The novel problem that COVID-19 delivered to everyone who takes care of patients was that in the early days of the disease, caregivers did not know much about how a patient’s course would progress.
Caregivers did not know if patients would gradually become sicker, or if there would be a sudden decline. In addition, they did not know how to identify high-risk patients early on in their disease, nor did they know the timeline for expected needs in terms of escalation of care. And, finally, caregivers were preparing for surges that might overwhelm health systems in terms of volume alone.
“As a result, there was a great deal of angst, both on the provider side and the public side, when a patient tested positive for COVID-19, but was not sick enough to be admitted to the hospital,” said Dr. Tracey Hoke, chief of quality and performance improvement at University of Virginia Health System based in Charlottesville, Virginia.
“The decision to not admit a patient usually means not monitoring a patient, which was thought by many to represent a care plan that might not follow COVID-19 patients closely enough. This, combined with the threat of overwhelming volume, are the problems that drove our innovation in the COVID-19 population.”
“Establishing in-house testing was the first hurdle in designing a care-delivery model for COVID-19 patients,” Hoke explained. “Once we were able to provide rapid-turnaround testing, we were able to identify the group of patients who were COVID-positive, but did not need to be admitted to the hospital. As we now know, most patients who are positive for COVID-19 aren’t sick enough – or not yet sick enough – to require hospitalization.”
This said, it was the feeling of UVA providers that they needed some sort of warm follow up, ideally where they could monitor subjective clinical progression of disease (like respiratory effort), but also objective physical findings and trends like temperature, heart rate, respiratory rate and blood pressure.
"The Interactive Home Monitoring team was able to educate, clinically follow patients and ultimately intervene if a patient seemed to be in decline."
Dr. Tracy Hoke, University of Virginia Health System
“We capitalized on a technology platform that was already in place at UVA for other high-risk populations, such as NICU babies, babies with congenital heart disease, transplant candidates/patients, and adults with heart failure and other chronic diseases,” Hoke said. “The Locus Health pediatric telehealth platform allows for patient-data collection and integration into our EHR, and is also capable of facilitating communication through email, calls and video.”
The platform is loaded onto iPads that caregivers routinely deliver to other patient populations, so they did not require either a new technical product or a bring-your-own-device approach. In addition, UVA had to marry that platform to a program of clinicians who were charged with patient education after a clinic or emergency room encounter that did not result in an admission, and also after hospital discharge.
“The Interactive Home Monitoring team was able to educate, clinically follow patients and ultimately intervene if a patient seemed to be in decline,” Hoke explained. “This allowed us to bring patients back to care sooner than they might have come on their own, an intervention that we quickly learned the value of as we recognized that many patients who require hospitalization experience a very rapid decline in the days before admission.”
One of the things UVA learned about the disease, as it started to take care of patients who had it, is that the decline in respiratory status is often quite sudden: that a patient might be ill for a couple of days, or even weeks, and then suddenly become short of breath and require hospitalization and advanced supportive care.
“Because there is often a change in oxygenation before the patient complains of shortness of breath, that physiologic monitoring allows us a window to bring people back in a controlled anticipatory manner,” Hoke said.
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MEETING THE CHALLENGE
In the very beginning – the first week or so of COVID-19 arriving in Charlottesville – UVA stood up in-house testing and a clinic for patients that were afraid that they might have COVID-19 or have been exposed to COVID-19. UVA established a process that facilitated activation of the Interactive Home Monitoring team at the time of COVID-19 clinic discharge.
In order to streamline the process for providers, UVA established a referral process that is integrated into its Epic EHR. With a single click, the Interactive Home Monitoring team was activated, and it delivered the Locus iPads and monitoring equipment to those who needed it. In the same effort, patients were also enrolled in regular follow-up by the team.
“We sent patients home with iPads, loaded with the Locus platform, as well as pulse oximeters, heart rate monitors and blood pressure monitors,” Hoke explained. “We then asked them to report at regular intervals on their respiratory rate and whether they felt short of breath. These data points feed right back into Epic and are monitored by a clinician on the home-monitoring team.”
The direct integration with Epic is a huge help, both because it provides transparency to the patient’s providers outside of the Interactive Home Monitoring team, and also because it allows a direct connection between that team’s clinicians and other care teams should an escalation of care be required, she added.
“We established a similar activation system for our emergency room staff, which allowed us to avoid hospital discharge and to control COVID in our community by supporting our homeless population,” she said.
Perhaps the UVA team most grateful for Interactive Home Monitoring is the COVID-19 admission team, as they are able to avoid hospital days and team-member exposure by using the platform and the program at the time of hospital discharge, she added.
“Again, patients are very sick for a very long time with COVID-19 if they require hospitalization,” she said. “What we found is that admission teams weren’t comfortable sending patients home without any kind of monitoring or follow-up beyond a clinic appointment. They were more comfortable once these providers could access the home-monitoring team and know that physiologic monitoring was included in the program.”
What UVA is seeing now – the most novel use – is that COVID-19 patients are coming through clinics across the system as more and more ambulatory sites open up for business. At this point, providers across the system are accessing the team and the tools to support their most vulnerable populations.
“We have discharged more than 100 COVID-19-positive patients with Locus iPads and Interactive Home Monitoring,” Hoke reported. “Fewer than 6% have been readmitted, and less than 1% of those discharged were readmitted for COVID-related reasons.”
In addition, more than 85 COVID-19-positive patients have been referred to the Interactive Home Monitoring program either through the COVID-19 clinic, ER or a primary care practice. Fewer than 10% have been admitted to the hospital, and fewer than 6% were admitted for COVID-related reasons.
“What it really does is extend our care-delivery arm, whether that is in the clinic, the emergency department or the hospital,” Hoke said. “Without this program, we wouldn’t be able to avoid some admissions or facilitate early discharges.”
ADVICE FOR OTHERS
“The key to an effort designed to keep sick patients out of the hospital – whether that’s avoiding admission from clinics and the ER or allowing sick patients to go home sooner – is the marriage of a technology platform that allows real-time communication, visualization, image sharing, physiologic monitoring, etc., and a program that actually monitors all of this data, communicating with the patient and their PCP,” Hoke advised. “There’s a team piece and a technology piece, a program piece and a platform piece, and without both, either is handicapped.”
Given the surge in the COVID-19 population on top of usual healthcare business, Hoke suspects that UVA would not have been able to stand this program up so quickly if it had just put monitoring into place, and expected PCPs to be able to deliver the same care that the home-monitoring team does. Nor does she think the effectiveness of the home-monitoring team would have been as high if it did not have real data, versus subjective reporting, from a patient or their family to go on.