Telehealth innovation and transitions and the effect of COVID-19 on primary care practices
On March 11, 2020, the Atlanta Hawks lost in overtime to the visiting New York Knicks. While disappointed, the 10,000+ individuals in the State Farm Arena crowd had won a free chicken sandwich (a Knicks player had missed two 4th quarter foul/“fowl” shots). Yet as the arena began clearing, Hawks officials quickly suspended handing out food coupons due to “health concerns.” That same day, the World Health Organization officially declared the coronavirus a pandemic.
If early medical reports of COVID-19 cases in Washington state, New York City or even South Georgia had not worried everyone, the end of college and professional basketball got the attention of many.
By the first of April 2020, the Georgia Department of Public Health reported a cumulative total of 4,805 Georgia COVID-19 cases and 135 deaths. Mortality was higher in older adults, African-Americans (and later Hispanic communities), and those with chronic conditions, worsening health disparities. These dramatic times affected Metro Atlanta’s primary care providers (PCPs), primary care (PC) practices and patients.
COVID-19 outbreaks came with hospital and clinic shortages of PPE, a lack of testing protocols and gaping holes in needed scientific knowledge about this pandemic. In Emory PC, we implemented daily huddles for our providers and staff members to disseminate available scientific knowledge and address concerns. This increased our frequency of PCP connection from a one-night-a-month contact to a daily weekday morning contact. It seems hard to remember, but given the early initial lack of SARS-CoV-2 diagnostic testing, many patients were termed “persons under investigation (PUIs)” with “influenza-like illness (ILI).” Most health systems concentrated their personal protective equipment (PPE) and limited tests to hospitals and emergency rooms.
By April 2, 2020, Governor Kemp issued a month-long shelter-in-place order for all in the state of Georgia. Many PC practices dramatically slowed or even temporarily shuttered. Health systems consolidated locations. U.S. and Georgia regulations for phone and video-telemedicine visits quickly relaxed. Neighboring states occasionally and temporarily permitted licensure exceptions to allow Georgia-licensed PC providers to their patients temporarily sheltering in neighboring states.
Early in the pandemic, ICU unit beds and hospital floor beds were scarce. Medical personnel were also scarce, resulting in PCPs volunteering for duty in ICU, hospital, emergency room and COVID-19 testing clinic settings. Staff at practices were flexed to other locations and in some cases were furloughed.
In addition to these pressures on the PC practices, hospital leaders were reaching out to primary care leadership asking for innovation and closer connection between PC clinics and hospital and ERs for handoffs of discharged patients back to the ambulatory care setting. Many had been keeping the patients in the hospital longer since there was concern about illness trajectory and worry about potential lapses in care.
This set the stage for two additional major initiatives: the reopening of PC practices for select patients to return to the in-person practice locations and the innovation initiatives to connect the ambulatory setting to the ER, the hospital and the COVID-19 call line.
By mid-March, the Emory Healthcare Telehealth launched training for immediate implementation of video telemedicine PCP visits that would cover specifics regarding an overview of telehealth and telemedicine, Georgia regulations on telemedicine and best practices to conduct a telemedicine visit. Emory PC launched workflows to deepen coordination activities with Emory hospital medicine. By late March 2020, Emory PC and nursing opened the Virtual Online Management Clinic (VOMC) for COVID-19 patients. By early April 2020, Emory PC and Infectious Diseases opened the Acute Respiratory Clinic.
PC telemedicine visits allowed patients to remain sheltered in place and receive routine and episodic care for chronic and acute care conditions. Emory PCPs who volunteered to lead this effort within their section provided online training, tailored coaching and tips on daily huddle calls.
The PC VOMC for COVID-19 enabled patients potentially still infectious to be seen via video-telemedicine. As hospitals censuses began to go up and personnel became a finite commodity, we needed to ensure that the lengths of stay were appropriate and that the patients were cared for when they were released from the hospital.
The COVID-19 pandemic intensified pressure on making sure these transitions happened without gaps. Hospital medicine care teams needed to be expanded, patients needed to be released sooner, and some patients would be handled as outpatients. As time progressed and we learned more about COVID-19, it was clear that many patients would need care for weeks to months. Much of the care, therefore, would have to be handled in the outpatient setting since patients only needed to stay in the hospital for severe symptoms but could be managed in the outpatient setting with very careful, high-touch follow up.
