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Vision and Voice

Helping Patients Get Home and Stay Home

To say that COVID-19 accelerated the growth of our remote monitoring and home telehealth programs would be an understatement. It solidified their importance to providing the best care possible to our patients and keeping our team members safe — for the next phase of the pandemic and beyond. And it all happened because our team members saw an opportunity to rethink our care model and develop an innovative solution.

In just a week from conception to reality, we swiftly stood up an Interactive Home Monitoring program for COVID patients in March 2020 — allowing them to receive extended care after their discharge from the Medical Center. Nearly two years later, this innovative program has enabled more than 1,300 COVID patients to rejoin their families, knowing that UVA Health teams continue to monitor and manage their recovery.

We pivoted quickly by reimagining our existing Interactive Home Monitoring program primarily designed to help safely discharge patients sooner with the support of healthcare providers and pharmacy intervention, as well as clinical escalation protocols. A team of Advanced Practice Nurses and Physician Assistants (APP) provides in-home monitoring care 7-days a week for COVID patients at no charge. The healthcare team addresses medical and pharmacy concerns, monitors vital signs, prescribes appropriate medications, and offers access to healthcare resources available throughout the community.

Overall, the program has improved patient outcomes, including lowering the rate of Emergency Department visits and hospital readmissions — both for patients recovering from COVID-19 and those with ongoing conditions such as high blood pressure and diabetes. The home monitoring program also supports several groups of patients, including pregnant mothers at high risk for delivering early; transplant patients; premature infants; patients with serious chronic conditions such as heart failure and COPD; and young children born with serious heart conditions. Throughout all these programs, we serve more than 5,000 patients per year. This success recently garnered the program a three-year, $4.4 million federal grant to expand the number of patients served.

Our team members can make a big difference by making their voices heard, especially when pointing out barriers to care and offering unique solutions. This is but one of many examples I see around UVA Health daily.

So, thank you to our Population Health and supporting APP teams for these new ideas, suggestions, and innovations that have made us all stronger, safer, and more resilient. I'm grateful for their willingness to adjust to unique circumstances with enthusiasm and grace. We have weathered many challenges together, and I'm proud that our UVA Health teams continue to rise to meet and overcome these challenges every time.

Take care and be well!