April 2, 2020

VUMC teams follow up with COVID-19 patients at home

Several components of Vanderbilt University Medical Center have come together to provide coordinated follow-up care for patients isolated at home with COVID-19.


by Paul Govern

Several components of Vanderbilt University Medical Center have come together to provide coordinated follow-up care for patients isolated at home with COVID-19.

To assist this coordination, anyone who has tested positive for COVID-19 at any site across the VUMC network automatically goes into an electronic patient registry the moment the test is resulted.

“Using our Population Health care coordinators, as well as clinicians whom we’ve deputized for this purpose, we follow up with everyone for 14 days by telephone. And beyond that, based on clinical symptoms, we have a spectrum of ways we can monitor patients at home and escalate their care as appropriate,” said Victor Legner, MD, MS, associate professor of Medicine and executive medical director, medicine patient care center ambulatory services.

The home follow-up program is available whether or not the patient has ever received care at VUMC.

“Vanderbilt is looking at this from a true population health standpoint, and from the perspective of a patient who may be scared, who may need somebody who can help them through clinical details and reassure them. For patients it’s really nice to know there’s a team helping to monitor them and give medical advice,” Legner said.

If a patient who lands on the COVID-19 electronic registry already has a clinician in the community or at VUMC, Population Health first contacts the patient to briefly check his or her health status, then contacts the clinician’s office.

In a vast majority of cases, Vanderbilt Medical Group clinicians are electing to have their own teams follow any COVID-19 patients; to follow these patients at home, VMG nurses use the same protocols used by Population Health care coordinators.

If the patient isn’t doing well at home, coordinators escalate follow-up to advanced practice nurses at Vanderbilt Health OnCall, who do telemedicine visits and, if needed, can go see patients at their homes to further assess and provide services.

“If at any time the patient is deemed to be more ill — say, for example, they have worsening shortness of breath and we want to monitor their oxygen levels — we then have the ability to send out Home Health to provide remote pulse oximetry monitoring, once-a-day in-home nurse monitoring or telemedicine monitoring, along with daily phone calls, to try to take care of the person and keep them well at home as opposed to bringing them back into the hospital. If the patient does need to come back into the hospital, this close home monitoring allows that to happen sooner than it might otherwise,” Legner said.

HealthIT created the electronic COVID-19 patient registry. The follow-up program is also assisted by Quality, Safety and Risk Management.

“I really think that what we’ve set up for COVID is going to be the design for health care delivery in the future. We’ve developed a way to monitor patients remotely and very closely, and then escalate as needed, providing care where they live and only having them come to the centralized location when higher intensity services are needed,” Legner said.

Population Health care coordinators are nurses. Employees deputized by Population Health to assist telephone follow-up include physicians, nurse practitioners and nurses who have volunteered to assist or who are currently exempted from patient contact.