The program serves to monitor patients' chronic conditions and enable them to take control of their health.
In the early days of the pandemic, Vanderbilt University Medical Center in Nashville, Tennessee, set up a COVID-to-home program to prevent capacity issues for the hospital.
While it initially served to streamline care for patients in different care settings, it has developed into a chronic disease monitoring program for Vanderbilt Home Care Services.
"When COVID numbers were thankfully starting to decline, we recognized that there were components of that program which were very beneficial to patients," Tara Horr, chief medical advisor for Vanderbilt Home Care, told HealthLeaders. "And so, we looked to adapt some of the roles from that program to carry forward and apply to other patient populations.
The program, which started in February 2022, serves between 50 and 60 patients a month, 35 patients at a time, with a total home healthcare census of 600 to 800 patients, according to Kristina Niehoff, Vanderbilt Home Care's pharmacist.
"Our two most common conditions that we [see] right now are heart failure and diabetes, with COPD being the third," she said.
The program's structure is simple, with staff communicating with patients via telephone to monitor their conditions.
"We think that it is beneficial to provide patients with a type of monitoring that can be ongoing and so we aim to look at the types of supplies that patients have in their home that allow them long-standing ability to monitor their disease," Horr said.
Vanderbilt Home Care uses scales, blood pressure cuffs, and oximeters and teaches patients how to use them. By relying on phone calls, Vanderbilt is able to reach a broader patient population, Horr said.
"We also ensure that the patients know how to record their values. If there's low or high blood pressure, we can ask further questions to help the patient learn what symptoms to watch out for," Niehoff said.
"It's a more hands-on approach to education and shows the patients how to manage their chronic conditions at home."
The increased contact with patients and emphasis on educating them also helps guide the Vanderbilt Home Care team's use of other resources within the health system.
"We make sure they know what to do and who to go to, so that if they see a value that is outside of the norm for them, they know how to reach someone to address that concern," Horr said. "And thereby, hopefully, decrease the number of urgent care and emergency room visits."
With the ongoing workforce shortage, the program also enables staff to maintain regular communication with patients.
"We can see that sometimes patients are at risk for readmission and that period of being discharged from the hospital is a very vulnerable time, and so this can allow us to make contact with the patient sooner," Horr said.
“We think that it is beneficial to provide patients with a type of monitoring that can be ongoing and so we aim to look at the types of supplies that patients have in their home that allow them long-standing ability to monitor their disease.”
Tara Horr, chief medical advisor, Vanderbilt Home Care Services
Jasmyne Ray is the revenue cycle editor at HealthLeaders.
KEY TAKEAWAYS
The chronic disease management program was initially a COVID-to-home program, to prevent capacity issues for Vanderbilt University Medical Center.
The program uses phone calls, and additional equipment like blood pressure cuffs where patients record the values, to monitor chronic diseases.
In addition to providing care, Vanderbilt emphasizes education with the Chronic Disease Management Program; teaching patients how to use equipment and what symptoms to look out for.