Home and Outpatient Management

Please note that as of April 2023, this website is no longer actively being updated.Copy Link!

Household Assessment and PreparationCopy Link!

Updated Date: December 20, 2020
Literature Review (Ambulatory Management): Gallery View, Grid View

Whether or not a patient is clinically well enough to be managed at home is addressed in:

1. Acuity Triage
2. Disease Severity and Disposition

Providers should then evaluate if the patient can safely isolate at home for the full Duration of Isolation:

1. Home Assessment and Education: Review the Requirements for Home Isolation with the patient. If possible, a healthcare or community health worker should have the patient talk them through the procedures in the patient’s particular environment/home and do a verbal walk through (or video call) of the place where they are isolating in order to ensure a safe environment.

• For additional information on masks, social distancing, pets, and more see Transmission

2. Communication: The patient and family should be provided with clear instructions of what to do and who to call if the condition worsens (see When to Seek Care).
3. Caretakers, proxies, and goals of care: For all patients with COVID, it’s important to identify a single person who can be the primary caretaker at home. You should engage the patient in a goals of care conversation and have them designate someone to make decisions for them if they are unable to make decisions for themself (regardless of age, comorbidity, or severity). See Discussing Goals of Care. Caretakers should be trained in methods for masking, distancing, hand hygiene, and cleaning surfaces (see Transmission Prevention).
4. Resources: Assess for and provide home care kits including food support, hygiene and cleaning supplies such as chlorine and soap and individual patient items such as plate, utensil, blanket and mask. Social/economic support, including food supplementation is critical and should be delivered in a way that is in line with infection prevention.
5. Psychological support: See Psychosocial Support for information on mental health and psychological support.
6. Close contacts: All symptomatic contacts should be tested and Quarantined. Depending on local epidemiology and practices, some places recommend that asymptomatic contacts also be tested (see COVID Exposures) and engage a contact tracing team where relevant.

Followup and MonitoringCopy Link!

Updated Date: December 2022

Follow-Up Visit ScheduleCopy Link!

Patients in outpatient isolation or post-hospitalization require followup visits based on risk level. These visits can be performed virtually if possible (by phone, or by video). In some places, community health workers may conduct these visits physically at the home if unable to connect via phone or video.

• Individuals adversely affected by social determinants of health are less likely to be able to engage care via telemedicine and may become lost to follow-up with decreased in-person accessibility. It is critical to account for inequitable access to these resources when rolling out telehealth and virtual care models (Wood et al).

If community health workers or clinicians conduct home visits, they should have:

• Adequate PPE. If PPE is not available, conduct the visit outside the home (rather than entering) maintaining a distance of at least 2 meters.
• Refer patients to a different clinician or a higher level of care if needed.

Tool: PIH COVID-19 Patient Intake and Symptoms Screening Data Collection Forms
Tool: BWH Telephone and Video Visit Tips
Literature Review (Virtual Care): Gallery View, Grid View

Suggested Home or Phone Visit FrequencyCopy Link!

Community Health Workers:

• For patients at low risk of complications: Visit every 2-3 days in person (or via phone or video if available).
• For patients at high risk of complications: Visit every 1-2 days in person (or via phone or video if available). If the patient has any danger signs contact the health facility via phone or refer/accompany to the health facility.
• After hospital discharge: Visit within 3 days of discharge (or via phone or video if available) unless the patient will return to the facility for follow up.

Clinicians:

• For patients at low risk of complications: Day 5 of symptoms via phone or video if available (in-person if not)
• For patients at high risk of complications: age>60, COPD, hypertension, diabetes, cardiovascular disease, chronic kidney disease, liver disease, obesity, immune deficiency or immunosuppression Days 4, 7, and 10 of symptoms by phone or video, more frequently or in-person if needed (see Acuity Triage to determine if your patient should be seen in person).
• After hospital discharge follow-up: 2 days

Longer-Term Followup:

• For people with severe COVID or with symptoms that last over 4 weeks, please see Post-COVID care, specifically Outpatient Workup.

When to Seek CareCopy Link!

Patients should call a healthcare provider or report to a facility if any of the following danger signs develop:

Pulse OximetryCopy Link!

Literature Review: Gallery View, Grid View

Why use home oximetry: If patients or community health workers have access to pulse oximetry, this can be a helpful adjunct to symptom monitoring, since hypoxemia out of proportion to respiratory effort has been seen in patients with COVID-19. Home pulse oximetry can also be used in conjunction with Awake Proning.

