Insights From Rapid Deployment of a “Virtual Hospital” as Standard Care During the COVID-19 Pandemic

“Hospital at home (HaH), a care model that provides acute hospital-level care in patients’ homes, has been well characterized. Controlled trials and subsequent meta-analyses have suggested the efficacy of HaH, demonstrating noninferior or even superior mortality, readmission, and length of stay outcomes compared with traditional hospitalization for heterogeneous patient populations.

[..] Reasons for low adoption include misaligned or lack of financial incentives and challenges inherent in implementing a complex intervention. For example, even when home hospitalization models have been implemented in the United States in study settings or those with aligned payment incentives, low participation rates have been ubiquitous (ranging from 7 to 15 patients per month).

[..] Atrium Health hospital at home (AH-HaH), enhanced existing primary care by providing daily telemonitoring by a nurse for all low-acuity patients to proactively identify disease progression and escalate care as needed. For higher-acuity patients who would otherwise be hospitalized, it provided the option for hospital-level care in the home by deploying a hybrid of virtual and in-person services. In the planning and execution of AH-HaH, we preemptively addressed challenges inherent to implementing innovative care models by focusing on 1) reliance on a virtual care platform; 2) data-driven patient identification; 3) a health information technology foundation and workflows that mirror routine inpatient care; 4) a health literate communication and marketing strategy to support informed decision making; 5) expansion of an existing community paramedicine and care management program to deliver in-person care and monitor patients; and 6) rapid deployment of inexpensive, low-tech remote monitoring kits.

[..] AH-HaH is an extension of our hospital medicine division’s existing transition services program. This multidisciplinary program, established 5 years ago, serves patients who are discharged from the hospital and are at high risk for readmission. A robust virtual care platform enables the team to deliver care to this vulnerable patient population through frequent paramedicine and virtual in-home visits with proactive escalation and de-escalation of care intensity. Patient management and accountability for AH-HaH are housed within a dedicated group of virtual hospital medicine providers and nurses, who provide 24/7 coverage and monitoring with other specialties linked as needed for virtual consultations. This foundational virtual infrastructure served as the basis for a hub-and-spoke virtual hospital model.

[..] we created 2 virtual “floors” defined by the level of acuity. These floors are staffed with separate care teams that include physicians, advanced practice providers (APPs), registered nurses (RNs), pharmacists, social workers, and community paramedics. The “first floor,” or virtual observation unit (VOU), is designed for low-acuity patients who can be managed remotely with daily telemedicine-supported symptom monitoring by RNs. The “second floor,” or virtual acute care unit (VACU), is designed for patients who would otherwise have been admitted to a traditional brick-and-mortar hospital providing inpatient care, such as oxygen, medical treatments, daily virtual physician rounds, vital sign monitoring, twice-daily nursing assessments, and daily paramedic visits. We primarily focus on describing the AH-HaH VACU because it most closely resembles other frameworks for home-based hospital-level care.

[..] we used prespecified thresholds in 2 well-known pneumonia severity scoring tools: the modified DSCRB-65 (comorbid disease, oxygen saturation, confusion, respiratory rate ≥30 breaths/min, systolic blood pressure <90 mm Hg or diastolic blood pressure ≤60 mm Hg , age ≥65 years) and the American Thoracic Society/Infectious Diseases Society of America Major and Minor Criteria for Severe Pneumonia. All patients who were not living in an institutional setting and who had a positive SARS-CoV-2 test and a DSCRB-65 score of 0 to 2 were offered enrollment into the VOU. Patients with a DSCRB-65 score greater than 2 and no major and 3 or fewer minor criteria for severe pneumonia were considered by the testing provider for VACU admission. In addition to standard provider education (e-mailed instructions and group meetings), the EHR included a reminder for the provider that AH-HaH was an available care option. As with any clinical decision support, a provider’s judgment always superseded the scoring triage system.

Patients identified as potentially eligible for VACU on the basis of these clinical triage scores were then evaluated by the testing site provider for additional AH-HaH patient environmental criteria (ability to comply with home monitoring devices for assessment of vital signs every 6 to 8 hours, ability to safely perform or be helped with basic activities of daily living, safe living situation, English or Spanish spoken by the patient or someone at home, a working phone, the support necessary to assist with food and medication administration) and clinical criteria (for example, no anticipated need for imaging or invasive procedures in the next 48 hours). The AH-HaH “quarterback” physician was readily available to review cases or questions through provider to provider phone calls.

Every patient admitted to the VACU is provided with a home monitoring kit that includes a blood pressure cuff, pulse oximeter, and thermometer. Along with the medical equipment, all patients are given written instructions in English or Spanish on how to use each device and a phone number to call for help. These devices are delivered to the patient at the first in-home mobile clinician visit.

[..] Implementation of a telemedicine mobile app interface allows patients to immediately escalate their concerns 24 hours a day through telephone calls directly to RNs or point-to-point messaging, guided by predefined symptom algorithms with temperature and pulse oximetry cutoffs. The virtual health care team follows up within 12 hours of VACU admission and telephones the patient to administer a 12-question structured COVID-19 nursing questionnaire (CNQ) evaluation in a Cerner EHR PowerForm developed to capture data, evaluate disease progression, and dictate a pathway of standardized care escalation and de-escalation. The CNQ is then readministered on the basis of the case progression and patient answers.