However, how could hospital med be assured that the patients would get this follow-up? If they did not, they would likely land back in the already crowded hospital or emergency room with symptoms that are likely worse. For PC patients discharged home with COVID-19 (or simply ILI), there were few data on readmission risk factors nor at-home care protocols. Most knew early in the COVID-19 pandemic that patients could decline precipitously.
PCPs did not want to mix patients with influenza-like illness with hypertension checks. Yet emergency rooms and urgent care centers were still extremely crowded. Emory PC partnered with the infectious diseases program to come up with the Acute Respiratory Clinic (ARC), where potentially infectious individuals with complex medical conditions could be seen in a high-PPE environment for acute needs, diagnostic testing and inter-specialty consultation.
All these quick disruptions caused multiple strains. PCPs have always been essential in the care of patients across the continuum of their lives. With healthcare changes and the creation of hospitalists, many PCPs no longer went to the hospital to follow their practice patients. This made care hand-offs essential in order to avoid gaps in care.
However, the COVID-positive patients discharged have additional complex, puzzling needs than most PCPs could provide in the face of PC patients returning to pared-down practices. These COVID-19 patients had a novel disease. They needed education about their disease. Families, loved ones and caregivers needed to be reassured. Many needed oxygen supplementation, and some needed new medications that they had no experience with, physical rehabilitation, wound care and home health coordination.
To meet the needs of the patient, a multidisciplinary approach would be needed. As discharge protocols changed, hospitalists and ambulatory providers needed a central team in order to communicate the post-discharge planning needs. However, many PCPs, especially the ones new to the system, did not have the experience working with care coordinators. COVID-19 transitions became their first experience.
Understanding that several teams would be needed to provide care for these patients, the primary care leadership connected with the ambulatory care coordination leadership to create a single process for hospital discharge. This was challenging as there were multiple hospitals with a variety of discharge planning and two separate electronic health records.
Hospital medicine were presented with a workflow that would streamline the process. They would create a discharge summary in their own EMR outlining the specific needs of the patient. The Ambulatory Care administrative team created a report from the Data Warehouse that indicated the COVID-positive discharged patients from all the hospitals in the system. The hospitalists could also send a secure message to the ACC team if the patient had specific needs that were not outlined in the summary.
Ambulatory care coordinators would reach out to the patients via phone within 2 days of discharge and perform medication reconciliation and close gaps in care. Primary care providers, who had been experiencing lower-than-normal patient volumes, had the capacity to care for their patients and were able to provide access to primary care virtual visits within 7 days. This allowed the transition team schedulers to place patients directly onto their schedules.
Patients who had non-Emory PCPs were encouraged to make a follow-up appointment with their PCP. Patients who did not have a PCP were assigned an Emory PCP who was previously identified as a PCP willing to accept new COVID patients.
Since most patients were still in the quarantine period, the visits were conducted via telemedicine. Patients who needed an in-person visit based on the clinical judgment of the RN coordinator were cared for in a centralized outpatient location that had been developed to handle these patients. Patients’ PCPs were taught the logistics of transition care management including billing and coding by the revenue integrity team. Telemedicine workflow development was essential in the care transition as was contacting transition care nurses and medical social workers.
Over the first 3 months of the program, 90 patients were transitioned to primary care. Challenges included retrieving data from two of six hospitals with different EMRs. Collaborating with the technology teams and explaining the reasons for the access was essential.
Some PCPs are very protective of their schedule templates. Constant communication about the process was essential to making PCPs comfortable with the ACC team accessing their schedule. Occasionally certain physicians were deployed to other areas in the system-testing, inpatient care or in-person COVID clinic. These PCPs would be covered by their office partners. Most of the hospitals did some follow-up program. The programs continue side-by-side. However, the nurses were not trained on specific COVID protocols and triage, so the ACC were still necessary.
As primary care continues to work with hospital medicine, the results will be rewarding. When the PCP is notified and the patient receives high-touch follow-up, there will be improved quality-reduced length of stay, fewer readmissions and provider satisfaction that they have been kept as a part of the care team.
Early on in the pandemic, PC practices were providing nearly 80% of all care over video-telemedicine. Some patients required telephone rescue of video-calls that could be completed. As COVID-19 cases are down, hospital beds are more available and SARS-CoV-2 testing positivity rate is down, there is a return to more in-person PC care. As PCPs began to open again, the demand for in-person care greatly exceeded the demand for video-telemedicine. Currently, we are providing 65% of our visits in person and 35% over video-telemedicine. Still, the pandemic has taken a disproportionate effect on those workers with small children at home who are not yet back in school.
And now, here comes winter 2020.