COVID-19 Home Monitoring: An Institutional Approach to Bridging Care During a Pandemic

Introduction

During the coronavirus disease 2019 (COVID-19) pandemic, there have been multiple care and education gaps recognized in the health care system.^1,2 One such gap is in the medical care of patients after a diagnosis of COVID-19 who have been discharged from the hospital or were diagnosed with COVID-19 but never admitted. This cohort of patients has limited access to community support and in-person medical care during their COVID-19 isolation period.

These gaps in care have been most apparent in our vulnerable populations, who have also been disproportionately affected by COVID-19. These populations are commonly cared for in safety net clinics that are often supported by residency programs. The primary care medicine clinic (PCMC) is our institution’s main resident clinic that supports ∼11,000 patients. These barriers further magnify the care access gaps seen with COVID-19.³

Given the mentioned disparities and barriers, we sought to increase patients’ access to care by implementing a home monitoring program (HMP) for clinic patients diagnosed with COVID-19. The objectives of this study were to describe a telehealth-based program to monitor patients in the outpatient setting, assess the feasibility of establishing and maintaining such a program, and to briefly describe and compare the outcomes of our clinic patients with those in our greater local community.

Materials and Methods

Design

This is a retrospective feasibility cohort study describing a single academic primary care center’s experience in caring for patients during the COVID-19 pandemic. This study was approved by the institutional review board of Washington University in St. Louis (IRB #202010201). This study follows the general Standards for Reporting Implementation Studies (StaRI) guidelines.⁴ The HMP began operating on March 21, 2020, and continues operating at the time of submission of this publication.

Description of The HMP

Goals of the program

At the onset of the COVID-19 pandemic, medical students at our institution were eager to assist in the local response. Through partnership with the students, the PCMC was able to rapidly design and implement a HMP in response to patient needs. The goals of our HMP were to (1) assess for signs and symptoms of potential clinical decline in patients with COVID-19, (2) provide education regarding preventing at-home and community-based spread in line with CDC recommendations, and (3) connect clinic patients with important resources during times of isolation and/or quarantine.

Staffing and training

At the initiation of the HMP, the program was staffed by volunteer third- and fourth-year medical students. These students were trained regarding what signs and symptoms they should assess HMP patients for, how to refer patients to available resources, when to involve supervising PCMC attending physicians, how to document phone encounters, and how to maintain a prospective database of patients enrolled in the HMP.

The HMP subsequently partnered with the third-year medicine clerkship director to create a clerkship-based experience in which students learn and practice telehealth, fulfill clinical educational time, and simultaneously minimize their in-person exposure risk. To standardize phone encounters and documentation, scripts and electronic medical record note templates were provided to all HMP staff (Supplementary Appendix SA1 and SA2). Interpreter services and outpatient pharmacy assistance for medication access issues were also available on an as-needed basis.

Eligibility criteria

Eligible patients for the HMP were patients who (1) had visited the PCMC in the past 2 years or were establishing care at the PCMC after a recent hospitalization at our institution’s medical center and (2) were diagnosed with COVID-19 through polymerase chain reaction-based assay. A small number of patients were enrolled who were clinically diagnosed (experiencing clinical signs and symptoms of COVID-19 with recent personal contact with a confirmed COVID-19 patient) by a PCMC clinician, but who had not received confirmatory testing.

Enrollment

The HMP operated during business hours Monday through Friday. Eligible patients for HMP enrollment were identified daily through a report run from our institution’s electronic medical record based on the criteria already described. This report was provided to the HMP staff members who would assess whether patients on the list should be contacted. Eligible patients were contacted if they were infectious (as per the most recent CDC-based clinical guidelines), in the ambulatory setting, and had not previously been contacted.⁵

If patients were eligible for the HMP and COVID-19 recovered but had not yet been contacted by the HMP, they received a one-time call to assess their clinical status and provide needed resources. If patients were not initially contacted because of inpatient status, HMP staff initiated contact upon discharge. All HMP encounters occurred through telephone; visits were not performed with videoconferencing. If patients were already scheduled for an appointment at the PCMC on the day the HMP would otherwise have initiated contact, HMP staff contacted the patient the following business day.

All patients were provided the opportunity to decline services at initial contact. If patients did not decline, they were contacted on a daily basis until they were COVID-19 recovered. The definition of COVID-19 recovered was the completion of isolation for the infectious period as defined by the CDC guidance of that time.

Services provided

Symptom monitoring

All patients were assessed for clinical signs and symptoms of COVID-19 upon each phone encounter. These included fevers (subjective or objective), myalgias, cough, shortness of breath, chest pain, altered mental status, abdominal pain, nausea, vomiting, diarrhea, oral intake, altered urine output, decreased energy, and decreased sleep. Concerning symptoms such as severe shortness of breath, chest pain, altered mental status, or inability to tolerate oral intake prompted discussion with a supervising attending physician and likely referral to the emergency department or same-day video telehealth visit with a PCMC physician.

