Primary Care as a Bulwark Against COVID-19

While the coronavirus pandemic has placed extraordinary strain on hospitals and emergency departments (EDs), it has also had a dramatic impact on primary care practices, which are managing less-acute cases of COVID-19 while tending to the ongoing needs of patients with chronic conditions. We reached out to three primary care practices: ChenMed, a large medical group serving Medicare Advantage members in eight states; Coastal Medical, a large primary care practice serving 120,000 patients across Rhode Island; and West County Health Centers, a federally qualified health center with four clinics across Northern California. While different in size and structure, all three organizations had been experimenting with new care delivery models and tools, including the use of telehealth and risk stratification of patients, before the pandemic. They are now doubling down on these efforts, thanks to the flexibility that comes from not being solely or largely dependent on fee-for-service payments.

Christopher Chen, M.D., the CEO of ChenMed, a multistate medical group serving some of the most vulnerable Medicare beneficiaries, has been trying to outflank the novel coronavirus, which has been spreading rapidly in many of ChenMed’s markets, including New Orleans, Chicago, and Miami.

Three-quarters of ChenMed’s patients have five or more major chronic conditions, including congestive heart failure, chronic obstructive pulmonary disease, and diabetes, all of which can turn a COVID-19 infection into a death sentence. With an average age of 72, ChenMed’s patient population is at such high risk of complications that Chen has authorized staff to do — and spend — whatever it takes to keep patients in their homes and away from hospitals and EDs. “I have not put any guardrails around it other than complying with Medicare rules,” he says.

Told to think creatively, ChenMed staff have begun making deliveries of toilet paper, meals, and prescriptions and offering help with the Instacart app. Doctors and other care team members are also calling patients at least once a week to check in, and the medical group is sending texts twice-weekly to remind patients of the importance of social distancing, especially with grandchildren. “Their anxiety level is through the roof,” says Gordon Chen, M.D., Christopher’s brother and ChenMed’s chief medical officer. “We want to provide information and local updates that they can trust. And we keep reminding our patients that this disease is preventable by taking needed precautions.”

Going Virtual

To minimize risk before the novel coronavirus’s spread, ChenMed also converted 95 percent of medical visits to its telemedicine platform within one week. While the practice has kept its 59 centers open for patients still needing face-to-face care, ChenMed clinicians also make home visits when needed.

Employees age 65 and older, as well as those with chronic conditions that put them at higher risk of COVID-19 complications, have been ordered to work from home, with many assigned the task of making what ChenMed leaders refer to as “love calls” to isolated seniors.

The quick pivot was made possible by ChenMed’s business model: the company receives a set amount from Medicare Advantage plans each month. Because it is on the hook for patients’ health care costs, including medications, ED visits, and hospitalizations, ChenMed’s providers have strong incentives during the pandemic to keep patients healthy. Before COVID-19’s emergence, ChenMed providers did so by increasing face-to-face time with patients (210 minutes per year on average) and by reducing panel sizes. ChenMed’s primary care providers each serve at most 400 patients, a fraction of the U.S. average (2,300) for primary care physicians. ChenMed made dramatic gains with its high-touch model before COVID-19 hit: hospitalizations among its patients were generally half the average for Medicare beneficiaries in its markets, the company says. Its investment in a homegrown, cloud-based electronic health record system also has made it easier for providers to care for patients during the pandemic.

Risk Stratification

In Rhode Island, Coastal Medical, a large primary care practice and accountable care organization with 125 physicians and advanced practitioners, also has accelerated its outbound contacts with patients, in part by repurposing a texting platform it had been planning to use to manage hypertension and heart failure. Since March, Coastal has been using the platform to query patients who have or are assumed to have COVID-19; every day, a text is sent asking them how they feel compared to the previous day, if they have a fever, and whether they’re having difficulty breathing. Nearly three-quarters of patients complete the survey within two hours, says Sarah Thompson, Pharm.D., Coastal’s vice president of clinical operations and pharmacy. Clinicians follow up with patients who report problems.

Coastal also has developed an algorithm (see box) to identify patients whose underlying medical and behavioral health conditions or social challenges put them at higher risk of poor outcomes should they contract the coronavirus.

