Recognizing the rapid spread of COVID-19 and the projected strain on their health system, leaders at association member Cambridge Health Alliance (CHA) developed a community management framework for a primary care–focused, telemedicine-based approach to care.
CHA leaders drew from a respiratory clinic model popularized in China, in which all symptomatic patients were evaluated at a fever clinic and quarantined at a hospital, regardless of symptom severity. While successful, this model is difficult to replicate in the United States, where limited inpatient resources, personal protective equipment shortages, and inadequate staffing pose challenges.
CHA created a triage center staffed by 14 nurses who take calls for the entire health system, which comprises 130,000 patients and 12 primary care clinics. Since its March 18 launch, the clinic has triaged about 13,000 calls, averaging 550 a day.
Primary care teams manage patients with low risk of complications by phone or televisit. The community management arm follows patients older than 65 and patients with conditions believed to increase their risk of complications, including comorbidities, heart failure, and immunosuppression.
“The really critical link right now is how it’s embedded in a larger continuum of follow-up,” says Janice John, MHS, MHCDS, medical director of CHA’s COVID-19 respiratory clinic.
Community management teams call patients at points in the disease process associated with significant changes in clinical course, including four, seven, and 10 days after symptom onset. Patients at highest risk receive calls daily, sometimes multiple times a day. This triage process reserves the respiratory clinic for severely ill patients who have developed dyspnea, or shortness of breath, and enabled CHA to manage most patients without hospitalization.
Of the first 1,100 respiratory clinic patients seen, 92 percent were managed in the outpatient setting, and only eight percent were seen in the emergency department or admitted to the hospital. In a review of the first 20 patients who met the criteria for inpatient admission at other area hospitals, CHA leaders estimated the community management system saved 39 hospital days. Adapting China’s successful clinic model to leverage CHA’s primary care structure and telehealth program helped reduce strain on the system and prevent further spread of the virus.
Amid COVID-19 test shortages and delayed results, CHA leaders shaped their response strategy on historic observations, noting that a test alone can’t guide management.
“I think one thing that is hard for patients is that a test is not a treatment, it’s not a cure, it’s not really much of anything, to be honest, if it’s not accompanied by appropriate reactions to the results,” says Jessamyn Blau, MD, an internal medicine physician and medical director of COVID-19 outpatient management at CHA.
For the community CHA serves, the appropriate reactions must consider the social determinants of health that increase the risk of severe disease due to COVID-19. Many CHA patients have unstable housing or live in multigenerational households, increasing the risk of virus transmission. Poverty, racism, and food insecurity also complicate that risk.
“The cracks that we always knew were there in society are being magnified right now,” John says. “With communities that have deep trauma connected to the medical system and deep trauma connected to life … I think we risk people avoiding care [who] need care. We have to be really careful to be trust builders.”
To build trust and target social risk factors during the COVID-19 pandemic, CHA leaders have leveraged existing community partnerships and worked to build new ones. Health care providers screen patients for social risk factors and link them to relevant resources. This week, the health system will begin partnering with community organizations to deliver food to patients in need. While these partnerships take time to forge, John urges her team to keep an open mind.
“We all have become learners, and we all kind of have to have had a beginner’s mind, and with that comes this great vulnerability, and I think vulnerability is where creative partnerships really thrive.”
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