COVID-19 Drives Healthcare Adaptation for Remote Monitoring, Behavioral Health, Telemedicine, Home Health, and Long Term Care

Coronavirus Continues to See Evolution Within Medicine

By Abbas Mooraj, Managing Director, Health and Life Sciences, Cloudera

This article is part of a series about the COVID-19 pandemic. My intent is to offer information, insights, and inspiration across the entire healthcare ecosystem, as you can see from my first article that offered a roundup of what was happening across healthcare and the second article that focused on healthcare supply chain and testing challenges.

In this piece, I’m going to discuss how the pandemic is driving a day-to-day evolution within healthcare for remote monitoring, telemedicine, behavioral and home health, and long term care, and how these organizations are showing remarkable adaptability during this challenging time.

Remote Monitoring Helps Keep Patients and Caregivers Safe

Some healthcare device makers are gaining ground with the FDA to use remote monitoring for COVID-19 patients who are asked to stay home and monitor symptoms, and also patients in the ICU. These devices help maintain physical distancing recommendations to keep healthcare workers and others safe.

As Randy Davis, Vice President and CIO of CGH Medical Center in Sterling, Ill, says: “Home monitoring will take off. Patients not wishing to sit in waiting rooms with others will push the technology forward, and they should.”

Here are a few examples of how remote monitoring is being used:

• A patient who tested positive for COVID-19 with mild symptoms can stay at home and have their temperature, respiration, and heart rates tracked wirelessly with a biosensor patch that monitors disease progression. The showerproof patch affixes on the chest and stays in place for five days to monitor vital signs, movement, and electrical activity with an ECG. If the patient develops stronger symptoms, healthcare workers are alerted.
• Biosensor patch maker LifeSignals plans a June rollout of a patch to track blood oxygen saturation for monitoring patients recovering in ICUs that would help hospitals move patients to other wards or off-site to free up hospital beds.
• Spry Health launched a clinician-led monitoring service for the Loop wearable, a wrist-worn device that tracks heart rates, pulse oximetry, and breathing to help reduce strain on already stressed hospital emergency departments.
• UTM:Healthcare started incorporating Bluetooth-enabled thermometers into smartphone apps that alert doctors if patients need care.
• ObvioHealth launched a virtual COVID-19 patient registry for 10,000 people in the US who volunteered to have their symptoms and immune response tracked.
• Cleveland Clinic and Epic developed a home monitoring tool that proactively surveys COVID-19 patients about their condition and offers educational content. If new symptoms begin or existing ones worsen, clinicians are alerted.
• Stanford Health is conducting research to use wearable device data to detect the early onset of COVID.

All of these devices, registries, and programs are designed to keep patients, caregivers, and patients’ families safe during the pandemic.

Telemedicine Alleviates Strain on Clinics and EDs

As this pandemic unfolds, fewer people are going to the doctor. Clinic parking lots are virtually empty, with more patients being diverted to telemedicine to protect not only their own health but the health of the caregivers. Research conducted by Harvard University and Phreesia indicate a drop of 60% in ambulatory care visits among 50,000 providers. Hospitals have also canceled or postponed elective procedures to preserve space in their facilities for surges in coronavirus patients.

Evidence of the sea change for telemedicine can be seen in the Centers for Medicare & Medicaid Services (CMS) broadening access to telehealth to include a wider range of services for Medicare beneficiaries. Even though this is considered a temporary change as part of the country’s emergency response plan, telemedicine has found a more permanent place in the healthcare system of the future.

Some indications of how telemedicine use has spiked:

• Partners Healthcare saw a spike in telehealth visits of 1,600 in February to 90,000 in March.
• One health network in New York saw a single daily spike from zero to 5,500 visits.
• Houston Methodist virtual visits went from averaging 50 a day to more than 2,000 per day.
• CVS Health is seeing increases in telehealth and home delivery, with a 600% increase in telehealth and virtual visits at its MinuteClinics for the first quarter of 2020. Home prescription deliveries were up 1000% for the same period.
• Stanford Medicine used to see 1,000 patients a week via telehealth and now sees 3,000 a day.

