What began as a pandemic-era effort to relieve pressure on hospital capacity has evolved into one of Virtua Health’s most significant care delivery initiatives.
The Marlton, N.J.-based health system launched its hospital-at-home program in early 2022 as COVID-19 surges strained inpatient capacity and health systems searched for alternatives to traditional hospital care. But leaders soon discovered that another challenge remained: what happened after patients went home.
“We also realized in doing hospital at home that patients were really challenged in the transition as we went away,” Michael Capriotti, senior vice president and president of advanced care operations and logistics at Virtua Health, told Becker’s. “They were just overwhelmed.”
That realization led Virtua to create Care After Discharge, a program designed to support patients during the critical 24-to-72-hour period after leaving the hospital.
Patients enrolled in the program receive continuous biometric monitoring, medication reconciliation, a physician visit within 24 hours, assistance scheduling follow-up appointments and access to a 24/7 command center staffed by clinicians. Emergency medical technicians or paramedics can also visit patients in their homes, and pharmacists are available for virtual consultations when needed.
The program leverages the same infrastructure Virtua built for its hospital-at-home initiative, including remote patient monitoring technology, physicians, nurses and an around-the-clock command center. Rather than creating a separate operation, the health system expanded an existing platform to support patients transitioning back into the community.
The strategy has helped Virtua scale its home-based care efforts. After treating approximately 320 patients through its hospital-at-home program in 2022, the health system cared for roughly 6,500 patients last year across its hospital-at-home and Care After Discharge programs. Daily census grew from roughly one to five patients to between 50 and 80 patients per day.
The clinical results have been notable as well.
Mr. Capriotti said Virtua has seen a roughly one-day reduction in length of stay across both programs and single-digit readmission rates among patients who participate in Care After Discharge and the health system’s longitudinal remote monitoring programs. Virtua also reported statistically significant reductions in readmissions for patients with acute myocardial infarction, COPD, pneumonia and congestive heart failure.
Much of that success stems from addressing issues that often go undetected before patients leave the hospital.
Care teams have discovered patients do not have medications they believed they had, qualify for home health services that were not initially identified, or require medical equipment that was never delivered. In other cases, clinicians have identified signs of deterioration through continuous monitoring and have intervened before a hospital readmission became necessary.
“We’re correcting for all those issues and helping support them,” Mr. Capriotti said.
The experience also changed how physicians interacted with patients. Rather than seeing them only during a hospital stay, clinicians gained visibility into the realities of patients’ home environments and the factors influencing their recovery.
“I’m in their kitchen, I’m also talking to their family members, I can see their dog, I know what’s happening,” Mr. Capriotti said.
Lessons learned from remote monitoring and virtual care have informed new technology deployments across Virtua’s hospitals. The health system has installed cameras and ambient sensors in approximately 1,200 hospital rooms and developed nearly 20 virtual care use cases, including virtual nursing, tele-ICU services and virtual patient observation.
Virtua is also preparing to expand continuous monitoring inside its hospitals through wearable biosensor patches for medical-surgical patients. The long-term goal is to create a seamless transition from inpatient care to home-based monitoring, allowing patients to move between levels of care without experiencing disconnected episodes of treatment.
For Mr. Capriotti, programs such as Care After Discharge represent more than a post-acute service line. They are becoming a core part of how health systems think about capacity management.
Virtua has integrated its hospital-at-home, Care After Discharge, remote monitoring, virtual nursing and telehealth operations with patient logistics functions such as bed placement, transfer coordination and staffing management. The goal is to use virtual care capabilities as additional levers for managing patient flow throughout the health system.
As hospitals continue to face capacity constraints, workforce shortages and growing demand, Mr. Capriotti believes home-based transitional care programs will become increasingly common and make care transitions feel less fragmented for patients.
“It’s not going to feel like episodes of care,” he said. “It’s going to feel more like one continuous journey for them.”
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