Resource provision

Resources provided by the HMP included isolation/quarantine instructions; offer of a free personal protective equipment (PPE) kit delivered to their home (including gloves, hand sanitizer, masks, and cleaning supplies); a medication reconciliation (including verbal confirmation of medication access and referral, if necessary, to the clinic outpatient pharmacist for assistance); grocery delivery assistance; and education about presenting to medical care if concerning symptoms developed.

Patients were also offered the opportunity to participate in a clinical research study during the relevant enrollment period.⁶ PPE kit delivery and grocery delivery assistance were arranged by providing patients with contact information (e.g., telephone number and/or website) to local community organizations. The PPE kit was aimed to reduce transmission of COVID-19 to household members. Grocery delivery and PPE kit assistance were available to patients within a 30-minute driving time from Washington University School of Medicine.

Alternative monitoring: After the initial months of the HMP, our institution’s health care organization (Barnes-Jewish Christian [BJC]) created a HMP for all BJC COVID-19 patients, which only offered symptom monitoring. Patients in BJC HMP were eligible for home pulse oximeter if saturations were low in the hospital or it was felt shortness of breath was worsening at home. Otherwise, if patients had their own thermometer or pulse oximeter, the reading was documented, and patients were also assessed for shortness of breath, cough, overall weakness, appetite, vomiting, and diarrhea.

We partnered with them to provide home monitoring services to patients of the PCMC. Patients were eligible to be monitored by both programs and were offered the opportunity to be followed by the program of their choice. We found that many patients preferred to communicate with their primary care doctor’s office rather than the larger medical organization, as 61.8% of patients elected to follow with the PCMC HMP for remote monitoring.

Patients were contacted by the HMP daily on weekdays until they were (1) COVID-19 recovered and connected with all requested resources, (2) connected to BJC-based HMP and all PCMC-offered resources, or (3) declined further services.

Data Collection

To facilitate administrative documentation and tracking of patient’s clinical status, all HMP-eligible patients were entered into an encrypted online database that documented each patient’s medical record number, name, date of birth, date of symptom onset, date of first positive COVID-19 confirmatory test, date of HMP calls, whether or not they were reached, date of final contact, and reason for discontinuing from the HMP.

To better describe the HMP’s clinical cohort, a retrospective data collection was performed including patients enrolled from the HMP initiation on March 31, 2020, through November 20, 2020. Data collected included the mentioned variables as well as gender, race, ethnicity, health insurance status, zip code of residence, location of COVID-19 diagnosis (e.g., outpatient, inpatient, emergency room), select comorbidities (listed in Table 1), hospital admissions with a COVID-19 diagnosis, and mortality.

The presence of comorbidities was determined by automated review of the ICD-10 codes of each patient’s problem list except for obesity, which was determined by their last reported body mass index. Patients with an ICD-10 code for malignancy underwent hand review of their charts to determine whether it was active. Patients who died were hand audited to determine whether COVID-19 caused or contributed to their death.

Statistical Analysis

Data are presented as summary statistics. As there were no historical or contemporaneous control groups and the purpose of this report was descriptive, we did not perform statistical hypothesis testing.

Results

Characteristics of Patients Enrolled in the HMP

Between March 31, 2020, and November 20, 2020, we identified a total of 403 potential patients, of whom 296 were found to be eligible to participate (Fig. 1 and Table 1). The average age was 48.6 years, with 57.1% women and 42.9% men. The majority identified as black or African American at 82.4%, with the next most common races being white at 13.9% and Asian at 2.4%. Insurance status was a relatively equal distribution, 32.4% had Medicaid, 29.1% had Medicare, 23.3% had commercial insurance, and 25.7% were uninsured. There were 31 patients with both Medicaid and Medicare. The most common baseline comorbidities were obesity, hypertension, and diabetes mellitus.

The characteristics of the four patients who died are summarized in Table 2. Their average age was 62.5 years with a range of 47–85 years. Three of them were men (75%), three identified as black or African American (75%), and one identified as Hispanic (25%). Two of them had Medicare, one had Medicaid, and one was uninsured.

Table 2. Patients in the Home Monitoring Program Who Died of Coronavirus Disease 2019

PATIENT	AGE	GENDER	RACE	ETHNICITY	INSURANCE	COMORBIDITIES
1	51	Man	Black or African American	Non-Hispanic	Medicaid	HTN, obesity, DM
2	67	Woman	Black or African American	Non-Hispanic	Medicare	DM, active malignancy
3	47	Man	Black or African American	Non-Hispanic	Uninsured
4	85	Man	White	Hispanic	Medicare	CAD, HTN, DM, active malignancy

HMP Work Performed and Health Outcomes of Enrolled Patients

The most common location of COVID-19 testing was inpatient at 42.2%, followed by emergency department at 28.7%, and outpatient clinic or drive-up testing location at 20.6% (Table 3). Over 800 monitoring phone calls were placed during the 8-month study period. The number of phone calls placed to each patient ranged from 1 to 11, and the average number was 2.79. A total of 30 medical students participated.

