From Hospital to Home: An Intensive Transitional Care Management Intervention for Patients with COVID-19

Area of Science:

• Health Services Research
• Infectious Disease Management
• Healthcare Operations

Background:

• The COVID-19 pandemic strained hospital resources, necessitating innovative patient management strategies.
• Optimizing patient throughput and surge capacity is critical during public health emergencies.
• Traditional hospital admission pathways may not be suitable for all patients with mild-to-moderate COVID-19.

Purpose of the Study:

• To evaluate the effectiveness of an Intensive Transitional Care Management (ITCM) intervention.
• To assess ITCM's impact on hospital bed capacity and patient outcomes during the COVID-19 pandemic.
• To determine if ITCM can safely reduce inpatient admissions for COVID-19 patients.

Main Methods:

• An observational cohort study was conducted in a large health system in New Jersey.
• The intervention group (192 patients) received ITCM, including home oxygen, home care, and tele-management.
• Outcomes were compared to a matched control group (593 patients) admitted with similar COVID-19 severity.

Main Results:

• The ITCM intervention avoided 481.6 inpatient days for 78 patients discharged from the ED or observation unit.
• No significant difference in re-encounter rates (ED, observation, or readmission) was observed between groups.
• ITCM proved to be a feasible strategy for managing COVID-19 patients and increasing hospital bed availability.

Conclusions:

• Intensive Transitional Care Management is a viable approach to optimize hospital capacity during pandemics.
• Tele-management and home-based care can safely support COVID-19 patients, reducing the need for inpatient stays.
• This intervention model offers a scalable solution for enhancing healthcare system resilience during surges.