Upstate University Hospital has created a COVID Transitions Clinic program to provide additional, ongoing support services for COVID-19 positive patients who are now recovering at home.

The COVID Transitions Clinic is providing an array of resources to COVID-19 positive patients who were treated and released from Upstate, an Upstate emergency department or tested positive at the Upstate testing site. Patients are strongly encouraged to accept the service as a way to facilitate recovery from the virus.  

“A case manager from our Intensive Transitions Team reaches out to the patient and introduces the program to let them know that it’s important we stay in touch once they’re discharged,” said Director of Transitional Care Diane Nanno, MS, CNS, RN, NE-BC, CCCTM. “We want to make sure they are doing well, their symptoms are controlled, they know how to quarantine and how they can protect the rest of their family. Social work then steps in if needed to assist with any issues that would be addressed by the expertise of a social worker, including food or housing insecurity or any other social determinants that may affect a positive outcome.”

Transitions Clinic staff will connect the patient to a primary care doctor and schedule daily telehealth conferences with an Upstate physician to assess his or her symptoms and also connect with the patient’s primary care physician.

Amit Dhamoon, MD, PhD, is one of the Upstate physicians working with COVID-19 patients daily through telehealth visits. He said being able to speak on camera to the person daily has been helpful in tracking the progression of the disease, which varies greatly from patient to patient.

“A big part of this is to be able to assess a patient through telehealth to see how they look,” he said. “Do they appear ill? Is their breathing labored? Do they look uncomfortable? You can see the clinical progression of how patients are affected with COVID-19 by following them daily.”

The COVID Transitions Clinic has a 24-hour hotline that patients may call with questions or if their symptoms get worse. The hotline and telehealth visits also allow Upstate doctors to fast-track a patient’s readmission to the hospital if necessary. That process creates a streamlined pathway for the patient and can relieve the emergency departments, Nanno and Dhamoon said.

Nanno and her team also created COVID Comfort kits, which she described as a “virtual hug” to let patients know Upstate is thinking of their needs as they recover at home. The kits include a cloth mask, teaching materials, a thermometer, a homemade greeting card and anything else the team determines might be important for the patient’s smooth and safe transition to home.

“What we really want to convey is that we’re there for people,” Nanno said. “We understand this is scary. We understand that they are sick and they are worried about their own health and their family’s health.”

Dhamoon said he recognized and appreciated that his telehealth conversations with patients were about more than just clinical care.

“A big part of this process is to see how our patients and families are coping with this disease,” Dhamoon said.

Many of the patients the clinic is reaching out to do not have a primary care physician and do not speak English, Nanno said. Clinic staff are using Upstate’s Interpreter Services to ensure those patients are receiving the care they need, she said. If the patient does have a primary care physician, the clinic’s interactions with the patient are also relayed to his or her regular doctor, she said. 

As of Thursday, the clinic was working with 14 patients with several more expected to be discharged that day. The only two types of patients not working with the clinic are Upstate employees who are receiving services from Employee Health and nursing home residents who are returning to a skilled nursing facility upon discharge.

Nanno recently acquired a small number of bracelet oximeters, which will be offered to select COVID-19 positive patients who are at a higher risk for disease progression, she said. The oximeter looks a lot like a Fitbit step tracker and constantly measures the patient’s oxygen levels, pulse and skin temperature. That data feeds to a digital application that can be seen and monitored by the patient and a doctor at Upstate, Nanno said. The team is also using pulse oximeters that do not require a smart phone.

Upstate physicians will follow COVID-19 positive patients through the clinic until their symptoms are gone. 

Dhamoon said that as a primary care physician, working with this clinic has affirmed his belief in treating the whole person and the ways in which Upstate is working to help patients long after they leave the hospital.

“In primary care, connecting with patients and educating them about their disease is fundamental to promotion of health,” Dhamoon said. “This has just reinforced that we can do so much outside of the hospital environment. This team has reminded me that in medicine we are trying to prevent disease but also teach self-management of disease in the outpatient setting. It’s really a positive and empowering experience to be a part of.”

Caption: Director of Transitional Care Diane Nanno, MS, CNS, RN, NE-BC, CCCTM, poses with contents of a comfort kit that will be given to COVID-19 positive patients as they are discharged from Upstate.