Why the Monitoring Phase is Critical for Hospital Care at Home

Recently, I had an enlightening experience with a medication that I’ve taken for a long time. My prescription plan changed and stopped coverage. Between calling the pharmacy, my primary care physician and my insurance company, it took me two weeks to find a new, covered option. It struck me that if it was this difficult for me, a practicing physician, to sort through the complex maze of our health system, the average patient discharged after a complex illness is set with a truly daunting task indeed.  

We’ve long known that an acute health condition can bring on numerous new issues or cause comorbidities to become more severe. Many of us have painful recollections of an elderly loved one whose health rapidly deteriorated after an acute illness. What is less well known is that the period following discharge from an acute hospital stay is critical to a successful return to high-functioning independence and can crucially inform our ability to prevent subsequent events. It is a critical window for laying the foundation that determines a patient’s long-term health. Setting this up correctly represents a puzzle that is, in many ways, unique to each patient.  

However, research shows that certain common characteristics can tell us who is more likely to fail the hospitalization launch attempt. Factors such as coping ability, personal support needs, medical literacy, prolonged illness, food scarcity and having multiple chronic conditions generally make it much harder for people to live free of illness and medical facilities. Importantly, true long term health outcomes are largely driven by factors outside of healthcare environments and are only minimally reached by our stethoscopes, needles and prescription pads. 

Bringing medical care home extends support

Given these considerations, the design and configuration of the hospital at home model has been intentional about targeting resources and support to patients in the areas of their greatest need. At Contessa, the phased, calibrated process of supporting patients back to full health and independence is known as the “monitoring phase”.  

Often, when a patient leaves an acute care facility like a hospital, it is up to different care teams and family members to remember to check in on them and help with medications, appointments and household needs. For most people, this is a disconnected, decentralized process. Patients and their caregivers shoulder the burden of juggling calls from multiple physician specialists, pharmacies and other support services.  

In contrast, Contessa’s model is carefully coordinated. Patients are treated for their acute condition at home and then seamlessly transition to the monitoring phase, which completes their 30-day episode of care. It is of central importance that our patients continue to improve and that their environment is conducive to recovery. During our monitoring phase, the same care coordinators with whom the patient has become familiar, help ease the burden of coordination, scheduling, identifying gaps in care and serving as a single point of contact for any health care questions or needs.  

Moreover, care coordinators gain exclusive insights into patients’ home settings, family dynamics and lifestyle choices, which helps tailor services to improve overall health like chronic disease management, smoking cessation and additional longitudinal care. This element of the monitoring phase allows care coordinators to help patients overcome challenges of social determinants of health by directing patients to, and often coordinating with local resources. 

While a monitoring phase may not seem like a key part of acute care delivery in the home, in-home monitoring is rare, essential and often overlooked. It allows providers to better understand changes in peoples’ health. Patients benefit greatly from having a consistent, familiar point of contact while providers’ capabilities are enhanced with additional resources and data from the home setting.