COVID -ED to Home with Enhanced Monitoring

Cleveland Clinic is a large academic multi-location hospital system, with a central main campus and satellite Hospitals, and Family Health Centers spanning Northeast Ohio, the United States and the world. Change is a constant at the Cleveland Clinic, but change is supported by a clear guiding vision of “Patients First” and throughout every level of leadership by taking a “team of teams” approach. Never has change come so quickly as over the last year. This change was met with innovation, agility and teamwork across the enterprise.

One of the countless examples of innovation at the Cleveland Clinic is the COVID Home Monitoring Program. The program was designed to support patients, to ensure continued care delivery for existing conditions, and to decant system wide volumes in the face of COVID surges. It was designed also to serve as a learning opportunity, both about the novel Coronavirus and in population health programs.

Teams from across the Cleveland Clinic rallied to develop a new program, processes and disease management pathways in record time. IT solutions were developed to enable caregivers to work efficiently and accurately. The team partnered with Epic (EHR) to create a digital patient engagement platform, MyChart Care Companion for COVID monitoring.
A population management framework was developed. Patient reported data identified the need for nursing review. Nursing teams provided education, triaged, and escalated care when necessary. Social work and behavioral health teams were involved where needed. A team of physicians (Virtualist) was available on-demand to virtually assess the patient and treat. This framework proved efficient, and has been leveraged in other capacities including a chronic disease outreach program. Further development of the Virtualist program is in progress.

We maintained communication and feedback for process improvement. Analysis showed risk reduction in both ED at 30 days and inpatient admission at 30 and 90 days in the monitored population. A Cleveland Clinic risk model was developed to identify patients at increased risk of admission. Data showing reduced admissions, and ability to identify admission risk shifted focus toward the higher risk population. The Cleveland Clinic developed risk calculator was integrated into the EHR and is available to all Epic applications.

Narrowing the population allowed an increase in capacity. Additional capacity enabled partnership with Emergency Services IPU to develop of the ED to Home Enhanced Monitoring Program. Enhanced monitoring of patients allowed for patient care in the home with safety net of support. Reduced hospital admissions helped to preserve hospital capacity in the face of surging COVID diagnoses.

Tremendous effort went into development of this population monitoring program, and learnings from this experience are feeding development of new programs across the enterprise. Our goal is that the COVID Home Monitoring Program becomes an unnecessary population health effort, but that the framework and relationships built though its development can translate into population health disease management programs with even
broader reach.