• One prospective cohort study gave pulse oximeters to 77 ED or testing site patients suspected of having COVID-19 (42% with no comorbidities) and told them to measure their O2 sat three times daily and return to the ER if it dropped to <92%. This occurred for 19 patients, and of the 17 who returned to the ER, 8 returned solely because of the oxygen saturation, and 16/17 required admission. Resting home SpO2 < 92% was significantly associated with hospitalization (RR = 7.0, 95% CI = 3.4 to 14.5), ICU admission (RR = 9.8, 95% CI = 2.2 to 44.6), ARDS (RR = 8.2, 95% CI = 1.7 to 38.7), and septic shock (RR = 6.6, 95% CI = 1.3 to 32.9) (Shah et al).
• Another randomized trial assessed a text message–based remote-monitoring program (which included twice-daily automated text messages inquiring about dyspnea and offering rapid callbacks from nurses when appropriate) supplemented with monitoring of oxygen saturation using a home pulse oximeter. Patients were randomized to the standard monitoring program in addition to home pulse oximetry versus the standard program alone. Patients in the pulse oximetry group were provided a pulse oximeter and monitored for subjective symptoms or a low or declining oxygen saturation. Among patients with test-confirmed Covid-19, there was no significant between-group difference in the number of days they were alive and out of the hospital at 30 days (mean, 29.4 days in the pulse oximetry group and 29.5 days in the standard program group; P=0.58; difference, −0.1 days; 95% confidence interval [CI], −0.4 to 0.2) (Lee et al)

How to use pulse oximeters:

1. A caution on reliability: Pulse oximeters are less reliable in people with darker skin tones, and may read artificially high. One study showed that pulse oximetry failed to correctly identify 11.7% of black patients with Sp02 of <88% on ABG, relative to only 3.6% of white patients (Sjoding et al). They also may not work properly in patients with blood flow abnormalities in their hands such as peripheral vascular disease or Raynaud’s syndrome (Luks et al).

1. SpO2 trending may be more reliable than a single value (i.e. baseline 100%, now at 94%) and using dynamic measures like ambulatory saturations can help identify patients who are at risk for decompensation.

2. How to use oximeters: Have patient’s check their saturations at home at least daily and as-needed for clinical worsening. They should take one measure while sitting and one measure while ambulating (or marching in place if they are quarantined in a small area). Instruct patients to seek care if Sp02≤94% or ≤ 92% with exertion.

1. Use the pulse oximeter on a finger without nail polish or nail abnormalities. Hands should ideally be warm and relaxed.
2. Wait at least 20 seconds for sampling time as the Sp02 displayed is generally the average of the last 10-15 seconds
3. If the pulse oximeter has a visible waveform (plethysmograph), the shape should show a regular rise and fall (corresponding with the pulse) when the machine is reading correctly. If the machine is not giving a reliable reading (not registering, number not steady, number very low), try it on a different finger.

Tool: How to Use Home Pulse Oximetry

Management of Mild DiseaseCopy Link!

Updated Date: February 25, 2022
Literature Review (Ambulatory Management): Gallery View, Grid View

Medical TreatmentsCopy Link!

Treatment for COVID-19 for patients with mild disease is largely supportive. A small number of places may have antibody therapies available for outpatients.

Please see Overview of Treatment by Severity of Disease, and Treatments for more details.

1. Patients without hypoxemia or risk factors

1. Symptomatic Treatments:

• Antipyretics (NSAIDs are acceptable)
• Cough Suppressants and Expectorants

2. Patients without hypoxemia but risk factors (Age >60, cardiovascular disease, hypertension, diabetes, COPD, cancer, immunosuppressive medications, detectable HIV viral load or CD4 <200, TB, pregnancy, malnutrition)

1. Symptomatic treatments
2. COVID Treatments:

• Antibody Therapies (monoclonal antibodies, convalescent plasma)
• Nirmatrelvir/ritonavir if indicated and available
• Remdesivir if indicated and available
• Molnupiravir if indicated and available when the above three options are unavailable
• Thrombosis prevention is generally not used for outpatients
  

Management of Existing Medications. Medications should not be discontinued without discussing with the prescriber.

• ACE inhibitors (RAAS inhibitors): no need to discontinue
• Immunosuppressants: case-by-case
• Nonsteroidal anti-inflammatory Drugs no need to discontinue in most patients
• Inhalers: no need to discontinue, avoid nebulizers if possible due to increased risk of transmission

Medications we DO NOT Recommend:

• Hydroxychloroquine
• Azithromycin and other antibiotics unless being used to treat bacterial infection

Vaccinations:

• Influenza vaccination: Recommended for all patients for whom there is not a contraindication.
• Pneumonia vaccinations: these should be given to patients who meet criteria.
• Please note: As SARS-CoV2 vaccines become available, present guidelines do not recommend administering them to patients with acute COVID-19 (see CDC guidance).

