Overview
Avera Health Launches COVID-19 Care@Home Program with Telehealth and RPM
Avera@Home provides comprehensive home health services to communities across South Dakota, North Dakota, Minnesota, Iowa, and Nebraska. As part of Avera Health, Avera@Home strives to make a positive impact in the lives and health of patients through quality, affordable healthcare.
Challenge
In 2019, Avera@Home launched a pilot telehealth and remote patient monitoring (RPM) cardiac program. In coordination with the Avera Heart Hospital, Avera@Home’s pilot program targeted high-risk cardiac patients to enhance outpatient care, mitigate patient anxiety, and reduce hospital readmissions and ED visits. Within six months, Avera@Home’s pilot program achieved a 3.6% overall 30-day hospital readmission rate and recorded a 95% patient satisfaction rate.
By April 2020, COVID-19 was spreading across South Dakota and neighboring states, prompting Avera@Home to leverage their experience with telehealth and RPM to address the following COVID-19 challenges:
Relieve hospital strain by maximizing bed capacity through early patient discharge and prevented hospitalizations.
Curb community spread by monitoring at-risk patient populations including those experiencing homelessness and non-English speaking communities.
Conserve PPE supplies and protect staff by limiting exposure and in-person visits.
Solution
The Avera COVID-19 Care@Home program aimed to identify and monitor high-risk patients, with a COVID-19 diagnosis or presumptive positive, all from the comfort of the patient’s home - conserving valuable hospital resources.
How Avera Leveraged Telehealth to Enhance COVID-19 Care Coordination:
- Upon discharge from the hospital or following an initial screening at an Avera ER, clinic, or COVID Command Center, patients were referred to the Care@Home program.
- Referred patients would undergo an in-person or virtual screening to determine eligibility. Assessments were performed by the Care@ Home team to reduce physician workload.
- Telehealth kits were delivered to patients’ homes the same day as enrollment, containing a 5G tablet, blood pressure cuff, pulse oximeter, weight scale, and thermometer.
- Virtual installation visits were performed by Care@Home nurses, creating cost savings and allowing for detailed instruction of the technology to patients.
- Patient vitals and symptoms were monitored 24/7, and daily phone and virtual visits were performed by the Care@Home team.
- Medications were delivered directly to patient homes, regardless of ability to pay, and social workers were available to provide mental and emotional support.
- Daily patient reports were shared with staff physicians to assess for care plan changes
We anticipated a swift and significant increase in patients and knew we needed to create a seamless process to ensure quality care. We involved provider groups and built a dedicated clinical telehealth team to keep open points of contact and streamline communication.— Dr. Chad Thury, MBA
Medical Director, Avera@Home
Hospitalization Rate
ED Visit Rate
Patient Satisfaction Rate
Results
From April through November of 2020, Avera Care@Home monitored a total of 3,840 patients including COVID-19, obstetrics, and pediatric patients, with COVID-19 being the primary diagnosis (3,499 patients).
During that time, Care@Home achieved an impressive 6.1% hospitalization rate and a 7.9% ED visit rate. In addition, Avera Care@Home marked high patient satisfaction rates, with over 95% of patients highly recommending the program.