Acknowledging the absence of evidence to guide clinical stability, we feel it is reasonable to include general guidance that incorporates clinical improvement, temperature, and oxygen requirement (e.g., ChristianaCare, Mount Sinai). Those wishing to provide more specific guidance to standardize care (acknowledging the absence of evidence to substantiate this approach) should look at algorithms from sites such as Johns Hopkins and University of Michigan.

At the very least, based on the data from existing studies, one should exercise caution in discharging patients who are still febrile, and consideration should be made to delaying discharge in patients with HTN (and maybe COPD, immunocompromise, and DM).

We recommend using the collective non-clinical criteria for discharge home from the participating sites (sites that have useful and fairly complete algorithms include Northwestern and OHSU). The same is true for logistical issues. Regarding discharge to destinations other than home, we agree with using strict criteria for discharge to congregate settings such as assisted living and group homes. Regarding discharge instructions, several sites have created detailed instructions that could serve as a model for others, including OHSU, New York–Presbyterian, and Northwestern.

While data substantiating their benefit is still forthcoming, we would recommend implementing some form of post-discharge monitoring program consistent with each site’s technology and other resources. At minimum, routine post-discharge phone calls or text-to-chat functionality should be adopted; sites with well-established patient portals with the ability to solicit patient-reported outcomes should consider using these tools as well.

Data regarding high-risk patients are currently insufficient to guide specific management protocols.

Spring 2021 Update of Current Challenges:

• Communicating changes to discharge plans
  • One challenge has been communicating information to clinicians as standards have changed; some sites use pathway-type systems such as Agile, integrated into the EHR
• Providing COVID-19 vaccines to inpatients
  • Programs are still in their infancy, but this is a fast-moving target. Determining eligibility and logistics remain the two major hurdles.
  • When present, generally provide vaccines to patients who were due for them (e.g., due for their second shot)
  • Concern that vaccine itself will cause symptoms, confusing the clinical picture
• Equity and efficacy in home monitoring programs
  • Concern that home monitoring programs, if limited to insured patients, could widen health care disparities
  • Capabilities of these programs could be overwhelmed by capacity during surges
  • Unclear if these programs have allowed for earlier discharge or just increased the comfort level of clinicians
  • Unclear if these programs have improved clinical outcomes
• Lack of data to guide discharge decisions
  • While clinicians’ comfort level has increased, we still do not know what discharge criteria actually correlate with risk of readmission or post-discharge death. Studies, including our own, are ongoing.

Key gaps:

The largest gap is in our understanding of the clinical criteria that optimize length of stay with post-discharge outcomes. This will require large-scale data collection and analysis, currently underway among several HOMERuN sites. A second gap is regarding the benefits of home monitoring, including how best to design and implement these programs. A third gap is in our understanding of whether and how to adjust isolation guidelines for patients with particular risk factors.

Future directions:

A multi-center study is currently underway to understand risk factors for poor post-discharge outcomes, including readmission and death within 30 days. Periodic surveys will continue to be administered to hospital medicine leaders in the HOMERuN consortium regarding discharge practices.