Non-Medical TreatmentsCopy Link!

Self-proning

• The Awake Prone position improves dyspnea and hypoxemia in some patients with severe COVID-19 illness. Proning could be used while awaiting ambulance transfer to a health facility or as part of terminal palliation.

Psychological and social support

• Psychosocial Support should be part of the care of all COVID-19 patients.

Referral for AdmissionCopy Link!

Patients should be referred for in-person evaluation if they develop any of the danger signs above, rapidly escalating symptoms, Sp02 below 94%, or moderate to severe dyspnea.

Where to send your patient? See Acuity Triage

Inpatient treatments to be aware of: Ambulatory providers should be aware of inpatient therapies so they can refer/admit patients appropriately.

• Corticosteroids
• Remdesivir

Home Oxygen CareCopy Link!

Updated Date: January 7, 2021

Patients who require oxygen for COVID pneumonia should be cared for in a health-care facility where possible, however capacity constraints and the long course of recovery make this impossible in some circumstances. The decision to offer home oxygen therapy is complex, and should be made by a certified provider familiar with the patient’s clinical condition, resources for care at home, proximity to health care facilities, and the availability of home oxygen delivery.

This section provides a framework for providers to use when considering this treatment plan as an option for certain patients when facility-based oxygen delivery is not available. The framework below is based on published literature and an ongoing home oxygen program developed for COVID19 care in the rural United States by providers from Gallup Indian Medical Center (GIMC).

Patient SelectionCopy Link!

Patient Medical Selection Criteria:

1. COVID-19 diagnosis established or strongly suspected with low suspicion for alternate diagnosis
2. Hypoxia at rest or with ambulation (O2 sat < 90% on room air)
3. Ideally, an oxygen requirement of < 2LPM NC is needed to achieve O2 saturation (SpO2) of > 92% at rest AND > 90% with exertion
4. Stable or improving clinical trajectory. Discharging patients with hypoxia without an observation period of 48 hours is high risk, and this is better suited to stable inpatients ready for discharge.

1. The patient’s vital signs have normalized after addition of supplemental O2 and other clinical interventions (e.g. antipyretics and fluids)
2. 4C Mortality Score < 9

5. Lower risk for decompensation:

1. In outpatients: mild severity risk features/comorbidities (See: Table 1 Sardesai et al)
2. In inpatients: mild or moderate risk features AND stability over 48 hours of observation (See: Table 1 Sardesai et al)

1. Patients with the following risk factors may be higher risk and not ideal candidates (Age>65, BMI>40, chronic kidney disease, liver disease, immunocompromised, diabetes, hypertension, obstructive lung disease)

Patient home-care ability selection criteria:

1. Ability to demonstrate understanding of the risks and benefits of this discharge plan. Confusion and pre-existing cognitive impairment are absolute contraindications to discharge with home oxygen. See Capacity Assessment.
2. Ability to use and troubleshoot pulse oximeter
3. Ability to use and troubleshoot supplemental oxygen equipment
4. Ability to engage in telephone (or community health worker) contact follow up (i.e. reliable phone service, language services, hearing or speech impairment does not necessarily preclude communication).
5. Ability to Isolate Safely at Home.

1. Household members do not have high risk comorbidities and can practice safe personal protective measures

6. Reliable power source, if discharging with home concentrator
7. Reliable transport or plan to provide transportation resources to medical care if the patient needs to be re-evaluated (including distance, weather, or road conditions between home and hospital)

Institutional criteria:

1. No inpatient bed is available
2. A provider determines the home oxygen discharge plan is safe
3. The patient has appropriate supply of oxygen (see calculator Tool and discussion below)

Tool: Determination of Eligibility for Short-Term Home O2
Resource: Home Care for Patients with Suspected or Confirmed COVID-19 by WHO
Resource: COVID19 Home Based Quality Care by HP+

Oxygen Discharge PlanCopy Link!

Patients must receive oxygen and supporting equipment as well as the instructions for use prior to discharge. They must also be educated in-person on how to use them, and counseled on return precautions using the Teach-Back technique. It is critical to confirm a working phone number for the patient.

