The Command Center:
There’s an inherent compact when, as physicians, we give a patient a connected medical device to use at home: their job is to collect data; our job is to interpret and act on those data. And since those data may reveal risk and become significant at any time, that small step of giving a patient a connected device creates huge responsibility.
Initially, clinicians may trade off responding to abnormal vital signs and patient concerns - or add it to the list of responsibilities of the on-call doctor. But as a virtual program scales, this approach is unsustainable. Furthermore, a reactive approach to virtual data—responding only when something goes wrong— misses the opportunity to spot trends and intervene before a patient genuinely deteriorates.
At scale, virtual care programs rely on a Clinical Command Center, which may resemble a pared-back version of NASA’s mission control, or be a virtual construct itself. What all Command Centers have in common is:
One or more skilled clinicians who know their patients and have their eyes on patient data 24/7/365
The resources to communicate with patients at any time
The ability to marshall in-home attention by picking up the phone
How has your organization solved this challenge when you empower patients with connected medical devices?
These Clinical Command Centers are already a staple in care-at-home programs that go beyond a handful of patients. And will surely become even more ubiquitous as more care is delivered in response to connected health data.
24/7 coverage:
When an organization first launches a virtual care program that ‘elevates’ the standard of care by providing monitoring and outreach services for patients that previously didn’t have them, it’s tempting to take an incrementalist’s approach to monitoring those patients. Patients with hypertension or congestive heart failure were stable on their own, the thinking goes, so when vital sign monitoring and telehealth is rolled out, monitoring vital signs intermittently is a step in the right direction.
This is true, however I think it misses the opportunity that virtual care creates: to proactively manage care, and to accelerate the response when something goes wrong.
Proactive care occurs when the vital sign monitoring allows an organization to trend data and interact - either via telehealth or using electronic data collection - in a way that consistently improves care over time. Medication titration, dietary monitoring, exercise support and encouragement - all of these interventions can be matched to data and become a drumbeat of wellness when applied proactively.
Accelerated response involves the 24/7/365 presence of a care team who can respond to the patient when something goes wrong - a hypertensive episode or an unexpected symptom - and intervene emergently if necessary (or reassure the patient and schedule interval follow-up if appropriate).
Sometimes daytime monitoring is a good way to start, but the best results happen when supervision - even with the lightest of touches - is available at all times.
CCCs: Build vs. Buy
Organizations looking to scale care at home will have to decide whether to build or buy their Clinical Command Center.
Building a Command Center is a big decision, mostly because it requires an institutional commitment to hire the clinicians to staff it and the administrative commitment to assure excellence. After vacations, sick time, and other leave are considered, seven FTEs are often required to staff a service 24/7/365.
The advantage of building it is that your team will be 100 percent dedicated to your patients, will get to know them, and can be your program’s eyes and hands at all times.
Another approach is to partner with an organization that will dedicate clinical resources to your patients for all or part of the day. Designed carefully, with regular touchpoints, daily clinical sign-out, and open communication, a partnered approach can be more cost-effective and equally high-quality.
When making the decision to build vs. buy this service, consider these factors:
Your goals for the scale of the program
The timeline for those goals
Your current staffing situation
Staffing availability - how easy is it to hire top-notch talent in your area?
Budget
Licensure:
When you are managing a virtual care program, and one of your patients needs help - they experience shortness of breath or their blood pressure cuff reads 185/95 - a nurse is typically their first recourse, often deployed through a triage service or Clinical Command Center. Because virtual care knows no geographic boundaries, the issue of licensure is non-trivial.
Healthcare providers typically must be licensed in the state where the patient lives, or at least in the state where the patient has been seen in an office (although certain exceptions remain in place due to the COVID-19 pandemic).
For organizations, such as Current Health, that provide services across state boundaries, licensure requires a strategy and careful execution. Fortunately, the Nurse Licensure Compact, allows nurses who live or work in one of 34 participating states to apply for a license that enables them to work in all states. That leaves just 16 individual license applications and a handful of territory applications - still a complex task, but significantly less daunting. (State compacts exist for physicians and advanced practice providers, but these tend to streamline - and not supersede - the individual state licensure processes.)
I’ve heard the argument made that triage isn’t the practice of nursing, and thus nurses don’t need to be licensed everywhere, but I’m not convinced. With purpose and planning, 50-state nurse licensure is a scalable proposition and serves as a major element of a high-quality nursing service for a virtual care organization.