The Osler catchment area experienced a high volume of Covid patients when the pandemic began. This necessitated a rapid and innovative response to home based care when timely ED/inpatient throughput was compromised. The COVID@home program was developed to provide in-home care for newly diagnosed, at risk COVID patients or for patients being discharged home either with or without oxygen, who needed support to safely transition home after a hospitalization. This program was unique in that appropriate patients were started on oxygen and steroids at the pre-acute phase with the goal to begin treatment prior to a hospital encounter. The care team was comprised of RN’s/RPN’s from Osler and Registered Respiratory Therapists from our home oxygen provider (Pro-Resp). Medical oversight for care escalations was provided by a Respirologist on-call. Patients deemed “at-risk” for deterioration were screened and referred by Pubic Health, ED’s and inpatient unit MD’s seeking early discharge for patients. Patients were given instructions on how to use a provided oximeter, the use of the Vivify GO app and an education kit as part of the onboarding process. Twice daily oximeter readings and symptom assessment questionnaires were uploaded into the monitoring dashboard. Patients were monitored for up to 14 days on the program. Texting and video conferencing requests from patients to the team could be accepted by the app while the nurses monitored for destabilizations. Patients without access to technology received proactive telephone calls twice per day to document biometrics and symptoms, and assess for stability and disease severity.
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