Table 3. Coronavirus Disease 2019 Testing Location, Monitoring Work Performed, and Clinical Outcomes in the Home Monitoring Program

No. of COVID-19 tests by location (%)
Clinic or drive up testing	61 (20.6)
Emergency department	85 (28.7)
Inpatient	125 (42.2)
No. of phone calls
Total	828
Median	2
Mean (standard deviation)	2.79 (2.11)
Clinical outcomes (%)
Hospitalized	159 (53.7)
Average length of stay (range)	6 (0–47)
ICU admission	37 (12.5)
Mortality	4 (1.4)

Discussion

There are multiple unique strengths to this study. First, this outpatient monitoring program developed as a collaboration between a resident physician clinic, medical students, and patients. This partnership combined resources to fulfill needs of outpatients in self-isolation for COVID-19 infection. It also gave medical students the opportunity to directly contribute to patient care, in particular, for those patients most affected by the pandemic.

Students gained experience obtaining histories, assessing symptoms, and provided space for patients to share their own experiences with COVID-19 while they were self-isolating. In addition, the students enabled frequent assessments that would not have been feasible without them. Offering patients resources for PPE, food delivery, and medication delivery enabled adherence to isolation policies, potentially reducing community spread of COVID-19. This was limited by an ∼30-minute driving radius from the hospital.

The HMP was successful for medical student education and transitioned from a volunteer program to a regularly scheduled rotation site for the medical school clerkship. Before the pandemic, our institution’s clinical curriculum had no telehealth component. This has begun to change as students are strongly encouraged to participate in available telehealth services on their rotation. In addition, in our institution’s newly introduced medical school curriculum, students are specifically assessed for participation in telehealth. We expect in the near future that telehealth training will become a requirement given it has become part of the resident training programs where our medical students regularly rotate.

The fact that 70.9% of tests resulted from the inpatient and emergency department settings likely reflects the limited availability of outpatient testing during the majority of the study. Initially ordering a COVID-19 test for an outpatient required going through an approval process due to limited availability. Other possible explanations for lower outpatient testing rates include lack of access to transportation or delay in seeking medical evaluation for symptoms. Indeed, these practical factors along with educational level, gender identity, and historic mistrust have all been cited to affect testing rates.^7–9

The patient characteristics and outcomes of this study are meant to qualitatively understand the course of illness for these patients. The majority of the HMP cohort was black or African American at 82%, which is higher than the 67% of our general clinic population. A similar trend was seen in St. Louis City.¹⁰ Over 50% of monitored patients required hospitalization, some before enrollment in this program and others afterward. The mortality rate of this cohort due to COVID-19 was 1.4%, similar to the St. Louis City average of 1.8% during this same period of time.¹¹

The four patients who died had a higher average age of 62.5 years compared with 48.6 years for the entire cohort but included one patient in their 40 and one in their 50s, highlighting that the risk of death was not restricted to the elderly. The majority of patients who died identified as black or African American and non-Hispanic, which was similar to the entire cohort. But they were also majority men, whereas the cohort was majority women.

It has been noted across urban centers throughout the United States that communities with higher population density and percentage minority populations experience relatively worse infection and mortality rates.^12–14 Given the high-risk population the HMP served, proactive outreach solidified patients’ access to health care and community services helped address disparities and likely improved outcomes.

There are multiple limitations to this study. Owing to staffing and training limitations, not all monitoring calls were documented, therefore, the reported data under-represents the total work performed. Camera access was limited to perform video visits that may have added to these audio-based clinical assessments, due to regularly scheduled clinic appointments. Patients who were clinically unwell at time of HMP calls, however, could be transitioned to a video virtual “sick” visit. Patient characteristic data were extracted from the electronic medical record, relying on documentation in the chart that may not be fully accurate. In addition, there is no control cohort with which to compare clinical outcomes and assess for statistically significant impact.

Conclusions

In summary, our institution was able to rapidly design, implement, and feasibly maintain a COVID-19 HMP integrated with our primary care clinic. The telephone-based monitoring ensured that the most vulnerable individuals were not left behind during an evolving pandemic. Lastly, our program also serves as a model for future implementation of medical student clinical training. Practical telemedicine educational experience such as this will likely play an integral role in medical education moving forward given the “new normal” of telemedicine in the world after COVID-19 and the possibility of future pandemics.

Authors’ Contributions

All authors (G.J.W., K.D., S.F., P.J.M., and N.F.) made substantial contributions to the conception and design of the study, data interpretation, and drafting/revision of the article. G.J.W., K.D., S.F., and P.J.M. were responsible for data acquisition and analysis. All authors approved the submitted version. All authors agree to be personally accountable for their own contributions and ensure the accuracy/integrity of any part of the study, even those in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgments

We thank Dr. Gerome Escota, Dr. Steven J. Lawrence, and Dr. Laura Marks of the Division of Infectious Diseases, Department of Internal Medicine, for their invaluable leadership and vision in creating and administering the HMP.

Ethical Statement

The Washington University Human Research Protection Office and institutional review board approved this study. Consent was not required for participation given the minimal risk of the study.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

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