Equipment:

1. Oxygen supply (Cylinders or oxygen concentrators)

1. Calculate total oxygen need, as not all sources will be able to provide continuous oxygen. Oxygen cylinders may run out too quickly to be practical for home use in patients with high needs
2. Cylinders:

1. If using oxygen cylinders, an oxygen conserving (i.e. pulse dose) device may be helpful
2. Tanks must be secured to avoid potential injury, especially with small children in the household

3. Oxygen concentrators: Most concentrators have 5 LPM max output, though some can do 10 LPM and very few can do more than 10 LPM. Patients requiring more than 2 LPM should ideally be cared for in a facility, and risks and benefits of home treatment require careful decision-making.

2. Pulse Oximeter (confirmed working) and instructions on use
3. Thermometer
4. Surgical masks to wear over nasal cannula to protect contacts at home
5. Working phone to conference with providers

Medications:

1. Patients receiving oxygen should get Corticosteroid Therapy unless contraindicated.
2. Patients should be discharged with other symptomatic treatments needed. See Medical Treatments for mild disease.

Instructions and education:

1. Self Proning Handout
2. Oxygen Self Titration Guidance

1. Oxygen saturation readings consistently less than 92% on flow rates prescribed at initiation of home oxygen therapy (regardless of symptoms).

3. Return Precautions:

1. Return criteria for worsening symptoms and Danger Signs.
2. Handout with instructions specific to the healthcare setting and available resources

4. Oxygen management instructions

1. Oxygen Supplier Contact
2. Phone Number for Help Line
3. Action plan for equipment failure, low supplies, or power failure

5. Fire safety plan at home (Table 3 from Sardesai et al)
6. Plan for food security

Resource: How to Use an Oxygen Concentrator

Tool: Oxygen Supply Calculator and Cylinder Duration Calculator

Tool: Tools for Home Oxygen Therapy

Follow-UpCopy Link!

Below is a sample protocol modified by one developed at GIMC.

For inpatients observed for >48 hours and then discharged on oxygen:

1. Should be called daily for at least 2 days after discharge
2. If remaining on 2L or less x 2 days may consider discharge from phone follow-up program, otherwise the same criteria above apply. For those on >2L, follow at least 10 days from oxygen initiation.

For patients sent home on oxygen with < 48 hours of observation (not preferred):

1. Should be called daily for at least 6 days unless weaned off oxygen sooner
2. After day 6, patients on 2L or less at rest x 2 days with improving trajectory may be discharged from phone follow-up
3. After day 10, patients on stable oxygen x 2 days (even if >2L) and an improving trajectory may be considered for discharge
4. High risk patients may remain in the program longer at provider discretion

Triggers to Consider Sending to ER

1. Please see Home Acuity Triage. In addition to the Danger Signs listed there:

1. O2 sat less than 90% at rest on >3L (depending on local practice)
2. Increase in oxygen requirement of more than 2L in <24hr
3. Inability to walk 5 steps without becoming severely short of breath
4. Resting heart rate over 120 or resting respiratory rate >28
5. Inability to toilet, eat, or navigate the home using bedside devices

Tool: Provider Note Template for Telephone Follow-up with Home Oxygen Patients

Test to TreatCopy Link!

Updated: December 2022

While vaccines remain the most effective way to prevent COVID infection, there are treatments available for those who have gotten infected. A test-to-treat program allows eligible patients to be tested, treated, and prescribed treatment for COVID-19 in one setting in a single visit. In this setting, a patient who tests positive for COVID-19 meets with a healthcare professional who makes a determination if the patient is eligible for oral therapy and, if eligible, provides a prescription (and, in most cases, the actual medication) to the patient. This not only allows for greater access and convenience to COVID treatment but allows for rapid initiation of treatment.

Based on efficacy data, nirmatrelvir/ritonavir (NMV/r) is the preferred agent, followed by molnupiravir.

Eligibility:Copy Link!

In general, patients who test positive and have been symptomatic for < 5 days, are at risk for complications from COVID infection but do not require a higher level of medical care are eligible for a Test to Treat program. Standard, evidence based screening and triage practices should still be practiced with the ability to stabilize and transfer to a higher-level of care if needed. Individuals with mild and moderate illness who do not require hospitalization but also are not eligible for oral antivirals (see criteria below) should be managed supportively and according to evidence-based guidelines.

Assessment:Copy Link!

• Step 1:

• Has the patient tested positive for COVID-19 (see Types of COVID tests), including a home test?
• Is the patient free of signs of severe COVID-19 illness?

• Worsening dyspnea or SpO2 < 94% on room air
• New oxygen requirement
• Respiratory distress
• Altered mental status
• Need for additional laboratory or radiologic testing

• Is the patient less than 5 days from onset of symptoms?
• Does the patient have high-risk factors?