Telehealth organizations have stepped up to offer vital resources for patients who may have mild symptoms and can’t get into their regular clinics. Upwards of 48% of physicians in the US are treating patients through telemedicine, up from 18% in 2018. Some of these telemedicine organizations and resources include:

• AmWell, which launched a COVID-19 response program to help hospitals, health systems, and health plans manage and mitigate the spread of the disease. AmWell also has a partnership with Netsmart to integrate telehealth into a substance use-specific electronic health record (EHR), where providers initiate virtual visits.
• Ro offers free online assessments for people who believe they have COVID-19 symptoms. While the organization cannot offer a diagnostic test, it can recommend tips for care and self-quarantine.
• Major healthcare systems continue to explore additional opportunities for doctors to provide care to patients at a distance by teaming with organizations like Teladoc, AmWell, and MDLive.
• Doctor on Demand signed a deal with the state of Massachusetts to provide free telehealth visits to the state’s uninsured during the pandemic.

CMS has also increased the number of audio-only telephone visits to include behavioral health and patient education visits. Retroactive to March 1, the payment rate for these visits will match those for similar office and outpatient visits.

Protecting Physical and Emotional Health

As mentioned above, more behavioral health treatments are going digital. While this has not been the traditional method of treatment in this field, online therapy company Talkspace has reported a 65% jump in clients since mid-February. Many mental health issues are cropping up not only for patients who have been on ventilators, and the healthcare workers who cared for them, but also the millions of Americans who will shelter in place for possibly several months, experiencing higher than normal levels of isolation, stress, depression, and anxiety, either about the pandemic itself or as a result of job loss, worries about money, and even more isolation for those who live alone.

For patients who have been on ventilators, some respond well to mild sedation, while others require heavier doses of medications that act on their brains. They may experience delirium as a result, which impacts their recovery, and also affects the sleep-wake cycle, mobility (greater levels of weakness), lower tolerance of nutrition, and ultimately causes them to develop PTSD (post-traumatic stress disorder) and impaired concentration once they are off the ventilator.

Clinical staff on the front lines of the battle who have worked on a COVID-19 inpatient unit feel very overwhelmed by the experience.

“The nature of this situation is different from others because there’s no clear end. There is a great deal of uncertainty. The amount of death on inpatient units is about tenfold the usual amount, and the number of people who have transferred into roles they didn’t previously have is very, very high. It’s much like the anxiety of an active military battle,” said Dr. Andrew Brotman, executive vice president and vice dean for clinical affairs and strategy at NYU Langone Health, as well as its chief clinical officer.

All of these behavioral health issues are driving a spike in the number of prescriptions for anti-anxiety, depression, and sleeplessness, with ExpressScripts seeing an increase in prescription use for all of these conditions of 21% from February to March 2020. Here are the increases by drug category for the same timeframe:

• Anti-anxiety prescriptions — 34.1%
• Antidepressants — 18.6%
• Anti-insomnia — 14.8%

These indications are in stark contrast to double-digit drops in the same medications for the last five years.

Even with the increased use of the prescription drugs named above, projections for additional fatalities indicate COVID-19 could cause an additional 75,000 deaths from suicide, drugs, and alcohol.

Because more behavioral health treatments have moved to telehealth visits, the door has been opened for other treatments to be prescribed via telehealth. The government suspended a federal law requiring in-person physician visits for prescribing medications to individuals with opioid addiction.

Home Health

While home health, defined as supportive care performed in the home by licensed healthcare professionals who provide medical treatment or by professional caregivers who offer assistance for activities of daily living, some among our most vulnerable populations are declining these services because they are worried the person coming into their home may give them COVID-19.

While reports from the Home Care Association of America, a professional organization that represents 3,000 agencies, indicate an uptick in requests for services, in other areas clients are now being cared for by family members who are sheltering in place at home.

However, for most people with pre-existing conditions who are at greater risk, and vulnerable populations on Medicare or Medicaid, home health can prove to be a lifeline.

One organization that offers home health services is CareMore, a subsidiary of Anthem Inc., which serves 100,000 patients across eight states. CareMore continues to provide care for patients and is following CDC guidelines for safety.

