Patient Experience in a COVID-19 Patient Home Monitoring Program

ABSTRACT

The COVID-19 pandemic accelerated the adoption of virtual care programs, but little is known about patient experience in these programs. In spring 2020, we created a patient home monitoring program for patients with COVID-19 who had clinical risk factors for decompensation. We sought to evaluate patient experience in this program via telephone survey of participants. In terms of overall quality of care, 91% of survey participants rated the program as a 9 or 10 of 10, and 90% would definitely recommend a similar program to family or friends with COVID-19 infections. In terms of ability to divert patients from the emergency department, 79% of responders indicated that their participation in the program made them less likely to seek care in the emergency department. Patients were satisfied with the overall care they received in this program.

Am J Accountable Care. 2023;11(2):23-26. https://doi.org/10.37765/ajac.2023.89381

After years of incremental growth in the United States, telemedicine utilization rapidly increased as a result of the COVID-19 pandemic and has become an integral route of health care delivery.^1,2 In the early months of the COVID-19 pandemic, public health measures, as well as regulatory and payment policies that were enacted in response to the pandemic, promoted increased use of telemedicine.^3,4

In response to the possibility of a surge of admissions overwhelming local hospital systems in spring 2020, we created a patient home monitoring program for COVID-19 patients in an urban safety-net health care system. Previous evaluations of patient experience in telemedicine programs have shown that patients report an increased sense of security and ability to manage their disease; however, little was known about patient perspectives on participating in patient monitoring programs during the COVID-19 pandemic.⁵ This study seeks to evaluate patient experience in a COVID-19 patient home monitoring program.

METHODS

Study Design

This study is a cross-sectional telephone survey of the patient experience in a COVID-19 patient home monitoring program.

Study Setting

Denver Health is an integrated safety-net health care system in Colorado providing primary and acute care services through 9 federally qualified community health and urgent care clinics throughout the city, as well as a main campus emergency department (ED) and 509-bed hospital. Most patients have government insurance (54% have Medicaid) or are uninsured (18%). More than half of patients are members of racial/ethnic minority groups (37% are Hispanic and 14% are Black).

COVID-19 Patient Home Monitoring Enrollment and Management

This program was developed to optimize inpatient bed utilization by providing supportive care and home monitoring to patients with suspected or confirmed COVID-19 infections who had risk factors for clinical deterioration but were otherwise clinically stable. The only requirements for patients to participate were to have an active, working phone number and willingness to participate in the program. Enrolled patients were provided with blood pressure cuffs, thermometers, and pulse oximeters (hereafter referred to as durable medical equipment [DME]) with which to complete home monitoring assessments.

In addition to twice-daily phone calls during which nursing staff and physicians assessed patients’ symptoms and self-measured vital signs, staff provided home oxygen, dexamethasone, and symptomatic therapies. Patients requiring escalation of care were seen in the ED through coordination with the hospital transfer center. Monitoring was continued until patients had gone 72 hours without fever, had gone more than 10 days since symptom onset, and had improving symptoms.

Study Participants

From its launch in April 2020 through November 2020, our program monitored a total of 668 patients referred from the ED, urgent care centers, community health clinics, and hospitalist services. Utilizing a random number generator, we randomly selected 155 patients (23%) from all referral sources to participate in this study. Patients enrolled had suspected COVID-19 diagnoses, with 63% eventually having a positive COVID-19 polymerase chain reaction (PCR) test, 28% having a negative PCR test, and 9% not having a test.

Survey Design

The survey included a total of 20 questions addressing 5 domains of the patient home monitoring experience: perception of care received through patient home monitoring, perception of DME use, program call frequency and duration, access to technology, and patient engagement. Patient demographics and medical history were derived through electronic health record data abstraction.

Data Collection

The surveys were administered by a bilingual research assistant (E.M.) from January 25 through February 25, 2021. Questions either asked for yes/no responses or had a range of possible options from which respondents could choose (such as 1-10 for care rating and never/sometimes/usually/always). Patients received up to 3 phone calls to complete the survey. All data were entered and recorded in REDCap.⁶ This project was reviewed and approved by the Denver Health Quality Improvement Review Committee.

RESULTS

A total of 80 patients completed surveys; 34 declined participation and 41 were unable to be reached. See Table 1 regarding characteristics of the population.

