Delivering Health Continuity Outside the Point of Care

An acute health condition can bring on numerous new ones or cause comorbidities to increase in severity. We have known that for quite some time. However, the ways in which providers monitor patients following an acute episode can inform our ability to prevent subsequent acute events and give us the opportunity to intervene in scenarios that may lead patients’ health to further deteriorate outside of a point-of-care setting. At Contessa, this critical period is known as the “monitoring phase”.

A monitoring phase, on the surface, may not seem like a differentiator in a model of care. Often, when a patient leaves an acute care facility, different care team members will check in on them with a phone call and home health visits. Contessa’s model is more comprehensively coordinated with continuity of caregivers. The patient is treated for their acute condition at home and then seamlessly transitions to the monitoring phase, which completes their 30-day episode of care. While a patient progresses through an illness, our care coordinators are there throughout the acute phase – and after.

Improvements during the first 30-days after an acute experience are critical to patients’ long-term health, but assuring an individual continues improving, and that their environment is conducive to such, is of equal importance. During our monitoring phase, the same care coordinators that the patient has become familiar with carry out the monitoring coordination and are able to identify any inconsistency to help recommend adjustments in treatment. Moreover, care coordinators are familiar with patients’ at-home settings and lifestyle to help tailor services to improve overall health, like disease management, smoking cessation and additional longitudinal care. Such monitoring allows care coordinators to help patients overcome challenges of social determinants of health they may be experiencing by directing patients to, and often coordinating, services with local resources.

Notably, during the ongoing COVID-19 pandemic, numerous COVID-19 patients have entered our care model, including the monitoring phase. In many instances, while screening showed patients were stable before entering hospital care at home, we were able to identify the need for clinical intervention related to other chronic medical conditions. Our ability to monitor and identify risks in patients’ homes as part of that phase allows for more proactive intervention to prevent further issues from arising.

While a monitoring phase may not seem like the selling point of acute care, an enhanced version with in-home monitoring allows providers to better understand changes in patient health. The home hospital care setting provides many advantages often overlooked when in acute care. Patients benefit greatly from having a consistent, familiar point of contact while providers’ capabilities are enhanced with additional resources and data from the at-home setting.

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Meet Our Expert

Mark Montoney, MD, MBA, Senior Medical Advisor

Mark has a deep history and passion for geriatric medicine. He was first drawn to Contessa because of its unique and specific delivery of care, which is often highly beneficial to geriatric patients. In his role at the organization, Mark advises on clinical operations, including quality and patient safety, utilization management, research and innovation, and physician leadership. Prior to this role, Mark served as the chief medical officer for Contessa, Tenet Healthcare, Vanguard Health Systems and OhioHealth, where he practiced internal medicine and geriatrics. Contact Dr. Mark Montoney