• Age ≥ 50
• BMI ≥ 30 kg/m2
• Pregnancy
• Diabetes
• Sickle cell disease
• Neurodevelopmental disorders
• Chronic kidney disease, stage 3b or worse
• Cardiovascular disease, hypertension, or lung disease
• Immunocompromising condition (e.g. HIV)
• Tuberculosis
• Clinician-determined medical condition, or demographic factor presumed to place the patient at high risk for disease progression

• Step 2 (if yes to all above in Step 1):
• Step 2A: Assess patient’s eligibility for nirmatrelvir/ritonavir (NMV/r)--If the answers are YES to each of the below, consider NMV/r for treatment of COVID-19 infection

• AGE: Is the patient ≥18, OR ≥12yrs AND ≥40kg? (88lbs)?
• DRUG INTERACTIONS: Confirm the patient is NOT on any drugs that interact with NMV/r and cannot be substituted?

• Statins – hold 8 days, pitavastatin and pravastatin do not need to be held
• DOACs—dabigatran and edoxaban likely safe, apixaban seek expert advice, avoid rivaroxaban
• Alpha-1 blockers – hold tamsulosin and others for 8 days
• Warfarin —monitor, INR may fall out of therapeutic range
• Inhaled beta agonists — hold salmeterol for 8 days, formoterol/albuterol fine
• Calcineurin inhibitors — Avoid if possible, careful monitoring and dose adjustment
• Calcium channel blockers — monitor and consider dose decrease
• Antipsychotics — avoid if possible, dose reduction needed
• Opiates —consider dose decrease by 50-75% for 8 days, except methadone
• Oral contraceptives— Barrier method recommended until next cycle
• SSRIs — monitor, toxicity unlikely in short course
• Triptans — hold eletriptan and zolmitriptan, sumatriptan fine
• Benzodiazepines— monitor, consider dose reduction, don’t use triazolam
• Chemotherapy and small molecule inhibitors— review with oncology
• Oral corticosteroids — monitor, consider 50-75% dose reduction
• Sildenafil/tadalafil/vardenafil — hold for 8 days
• Rifampin — concomitant use contraindicated
• Established ritonavir therapy — do not change established ritonavir dose

• RENAL or HEPATIC IMPAIRMENT: Is the patient free of severe renal impairment (GFR <30) or hepatic impairment?
• AVAILABILITY: Is NMV/r available for treatment

• Step 2B: ineligible for MNV/r: Assess patient’s eligibility for molnupiravir. If the answers are YES to each of the below, consider molnupiravir.

• Rule out that the patient is pregnant, trying to get pregnant, or breastfeeding?
• Is the patient > 18 years old?

• Step 2C: If ineligible for MNV/r or molnupiravir, consider IV antivirals if available and no contraindications.

Individuals who test positive for COVID-19 but are NOT eligible for immediate oral treatment are those with signs of severe illness including the following:

• Worsening dyspnea or SpO2 < 94% on room air
• New oxygen requirement
• Respiratory distress
• Altered mental status
• Need for additional laboratory or radiologic testing

Dosing/Drug MonitoringCopy Link!

For pharmacology, dosing, and toxicity, please refer to: Nirmatrelvir/ritonavir and Molnupiravir

Treatment PrioritizationCopy Link!

In many places, the number of patients that are eligible for test-to-treat outweighs the supply of medications. In such situations, the following is a guide to stratify patients based on their risk of progression to severe disease.

Courtesy of USAID COVID-19 Test-To-Treat algorithm

Community Health WorkersCopy Link!

Updated Date: December 20, 2020

While Community Health Workers (CHWs) are in a unique position to help with COVID response, they are also at risk of exposure. Programs that deploy CHWs should consider how COVID will impact their work and assess risk tolerance. This is particularly applicable for CHWs who have frequent patient contact (e.g. routine home visits) and may not have access to PPE. Workflows should be evaluated, and in some instances changed, in order to adequately protect CHWs. This may include measures such as remaining outside and at a distance greater than 2 meters during routine home visits and avoiding activities requiring close physical proximity and/or contact.

Below we outline two strategies for CHW engagement in the fight against COVID. These strategies should be adapted to the local context as well as CHWs’ training, availability, funding, compensation, and access to PPE.

Strategy 1: AdvisingCopy Link!

Most CHWs should be capable of implementing this strategy which does not require them to enter homes, meet in groups, or touch patients.

Strategy 2: AccompanimentCopy Link!

This requires sufficient funding, staffing, PPE, data systems, and integration with local health systems. Teams should map catchment areas, divide areas, and relay information systematically. Known cases should be communicated with the coordinating authorities.