The care model put in place by Vanderbilt University Medical Center (VUMC) ensures that anyone who has tested positive for the virus, at any site across its network of hospitals, is automatically included on an electronic patient registry the moment the individual’s test results are confirmed.

“Using our population health care co-ordinators, as well as clinicians whom we’ve deputised for this purpose, we follow up with everyone for 14 days by telephone,” said Victor Legner MD, an associate professor of medicine, and executive medical director for patient care centre ambulatory services. 

“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.” 

The home follow-up programme is available regardless of whether 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,” Legner said. “For patients it’s really nice to know there’s a team helping to monitor them and give medical advice.”

If a patient whose details are recorded on the COVID-19 electronic registry already has a clinician in the community or at VUMC, the population health team first contacts the patient to check their health status, before contacting the clinician’s office. 

In a vast majority of cases, Vanderbilt Medical Group (VMG) clinicians are electing to have their own teams follow any COVID-19 patients. To monitor these patients at home, VMG nurses follow the same protocols used by population health care co-ordinators.

If the patient isn’t doing well at home, co-ordinators escalate follow-up to advanced practice nurses at Vanderbilt Health OnCall. These nurses carry out telemedicine consultations and, if needed, can visit the patients at their homes for further assessment and to 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,” Legner said. This stage of the care model provides 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 instead of 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,” stresses Legner.

HealthIT created the electronic COVID-19 patient registry, with the follow-up programme 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 healthcare delivery in the future,” Legner said. “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 centralised location when higher intensity services are needed.”

The medical provider’s team of population health care co-ordinators are nurses. The team assisting telephone follow-up includes physicians, nurse practitioners, and nurses who have volunteered to assist or who are currently exempted from patient contact.