a diverse population of COVID-19 infected patients who do not meet admission criteria, yet have risk factors for severe COVID-19 complications. Remote monitoring may also be beneficial in managing future surge hospital capacities,” a recent research article written by Denver Health clinicians says.
The research article, which was published by Infection Control & Hospital Epidemiology and features data from more than 200 patients, includes several key data points.
- 81.5% of the patients in the VHH program were successfully discharged
- 13.3% of the patients in the VHH program required a higher level of care, with 38.7% of those patients admitted for hospitalization
- The majority of the VHH patients were either uninsured (28.3%) or covered by Colorado Medicaid (38.2%)
“The VHH provided a safe and effective mechanism to remotely monitor a population that has been disproportionately affected by the COVID-19 pandemic. As 95% of patients referred participated, it seemed to be well received by patients, and successfully managed the majority of patients within their own homes,” the research article’s co-authors wrote.
Virtual Hospital at Home benefits
The VHH program has four primary advantages in the care of low-acuity COVID-19 patients in the outpatient setting, according to the research article.
- The VHH program helps manage hospital-based resources in two ways. First, VHH allows emergency department clinicians to send low-acuity patients home rather than admitting them to an observation inpatient stay. Second, hospitalists can use the VHH program to safely discharge recovering COVID-19 patients to home, where they receive outpatient oversight and care guidance.
- VHH COVID-19 patients receive at least two phone calls per day—once from a clinician and once from a nurse. So, the telehealth approach allowed Denver Health to conserve personal protective equipment supplies.
- Many of the VHH participants were members of ethnic minority groups who were either uninsured or on some form of government insurance. These patients demonstrated an acceptance of the novel telehealth program.
- The VHH provided Denver Health with an opportunity to connect patients with primary care providers if they did not have an existing relationship with a primary care clinician.
Keys to home monitoring success
The daily calls to VHH patients were a crucial element of the program, two of the research article’s co-authors told HealthLeaders.
“The intent was for patients to receive one clinician call daily and one nurse call daily. We tried to make one call in the morning and one in the afternoon. The ability to have an ongoing dialogue all day allowed us to have a lot of back-and-forth interaction. Patients could sound very different in the morning vs. the afternoon,” said Jeremy Long, MD, MPH, medical director of the Intensive Outpatient Clinic at Denver Health.
“The biggest piece of advice that I would offer to other health systems is making sure that they have a sustainable way to have frequent touches with the patient. The patients can have big swings in their course—even within the same day. So, you need to make sure there are multiple touches with the patient throughout the day to make sure this is a safe program,” said Patrick Ryan, MD, medical director of the Hospital Transitions Clinic at Denver Health.
Targeting low-acuity patients also was pivotal for the VHH program’s success, Ryan said.
“For COVID-19 hospital admissions, it came down to whether patients needed supplemental oxygen or if the clinicians found reasons for the patients to receive IV antibiotics, IV fluids, or intensive cardiac monitoring such as telemetry. Those are services we would not be able to offer through our Virtual Hospital at Home program. With our Virtual Hospital at Home program, we are only able to monitor pulse, pulse oximetry, blood pressure, and temperature. With those limitations, patients who needed more intensive monitoring helped guide clinicians to admit patients for hospitalization rather than sending them home with Virtual Hospital at Home,” he said.
Ensuring that payers would support the VHH program also was important, Long said. “Another important piece is to be aligned with your payers. You need to be talking with the Medicaid program in your state and the Medicare Advantage companies to be sure there is alignment in terms of reimbursement. That is one of the things that helped us with this Virtual Hospital at Home program. We were doing provider visits over the phone and receiving reimbursement.”
In addition, effective internal communication at Denver Health was essential, Ryan said. “Our team communication was critical to ensure that this was a safe program for patients. Through our electronic health record, we have a chat function, so all members of the team on a given day can chat constantly to give updates on their phone calls with patients. This chat function helped monitor changes in the courses of patients at home, and it helped make decisions about whether patients could continue to be safely monitored at home or admitted to the hospital.”
Finally, having a narrow focus on COVID-19 patients helped achieve success in the VHH program, Long said.
“If we just wanted to shorten length of stay across the board in inpatient admissions through Virtual Hospital at Home, that would be hazardous. Focusing on a single disease process boosts safety. For example, with the right expertise and the right technology, heart failure patients could be good candidates for a Virtual Hospital at Home program. Other examples include emphysema, community-acquired pneumonia, and some infections, where patients can safely receive a transition from intravenous to oral antibiotics.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.