The latest surge of COVID-19 cases has renewed pressure on hospital leaders to find alternatives to inpatient care. A unique hospital-to-home program at Vanderbilt University Medical Center helps to lessen the problem by more quickly transitioning COVID patients to tiered care that can be managed outside of the hospital.
The program, launched in March 2020, offers a systematic framework for transitioning patients to acute in-home support and has succeeded in safely freeing up hospital beds, says Tara Horr, M.D., chief medical advisor to Vanderbilt home care services. Horr says team communication has been a particularly important element.
‘“A large part of our success depends on conscientious communication between our home care staff, inpatient COVID-19 teams, our ED and community referring providers,” she said. “It is a sobering responsibility to care for acutely ill patients, particularly those with new oxygen needs, so we have to be sure all providers are on the same page.”
“It is a sobering responsibility to care for acutely ill patients, particularly those with new oxygen needs, so we have to be sure all providers are on the same page.”
Vanderbilt offers the program to adult patients who have acute, but stable, COVID-19 illness. Since March, Horr says 368 patients have enrolled. Approximately 80 percent were referred from a Vanderbilt inpatient stay. The remainder were from the Vanderbilt ED, walk-in clinics or outpatient providers.
While the program is designed to address capacity constraints and reduce care costs, length of stay (LOS), hospital complications, wait time in the ED, and readmission, Horr says an overarching aim is to improve the acute care experience.
“Most patients want to be within the comfort of their own home, surrounded by loved ones,” she said. “Our program enables them to do this with greater peace of mind, knowing that their acute issues are being monitored and addressed.”
Patients’ individualized care includes at least two touchpoints per day – either a telephone call or an in-person visit. Caregivers are provided with a blood pressure cuff, a pulse oximeter and a thermometer, along with a diary for recording vital signs and instructions about when to call in and report a problem. A nurse or nurse practitioner visits all patients who become more symptomatic than they were at discharge.
Care must be highly individualized for this population, Horr says. Most COVID-19 hospital-to-home patients are discharged when they are stable at four liters of oxygen or less, and they are weaned off altogether once home. Yet early on, many patients exert more at home than in the hospital, Horr says, and this can result in a setback.
“Things can devolve quickly and ‘happy hypoxia’ can keep patients from realizing this,” Horr said. “Close monitoring of vital signs and our readiness to get to the home quickly, adjust oxygen needs or expedite transfer back to the hospital if conditions degrade, are all vital elements of our program.”
Along with oxygen, steroids may be supplied for home use. The team is in active discussion about offering monoclonal antibody treatments in the future.
Measures of Success
Horr says LOS has declined each month since the onset of the pandemic for patients in the program. “It has saved over 500 bed days since its inception, allowing for reduced capacity constraints in the hospital setting. The process that we have incorporated allows for qualifying patients to appropriately be cared for in a lower cost setting,” Horr said.
“It has saved over 500 bed days since its inception, allowing for reduced capacity constraints in the hospital setting.”
Patients referred to the program from the ED have a lower LOS in this expensive setting. In addition, Horr says unplanned readmission rates are down due to the close nature of the follow-up care.
The program’s ability to scale and succeed rests on an ongoing, strenuous effort, Horr says. “Our regular home care average daily census is 800 to 900 patients. Now we have added about 30-plus acutely ill patients. Our caregivers are moving mountains to accommodate all of our home-based patients so that we don’t overburden the hospital.”