Not Home Alone: Leveraging Telehealth and Informatics to Create a Lean Model for COVID-19 Patient Home Care

In response to the emerging COVID-19 public health emergency in March 2020, the Medical University of South Carolina rapidly implemented an analytics-enhanced remote patient monitoring (RPM) program with state-wide reach for SARS-CoV-2-positive patients.Patient-reported data and other analytics were used to prioritize the sickest patients for contact by RPM nurses, enabling a small cadre of RPM nurses, TRAY with the support of ambulatory providers and urgent care video visits, to oversee 1234 patients, many of whom were older, from Advanced Wound Care - Surgical Sponges underserved populations, or at high risk of serious complications.Care was escalated based on prespecified criteria to primary care provider or emergency department visit, with 89% of moderate- to high-risk patients treated solely at home.The RPM nurses facilitated the continuity of care during escalation or de-escalation of care, provided much-needed emotional support to patients quarantining at home and helped find medical homes for patients with tenuous ties to health care.