After 18 months of the COVID-19 pandemic, hospitals are learning how to efficiently and safely transition these patients to community settings.

For example, one study showed an emergency department (ED) and hospital patient throughput management program can save hundreds of hospital patient days after discharge from the ED or observation unit stays.1

Hospitals were in a much better position to handle COVID-19 patients by the spring of 2021, says Jennifer Puzziferro, DNP, CCM, RN-BC, corporate vice president for case management at RWJ Barnabas Health in West Orange, NJ.

“In the spring of 2020, we had hospitals exceeding capacity for COVID-19 patients,” she says. “We had to provide a care transition program. I had patients here I thought I could send home if we had a way to take care of them.”

Puzziferro contacted the director of patient care services and suggested they create a program using case managers to monitor patients in a home setting. Eligible patients were required to line up a caregiver, own a smartphone, and use an app called Health Connect that was developed internally.

“Ambulatory case managers were responsible for patient care in the home,” she says. “A nurse would contact patients until the physician would say they were medically clear.”

The patients also had to meet clinical criteria. They were sent home with a pulse oximeter and an oxygen tank, Puzziferro says. The tanks were delivered by a vendor partner who would go to the home, pick up the tank, clean it, and recycle it after the patient no longer needed it.

The intensive transitional care management intervention helps the hospital optimize bed capacity. It prevents inpatient admissions by discharging patients and providing them with in-home medical support and telehealth care management.1

In a retrospective study of five hospitals, researchers found ED providers can screen COVID-19 patients for risk factors that might require a stay of more than 48 hours. Long-stay patients were much more likely to be older than 60 years of age, have diabetes, chronic kidney disease, and ED vital sign abnormalities.2

“Our main study findings were that more patients than we expected were hospitalized or needed to be for a short period of time with COVID-19,” says Austin Kilaru, MD, MSHP, assistant professor of emergency medicine at the University of Pennsylvania. “We thought that people needed hospitalization for COVID-19 or to stay in the ICU setting for days to weeks, but found that a significant portion of people who needed to be hospitalized did get better quickly, and were discharged within 48 hours. We were trying to identify who those people might be based on the information available at admission into the hospital.”

Researchers found several risk factors for a short- or long-term hospital stay. “I thought one thing that was interesting and surprising was that patients with abnormal vital signs generally tended to be less likely to discharge within 48 hours,” he says.

Abnormal vital signs included low oxygen levels, tachycardia, fast breathing, and fever. “One criticism would be if a patient had normal vital signs in the emergency department, why did they even need to be admitted at all?” Kilaru asks. “That was actually important; we were identifying that patients could, on paper, look stable for discharge but for one reason or another they were perceived to still need some time in the hospital to make sure they were improving.”

Those patients might include people who were throwing up or showed subjective symptoms of troubled breathing, were elderly, or underwent previous transplants but still showed normal vital signs, he adds.

For the COVID-19 patient discharge process at RWJ Barnabas Health, case managers identified patients appropriate for discharge, Puzziferro says.

“We were able to create a truly solid connection between the inpatient case management team, which I have responsibility for, and ambulatory care providers,” she says. “Hospital case managers would hand off patients to a nurse in an ambulatory setting, where they were able to connect with patients and make sure they had the care they needed.”

During the acute management phase, hospital case managers would monitor patients until they were deemed stable. “If they had primary care providers in the community, we arranged for post-discharge to the primary care provider. If they didn’t, we would take care of them with post-discharge services, taking them on as a patient,” she explains.

The long-term effects of COVID-19 remain unknown. Case managers have learned to ask patients early about their primary care providers, Puzziferro says. The case management plan is to provide better continuity from the hospital to community, even during times of crisis.

“We need to make sure patients are receiving care consistently. It’s really important that we move to being more proactive than reactive in our care delivery system,” she explains.

A first step in safely transitioning COVID-19 patients home is to create a chart for the patient receiving telehealth visits and other case management services. This might include using a call center.

“The case manager asks if they have a primary care provider. If so, we document that and let the access center know,” Puzziferro says. “We see the patient in the acute stage of COVID-19 and then transition them back home.”

If a patient has not scheduled a telehealth visit with a primary care provider, the call center would contact the patient and ask if they would like to continue care through the health system.

“A nurse case manager contacts COVID-19 patients from the ED or inpatient setting and makes sure everything arrives as it should when patients return home,” Puzziferro says. “The case manager asks whether they have a pulse oximeter, what are their signs and symptoms, and gives basic instructions for if they need to go back to the ED.”

Through telehealth, physicians could see the patients daily as needed. Nurses also call the patients for follow-up, making sure they understand the discharge instructions and asking if they are feeling short of breath.

“If the patient is showing signs and symptoms of exacerbation, the nurse could facilitate a follow-up appointment with the provider so the patient would not have to go to the ED unless absolutely necessary,” Puzziferro says.

This type of care transition that provides telehealth, follow-up case management, nursing calls, and additional resources could work for other chronic illnesses besides COVID-19. But it could require bundled payment or shared savings plans to cover the cost.

“Our physician group learned they’re very good at doing telehealth and that it is a great option, so they’re doing that now as standard work,” she says. “Patients can access a telehealth visit at any time in lieu of ED or urgent care visits. It’s a great option for patients.”

Plan for Future Patient Surges

The COVID-19 crisis will not be the last time hospitals experience surges that overload beds and capacity. When this happens, they need plans in place to better predict which patients can be safely discharged and which need the beds.

Kilaru’s study helps clarify this issue. “The goal of the study was to show there are certain risk factors to predict early release,” he says.

The underlying concept is that some patients can be discharged early during a public health crisis. But it has to be a collaborative effort with case management, the ED, and physicians, Kilaru says.

“We need to identify those patients as quickly as possible,” he adds. “If there was some other public health emergency, we would want to develop these short-stay pathways quickly and adopt them to make sure the patients are safe, but we can also conserve greater hospital capacity.”

The pandemic created many challenges for health systems and case managers, but it also created opportunities for hospital case managers to think about care outside the walls of the hospital, Puzziferro notes.

“It was an unfortunate experience, but it was a great opportunity. We realized we have a very strong infrastructure in case management, and it’s something we want to grow and evolve,” she adds. “The length of stay and discharge planning have always been the focus, but ensuring patients are connected to the most cost-effective, high-quality care means we want to make sure patients are getting everything they need in the community.”


  1. Borgen I, Romney MC, Redwood N, et al. From hospital to home: An intensive transitional care management intervention for patients with COVID-19. Popul Health Manag 2021;24:27-34.
  2. Kilaru AS, Lee K, Grossman L, et al. Short-stay hospitalizations for patients with COVID-19: A retrospective cohort study. J Clin Med 2021;10:1966.