COVID-19 cases are once again surging across the U.S., and just like in the spring, hospitals and health systems are preparing to preserve resources such as beds, staffing and supplies for the sickest patients. In the Midwest specifically, the situation is getting more precarious by the day; data from the Washington Post shows that Upper Midwest and Plains states, particularly North and South Dakota, are leading the nation in new cases and deaths per capita over a recent seven-day window.
In Sioux Falls, S.D., leaders at Avera Health, a regional health system encompassing more than 300 locations in 100 communities throughout the Dakotas, Minnesota, Iowa, and Nebraska, have recognized that the demand for home care has grown with more patients preferring care in the comfort of their own homes. Although it is commonly presumed that patients who have contracted COVID-19 and need care should remain at the hospital, Avera leaders contend that it’s actually not necessary in many instances. The health system’s Avera@Home Care Transitions initiative has existed for eight years with the goal to reduce hospital readmissions and emergency room (ER) visits, and then back in April, the program shifted to meet the needs of COVID-19 patients.
The home care program for COVID patients are specifically for those who are at least moderately ill, and/or have multiple or some comorbidities that make them likely to get sicker as the illness progresses, says Rhonda Wiering, vice president, clinical growth and innovation for Avera@Home. “We believe that many asymptomatic patients, or those who have just mild illness, will do just fine with education and monitoring themselves at home. This program is not for that population,” she explains.
Rather, patients who test positive, have COVID-19 symptoms, and are at high risk can be referred to the health system’s Care Transitions program by their physician. These patients receive regular phone or video nurse calls and telehealth equipment. Avera@Home also delivers an at-home monitoring kit to the patient’s house. The kit allows the patient to monitor their oxygen levels, blood pressure, temperature and COVID symptoms, with all data transmitted instantly to the care team, health system officials noted.
More specifically, Avera’s Care Transitions team uses a variety of treatments and interventions to help patients cope with COVID-19 symptoms, from over-the-counter medications and humidifiers for cough and gastrointestinal distress, to cold packs for fever, lung exercises and the use of fans for shortness of breath, use of steroids and inhalers/nebulizers, and instruction on prone positioning. Experienced nurses are supported by internal medicine physicians, and this team is providing virtual care all day, every day for COVID patients, usually for the first seven to 10 days of their illness, or until they get over the worst part of it. “They’ve gotten very good at anticipating what patients need,” Wiering says.
For example, patients get asked daily symptom questions, and if any symptoms are out of the normal parameters, Avera’s team provides immediate follow-up and is available on a 24/7 basis. “Patients feel reassured that they can call us every hour of the day,” says Wiering. The program currently has approximately 50 nurses providing these services, and they use the electronic medical record’s (EMR) scheduling function to assign visits, or phone calls and video visits to respective nurses. “That’s what is really great; we're able to document within our medical record, and that information is shareable between our teams,” Wiering notes.
As an example, on a recent date, Care Transitions was caring for 1,142 patients at home, 159 of whom were on oxygen. “In most cases, these 159 patients would have been hospitalized. Among these moderately and severely ill patients, we are seeing success in keeping them out of the hospital, yet we are also monitoring them in order to get them hospital care at the right time, when intervention is needed,” Wiering notes.
Importantly, Wiering points out that there are absolutely those patients who need hospitalization and for those, Avera’s care providers follow best practices in determining the right course of care and treatment. “But when it’s possible, most patients want to recover at home, and we are able to give them the tools to make this happen in the majority of cases,” she adds.
Avera officials say that 3,000 COVID-19 patients have been seen between early April and mid-November via Avera@Home, and the program been successful in preventing admissions, while achieving a hospitalization rate of approximately 5.3 percent, which is significantly less than Avera’s models had predicted. Chad Thury, D.O., medical director of Avera@Home, adds that Avera hospitals might have around 300 COVID patients admitted in-person at any given time—though that number fluctuates daily—while the Care Transitions program is presently pushing 1,200 patients served. Predictive models show that the current surge across the Midwest could continue for several weeks, meaning the importance of this program will only grow, Thury says. “We are seeing increased hospitalizations across our system but also increased numbers in our at-home program. It’s clear that this remains a vital element in the continuum of care for COVID-19.”
Indeed, over the next four to six weeks, Thury and Wiering will be closely monitoring various different program elements. In addition to the typical outcomes they measure such as hospitalization and ER rates, and mortality rates, they will also be looking at new treatments and therapies. For example, care providers recently started implementing oral steroids to patients, which has been a big change in the hospital setting. When these patients start to drop their oxygen and become shorter of breath, in the hospital, they are getting Remdesivir and oral or intravenous (IV) steroids, Thury explains. “But [even] with Remdesivir, we didn’t think there was a need to put these patients in the hospital. We felt like we could get them steroids in the outpatient setting, so we have worked that into our treatment protocols,” he notes.
Another area they will be paying close attention to is the use of monoclonal antibodies, which were recently issued an emergency use authorization (EUA) by the FDA. Thury says his team will be looking at identifying those patients within the program who are really early in their course, meaning they might not even have symptoms yet—but Avera has identified them as high risk—and getting them the monoclonal antibodies. “So we want to see if the combination of those two things, along with the other things we are doing really well, [continues] to decrease our ER visits and hospitalizations. It will be very interesting to see what our numbers are looking like in four to six weeks,” he says.