In terms of overall quality of care, 91% of survey participants rated the program as a 9 or 10 of 10, and 90% would definitely recommend a similar program to their family or friends with COVID-19 infections (Table 2). Should a similar patient monitoring program be implemented surrounding transitions of care for non–COVID-19 conditions, 90% of participants reported that they would participate.

In assessing the COVID-19 patient home monitoring program’s impact on patients seeking higher levels of care, 79% of participants indicated that their participation in the program made them less likely to seek care in the ED or urgent care, whereas almost 5% felt that their participation made them more likely to go to an ED or urgent care. The majority of patients reported that participation in the program helped them feel more in control of their medical condition (88.9%) and helped them understand the nature of their medical condition (93.8%).

Use of DME by survey participants was less than expected. Approximately 70% of patients reported use of home DME, and most patients reported receiving training on the use of their DME telephonically by program staff (42%) or the ED staff (17.2%). However, 25.9% of participants described receiving no training on the use of their DME. Despite this finding, 91.6% of participants described feeling comfortable to very comfortable in the use of their DME.

The majority of participants described the volume of phone calls per day and the duration of their monitoring as adequate (87.7% and 95.1%, respectively); only 8.6% expressed a desire to have more frequent phone calls per day and 4.9% expressed wanting a longer duration of monitoring.

Although 85% of participants described having a smartphone and 74% reported having access to wireless internet, only 53% reported having access to our electronic health record patient portal and only 38% reported accessing this portal in the preceding 6 months.

DISCUSSION

This single-center study demonstrated that patients enrolled in a home monitoring program for patients with COVID-19 were satisfied with the overall care they received in the program as well as the communication with nursing staff and physicians. A primary goal of creating this home monitoring program was to offload local EDs and hospitals as COVID-19 cases rose. The majority of participants responded that participation in this program decreased their likelihood of seeking care in an ED or urgent care.

This program was designed and implemented urgently in response to the pandemic. As a result, an additional goal of this study was to assess the structure of the program to inform potential future use for diagnoses beyond COVID-19. Patients expressed overall satisfaction with how care was provided in this program, suggesting that its use for alternative diagnoses at transitions of care may be reasonable.

Our program’s ability to provide home monitoring relied not only on patients’ subjective accounts of their symptoms but also their communication of objective measures of clinical status by reporting vital signs obtained through use of DME. Only 60% of patients surveyed stated that they received any instructions for DME use. However, approximately 90% of patients stated that they were comfortable with the use of their DME. As technologic advances continue to broaden the role and capabilities of home monitoring programs, our health care system’s ability to access and appropriately train patients on the use of these tools also will need to expand.

Limitations

Several limitations may have affected the results of our study. Although a representative sample of patients who participated in this program was selected for the survey, only approximately 50% ultimately completed the survey. The overall positive feedback that we received regarding the program in this study therefore may be in part a result of response bias. Conducting surveys after patients have completed their care in the program can potentially affect respondents’ ability to accurately remember their experience. With a 6.5-month median time frame between program enrollment and survey participation, some of the responses we received may have been affected by recall bias. Also of note, more than 95% of patients who were asked to enroll in our program did so. This rate of participation may have been the result of increased patient adherence during the pandemic or the fact that our program did not require home visits.^7,8

CONCLUSIONS

Patients were satisfied with the care they received in our COVID-19 patient home monitoring program. The frequency and duration of monitoring was deemed appropriate by patients, but the ability to access and utilize technology could be improved, particularly to increase the role of virtual care platforms in standard transitions of care. This study will help inform future use of this platform with consideration toward expansion to additional diagnoses surrounding transitions of care.

Author Affiliations: Division of Hospital Medicine (NS) and Division of Primary Care and Internal Medicine (PR, EM, RH), Denver Health and Hospital Authority, Denver, CO; Division of Hospital Medicine, University of Colorado (NS, PR, RH), Aurora, CO.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (NS, PR, EM, RH); acquisition of data (PR, EM); analysis and interpretation of data (PR, RH); drafting of the manuscript (NS, PR, RH); critical revision of the manuscript for important intellectual content (NS, PR, RH); statistical analysis (PR); and administrative, technical, or logistic support (PR, EM, RH).

Send Correspondence to: Nicholas Scaletta, MD, Division of Hospital Medicine, Denver Health and Hospital Authority, 601 Broadway, Denver, CO 80209. Email: Nicholas.Scaletta@dhha.org.

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