After VACU admission, a team of mobile clinicians (paramedics and RNs) visits the patient’s home within the first 24 hours. The actual timing is based on the patient’s condition to enable a secure virtual visit with the covering physician by using Vidyo videoconferencing software. Our mobile clinicians have a formulary of therapies available, including intravenous fluids, intravenous and oral antiemetics, respiratory medications, and other medications to treat VACU patients as needed per standing protocols or provider orders. The mobile clinicians also can perform electrocardiography, blood samples for laboratory tests, and other tests if needed. The mobile clinicians also provide support and human touch for patients during an otherwise isolating and vulnerable time. These mobile clinician and virtual provider visits continue daily until a patient’s clinical condition improves to the point of de-escalation to the VOU for ongoing mobile app-driven symptom monitoring and telephonic CNQ nurse follow-up.

[..] The EHR workflow was integrated into the AH-HaH by creating a virtual facility location within the system’s EHR, so that the look, feel, and background functionality mirrored that of brick-and-mortar facilities. This allows for a seamless interface for patient care across encounters; creates a familiar structure for patients to be admitted, discharged, and transferred to other care locations from the AH-HaH; and allows our Atrium Health virtual care team to use standard physician, APP, and nurse workflows for patient assignment, patient tracking, clinical documentation, and ordering despite the patient’s home location. In line with COVID-19 disease progression, the option exists within the EHR workflows to escalate the patient from the VOU or VACU via direct admission to our brick-and-mortar hospital beds and to transfer patients from VACU to the VOU for ongoing, less acute telephonic monitoring. The care teams used daily proactive telemonitoring software (GetWellNetwork, Inc.), which generated frequent reminders for patients to report signs and symptoms to the virtual RN and facilitated direct communications from the patient to the care team to assist in clinical management.

Between 23 March and 7 May 2020, 2299 patients tested positive for COVID-19 in our health system and 1477 patients received care in the AH-HaH (64%). Of these 1477 patients, 1293 received all of their care (limited to RN telemonitoring) in the VOU and 184 received hospital-level care in the VACU. The median age of patients was 43 years in the VOU and 54 years in the VACU. In both groups, most patients were female and African American. Patients who received care in the VACU had a higher proportion of comorbid conditions at baseline than patients in the VOU; these conditions included asthma, congestive heart failure, diabetes, hypertension, chronic obstructive pulmonary disease, and obesity. The median total length of stay in the AH-HaH was 11 days for patients in the VOU and 12 days for patients ever admitted to the VACU.

Of the 1293 (88%) patients who were admitted to the VOU only, 40 required escalation of care from the VOU to inpatient hospitalization. Among those 40 transferred patients, 16 required ICU admission, 7 required mechanical ventilation, and 2 died during their hospital admission. Of the 184 (12%) patients ever admitted to the VACU, 21 required IVF, 16 received antibiotics (intravenous in 1 patient and oral in 15 patients), 40 required respiratory inhaler or nebulizer medications, and 41 used supplemental oxygen 1 to 4 L/min during the VACU stay. None of the patients in the VACU received noninvasive ventilation because they were escalated to higher level in-hospital care at the point of requiring greater than 4 L of oxygen. A total of 24 patients required transfer from the VACU to an inpatient hospital, of whom 10 required ICU admission, 1 required mechanical ventilation, and none died during their hospital admission.

[..] only 3% of VOU patients and 13% of VACU patients required admission to a brick-and-mortar hospital. In the absence of VACU availability, all 160 VACU patients who did not require transfer to a brick-and-mortar hospital can be viewed by extension as traditional hospital beds saved.

[..] First, we built a scalable, EHR-centered platform that mandated a data-informed patient eligibility assessment. Second, we used a virtual telemedicine platform to maximize provider scalability. Finally, we operationalized a patient- and resource-centric communication strategy and provided daily electronic monitoring with an overlay of telephonic nurse-to-patient structured proactive communication and monitoring.

[..] Our implementation of the AH-HaH has limitations. First, our eligibility criteria are intentionally broad, but they require patients to have a working telephone, English or Spanish spoken by someone at home if the patient does not, and the ability to comply with the monitoring protocols. Second, our AH-HaH implementation was facilitated in part by the existing infrastructure and collaborative culture developed through prior adoption of other transitional and virtual care programs in our system; thus, generalizability may be limited by requirements for a robust technology platform, a supply of mobile health care clinicians (such as community paramedics), home monitoring equipment, and an interoperable EHR. Yet, our description provides a framework for other health systems to examine adaptation of virtual care delivery to best fit within diverse local contexts. Finally, the sustainability of novel care delivery options such as AH-HaH will be threatened without permanent insurance reimbursement solutions to cover hospital care delivered in a home setting. Value-based payment models may serve to keep forward momentum for virtual hospital care until there is broader payment reform.”

Full article, Sitammagari K, Murphy S, Kowalkowski M et al. Annals of Internal Medicine, 2020.11.11