CareCentrix is another organization that offers patients post-acute care at home. They work with providers, health plans, and patients and also are following guidance from the CDC and offering resources to all of the organizations and people they partner with.

Another area impacted by COVID-19 is hospice and palliative care, which remains committed to offering vital services to families whose loved ones are in the final stages of life. Professional organizations such as the National Coalition of Hospice and Palliative Care offer a variety of resources from 10 affiliated care organizations, such as the American Academy of Hospice and Palliative Care Medicine, and the Association of Professional Chaplains. Their work continues, and may be called up to serve elderly COVID-19 patients who prefer to spend their final days at home.

Organizations like these and other home health agencies are positioning themselves into a stronger position within the larger healthcare continuum. People who work in non-medical roles in the homes of older patients play a particularly important role in spotting deteriorating health conditions of their patients because they see them every day, which may in turn help save lives.

Nursing Homes Are Ground Zero

Within our nursing homes in America, records indicate supply shortages, lapses in care, lack of transparency, and inadequate infection control that are fueling the spread of the coronavirus.

Reports from across the nation point toward elder care facilities being hit the hardest by COVID-19, with the following stories being reported:

• California eldercare makes up 40% of all deaths related to coronavirus
• Half of the fatalities in Massachusetts are in elder care facilities.
• New Jersey reported 1,530 of the 3,840 deaths (as of April 17) were individuals living in long-term care facilities.
• Colorado has reported the second-highest number of deaths from nursing home residents, with Minnesota reporting the highest number at 73% of all deaths.
• In New York, at least 4,813 people in nursing homes have died of COVID-19, with another 1,700 previously undisclosed deaths believed to be tied to the coronavirus as well. The total number of deaths in the state related to the coronavirus remains uncertain because the list does not include nursing home residents who were transferred to the hospital before dying.

Complicating matters, even more, is that not all states are reporting COVID-19 deaths related to elder care facilities, and states are counting mortalities differently. These challenges are not simply confined to facilities that were troubled before the pandemic, but also highly rated facilities. Workers struggle to identify, isolate, and treat patients who have been diagnosed with COVID-19, on top of doing their already demanding jobs. And while many facilities are taking measures to protect the residents, it’s left them even more vulnerable and closed off from family and friends.

Adding further complexity to what is happening in nursing homes was that they were not required to report COVID-19 cases among residents or staff to families, the residents themselves, or family representatives. To improve this communication, CMS issued requirements in mid-April for nursing homes to inform residents, their families and family representatives of COVID-19 cases within nursing home facilities. Reporting to the CDC is also required.

However, with more than 36,500 residents and staff at nursing homes contracting coronavirus as of April 24, and at least 7,000 deaths, or one-fifth the total number of reported COVID-19 deaths, CMS announced a new independent commission to conduct a comprehensive assessment of the nursing home response. The Commission will provide independent recommendations to help form immediate and future responses to COVID-19 in nursing homes.

Yes, the new requirements from CMS are welcome, but Forbes poses the question of whether they are enough for the following reasons:

• They are limited to nursing homes, which leave out assisted living, small group homes, and other elder care facilities.
• There’s no clear indication when facilities are expected to start reporting to the FDA and CDC.
• The rules appear lax, with indications that violations could result in enforcement action.
• Some facilities will not have to report staffing data for the first quarter of 2020, even though the facilities already have that information.

As better testing and contact tracing become available during this pandemic, elder care facilities will likely be primary targets for minimizing the death toll on this population.

Concluding Comments

The COVID-19 pandemic is taking a meandering, deadly path through our country, and I will continue to monitor how the healthcare ecosystem is responding. Healthcare continues to show extreme flexibility in many areas, including focusing on caregivers, patients, and their behavioral health-related struggles, using remote monitoring to continuously observe patients and protect caregivers and family members, and increasing the use of telemedicine. All areas of healthcare are responding from home health to hospice and palliative care to elder care facilities, with organizations beefing up their response to outbreaks of COVID-19. As always, please feel free to reach out to me and let me know about your challenges, victories, advances, and innovations. Let’s all stay connected, well, and strong.