INNOVATIVE USE OF TELEHEALTH TO MANAGE COVID-19 INFECTED OUTPATIENTS BY A VETERANS HEALTH CARE CENTER

ABSTRACT

STATEMENT OF PROBLEM/QUESTION In the spring of 2020 during the initial outbreak of COVID-19, the Rocky Mountain Regional VA (RMR) was tasked with ensuring the health of infected veterans. The RMR COVID-19 Telehealth Clinic was developed to support veterans in the community diagnosed with COVID-19, identify those with clinical deterioration requiring a higher level of care, and encourage appropriate isolation protocols. DESCRIPTION OF PROGRAM/INTERVENTION Patients were stratified by risk factors (obesity, CHF, DM, cancer, CAD, HTN, age > 64) and clinical status into 3 tiers, with high-risk (Tier 3) receiving daily telehealth, moderate-risk (Tier 2) telehealth every other day, and low-risk (Tier 1) telehealth every three or more days. Providing care seven days a week, Tier 1 veterans were contacted by nurses and advanced practitioners, while Tier 2 and 3 veterans were managed predominantly by resident physicians and attendings, who provided clinical care for exacerbations of chronic disease as well as comprehensive care of COVID-19 infection. Hypoxic patients were provided oxygen and closely monitored with pulse oximeters. MEASURES OF SUCCESS Between April 13 to October 5, 2020, 351 veterans testing positive for COVID-19 were followed. Thirty-eight were excluded (26 were outside study dates, 7 covid negative, 5 never received care). Charts for the remaining 313 patients were retrospectively evaluated for demographic data, comorbid conditions, duration of follow-up, and interventions provided, including prescribing and managing medications, referrals for emergency services, and escalating tiers. FINDINGS TO DATE Of the cohort, 88% were male, 43% obese, 34% over age 64, 40% HTN, and 27% DM. Veterans were followed for 10.4 days on average. Approximately 54% were assigned to Tier 1, 29% to Tier 2, and 16% to Tier 3. Medications were prescribed for 45% and 27% of Tier 3 and Tier 2 patients respectively, and emergency care was advised for 22% and 20% of Tier 3 and Tier 2 veterans. Of Tier 1 patients, medications were ordered on 5%, emergency care recommended for 3%, and only 7% were escalated to Tier 2. Of the five deaths that occurred, two were directly attributed to COVID-19. KEY LESSONS FOR DISSEMINATION A dedicated telehealth clinic for veterans with Covid-19 appropriately identified patients into low, moderate, and high-risk categories based on risk factor assessment. Low-risk patients were safely followed with intermittent telehealth emphasizing self-care and isolation, avoiding unnecessary Emergency Department visits. More frequent monitoring of symptoms and pulse oximetry in moderate to high-risk patients facilitated identification of patients with clinical deterioration requiring emergency evaluation and avoiding admissions for at-risk clinically stable patients. Tiered management resulted in judicious utilization of health care resources during a critical time marked by scarcity of hospital beds and personal protective equipment.