Using this algorithm, Coastal estimates that 12 percent to 18 percent of the medical group’s 120,000 patients fall into the highest risk category because they have three or more conditions that put them at risk. Their names have been shared with primary care clinicians, who prioritize contact with patients at greatest risk. “We want to let them know we’re here, we’re not closed, and we will provide them with high-quality care and information that is not biased,” says Edward McGookin, M.D., the organization’s chief medical officer. In calls with patients, clinicians emphasize the importance of sheltering in place to avoid getting sick to begin with.

Reaching Rural and Homeless Patients

Like ChenMed and Coastal Medical, West County Health Centers in California’s rural Sonoma County has been working to ensure that patients who suspect they have COVID-19 and/or those experiencing respiratory symptoms are sequestered from patients who may need to come to the clinic for others reasons, such as wound care, infections, STD checks, and hormone injections. Testing for COVID-19 is conducted three times a week in a remote part of a parking lot at one of the community health center’s four clinics. The health center tightly controls access to its clinics: visits that haven’t been shifted to telehealth are scheduled for every 20 minutes, so the waiting room never has more than one patient. Should a surge occur, the health center might establish a clinic dedicated to lower-acuity cases or deploy staff to work in a makeshift clinic at an unused college dormitory, says Jason Cunningham, D.O., who took over as CEO on March 9, days before California issued a shelter-in-place order.

West County had already been experimenting with using telehealth tools to engage patients, many of whom are elderly and geographically isolated, going so far as to conduct teleconferences with patients’ relatives who lived elsewhere. Soon after California responded to the coronavirus outbreak in March by directing health plans, including Medi-Cal plans, to pay the same rates for telehealth visits as for in-person visits, West County shifted most of its care to virtual visits.

West County also has been using technology to locate and monitor roughly 200 homeless people living in the area. It has collaborated with local homeless service providers and first responders to visit homeless encampments and shelters to screen individuals for cough and fever. These workers are also assessing the individuals’ basic needs (e.g., for food and ability to self-isolate) as well as their access to naloxone to reverse opioid overdoses. Assessments are captured in an HIPAA-compliant version of SurveyMonkey called Survey 123, which stores information along with a geographic tag. The survey results are then shared automatically with appropriate clinical staff, who can facilitate access to COVID-19 testing, food services, and naloxone. The clinic also hopes to use the data to identify hot spots and locations that might need extra resources, such as handwashing stations. The technology had been previously used to track patients during two wildfires and a flood in the area. “It’s made for this type of situation,” Cunningham says.

Disaster Preparedness and Leadership

These primary care practices all benefited from changes that were already underway when COVID-19 emerged. ChenMed, for instance, had had staff with infectious disease and disaster management expertise working on a plan for what was expected to be a bad flu season. Information the group has gathered on how to respond to pandemics is quickly relayed to management across eight states via thrice-weekly meetings, broadcast text messages, and video streams. Having a management structure that pairs clinical and business leaders also helps, says Chris Chen. “Our dyad leaders are almost like a married couple. They are able to cover one another’s blind spots while helping the family thrive.”

West County recently adopted a diversified management structure that encourages shared leadership and decision-making and is proving useful during the pandemic. Rather than resting with a single chief medical officer, the responsibility is shared among four physicians, each from one of the clinics. “It forces collaboration across sites,” Cunningham says.

For its part, Coastal had already invested in a remote monitoring system for patients with high blood pressure and heart failure and was able to shift quickly to monitoring those who may develop COVID-19. In the future, Coastal will be using the system to monitor the long-term effects of the disease and expand remote monitoring for patients with hypertension, heart failure, and diabetes.

If COVID-19 has a silver lining, these primary care leaders say, it is that it’s been a catalyst for changes they have wanted to make for a long time. It has accelerated Coastal’s plans to broaden the use of telehealth, for example. Even clinicians who had been resistant to technology have now embraced it and are now conducting up to 90 percent of visits via video or telephone. McGookin says Coastal’s clinicians have been pleasantly surprised by the intimacy of the medium, by the high resolution of images, and by how meaningful the exchanges can be even in the absence of a physical exam. “The only way for them to realize that was to experience it,” he says. “Having the ability to easily have a telemedicine exchange with a trusted health care provider — that is a change that’s here to stay.”