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Category: post-acute care

Virtual Nursing for Post-Acute and Transitional Care

Virtual nursing programs continue to make headway as health systems look for new solutions to the ongoing staffing crisis. Many of the virtual workflows sprouting up in inpatient departments have applicability in post-acute and transitional care, as well, where the impact of workforce shortages is also being felt.

Here is a look into how virtual nursing can support transitional care management, home care, population health, post-acute care, and hospital-at-home models.

Transitional Care Management

A patient’s discharge signals the start of a 30-day period where Medicare pays for services to help the patient transition from inpatient services to a community-based setting. Patients are typically moved to either a home, long-term care, or assisted living facility.

Many of the processes to prepare patients for care transitions can be fielded virtually. Providers are required to contact the patient within two business days of discharge, followed by a face-to-face visit within 14 calendar days of discharge for moderate-complexity patients and within 7 days for high-complexity patients. Supportive services provided by a virtual nurse can include:

Home Health

Traditionally, care has been delivered in person when patients transition to a home setting.

Hybrid “tele-home” care models are emerging where a home care nurse may see a patient in person on the first visit and then virtually after that unless hands-on nursing care is required (i.e., dressing changes, wound vac care, etc.) or in-person visits are deemed necessary.

If practitioner-ordered virtual visits are incorporated as part of the patient’s Plan of Care (POC), the virtual visit must address specific patient needs identified in the comprehensive assessment and incorporate interventions and measurable outcomes identified in the POC.

Many home health agencies provide patients with Bluetooth or wireless devices such as pulse oximeters, blood pressure cuffs, glucose monitors, and scales connected to a tablet. This allows virtual nurses to track patients more frequently, between formal visits, to catch trends and head off deterioration before resulting in an ED visit. A home care aide acting as a telepresenter for the virtual nurse can also be used for virtual nurse visits.

In a study of nearly 1,400 patients with 314 patients belonging to a hybrid model, there was a significant reduction in hospitalizations in both the 30- and 60-day time period for those in the hybrid model. This patient group also demonstrated better clinical outcomes across a variety of measures.

Population Health & Chronic Disease Management

Chronic diseases continue to plague approximately 46% of Americans, with almost 30 million people living with five or more chronic diseases. Leveraging virtual care can dramatically improve outcomes for patients living with difficult-to-manage chronic illnesses.

Employing virtual nursing to support chronic disease management increases patient adherence to their POC. It also provides a quick and easy way to connect with their care team more often for early intervention to prevent unnecessary trips to the ED or hospital.

Remote Patient Monitoring

Remote patient monitoring (RPM) helps achieve chronic disease management goals while reducing patient travel costs and infection risk. Conditions that are appropriate for RMP include hypertension, diabetes, cardiovascular heart disease, COPD, and asthma. RPM tools are sent to the patient’s home and may include scales, digital stethoscopes, blood pressure monitors, pulse oximeters, blood glucose meters, and questionnaires.

Use cases reimbursed by Medicare include remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate, set-up and patient education for equipment use, and treatment management services.

Knowing how to manage risk alerts is a key to success and guides the actions and interventions of the virtual nurse. In this way, patients are informed of self-care interventions, thus improving and reinforcing what they need to know the next time. In addition, alerts from remote monitoring devices help the virtual nurse monitor the maximum number of patients.

Skilled Nursing Facility & Long-Term Post-Acute Care

In 2018, Medicare spent nearly $5 billion on 377,000 potentially preventable readmissions occurring within 30 days of a skilled nursing facility (SNF) admission. According to the SNF Value-Based Purchasing (VBP) Program Hospital Readmission Measure, high readmission rates within 30 days of hospital discharge can lead to a 2% reduction of each post-acute care facility’s gross annual budget.

Telehealth can address over 50% of resident cases typically sent to the hospital, potentially avoiding readmission. To qualify for Medicare coverage, there must be a “qualifying event” that includes a three-night hospital stay that requires skilled nursing or rehabilitation for at least one hour daily, five days a week. Medicare SNF benefits last 100 days without a new qualifying event.

Post-acute workflows that can be performed virtually include:

Long-term care (LTC) facilities can utilize the same workflows, albeit at a lower frequency given lower patient acuity. LTC facilities provide long-term custodial care that is typically paid for byeither Medicaid, personal finances, or long-term care insurance.The use of a telepresenter is especially helpful within both populations.

Long-Term Acute Care Hospitals

Patients moving to a Long-Term Acute Care Hospital (LTACH) require direct skilled nursing care and have complex medical needs such as ventilator weaning and or complex wound care that can’t be met at a lower level of care. Patients are typically transferred from a hospital’s ICU to an LTACH.

LTACHs must maintain an average length of stay greater than 25 days. For optimal reimbursement, it’s imperative that the acute care hospital discharge patients to the LTACH as soon as feasibly appropriate. Every extra day spent in an ICU instead of the LTACH hinders LTACH reimbursement by minimizing LTACH length-of-stay (LOS), increasing costs and LOS for the acute care hospital.

Like other post-acute inpatient facilities, virtual workflows can support a multitude of use cases. Virtual observation can be more broadly used to support workflows beyond fall and safety monitoring by unlicensed personnel. Ventilator-dependent and other complex patients at high risk for deterioration or readmission can be observed continuously or rounded on more frequently by a virtual nurse.

These workflows can help to interrupt deterioration requiring hospital readmission, decrease adverse events, and keep the LTACH’s LOS intact by treating patients in place.

Hospital at Home

The Hospital at Home (HaH) care model has shown promise for reducing cost, improving outcomes, and enhancing the patient experience. HaH offers hospitals more flexibility to care for patients in the comfort of their own home.

Programs vary based on hospital capacity and patient population needs, but may include:

The combination of in-person and virtual nursing visits provides patients with 24/7 access to care. If necessary, the patient can visit the acute hospital for treatments that cannot be provided in the home (i.e., CT scan, MRI, etc.). The patient is discharged when stable.


When we think about keeping patients out of high-cost care settings and preventing unnecessary use of the ED and inpatient settings, virtual nurses are key players. They can advise multiple patients during their shift, provide timely care, perform competent assessments, document results in the EMR, and guide patients to the most appropriate level of care.

Nurse triage and advanced practice nurses do what they can to alleviate the pressure on providers who are in short supply and overtaxed. By providing sound care advice to patients on-demand, any time of the day or night, virtual nurses enable physicians to direct their expertise to patients who are high-risk, have chronic diseases, or are in the most fragile condition.

To learn more about virtual nursing’s role in post-acute care support and how to best support virtual workflows, access our on-demand webinar, A Guide to Virtual Nursing in Post-Acute Settings.