Engaging Community Medical Providers in the Age of COVID-19

                                                                        By Yun Boylston, MD, MBA

Do what you can, with what you’ve got, where you are.

In his autobiography,Theodore Roosevelt imparts the wisdom of Bill Widener to sum up what he considers to be one’s duty in life. More than a century later, this philosophy aptly describes the outlook of U.S. healthcare workers born out of necessity in the age of COVID-19. Faced with a scarcity of both supplies and knowledge to fight the virus, we seem to be collectively witnessing a game of Concentration in which tile pieces are laboriously matched and removed to reveal the detailed picture underneath.

As a community physician, it’s sobering to see the fragmented response at the federal and state levels, leaving community health systems and providers to face the reality that they are essentially on their own for the time-being. Do what you can, with what you’ve got. My independent medical practice has leaned into the rapid pace of change. Attending Zoom webinars with public health, medical, and business experts has become a part-time profession. Now less than a month into implementing and scaling telehealth, virtual encounters comprise 25% of our practice’s visit volume. We have also benefited from the generosity and ingenuity of our community. This includes donations of N95 masks from lawn service companies and homemade cloth masks. But good fortune has its limitations. Our PPE supply is still too scarce to be able to safely and sustainably provide community COVID-19 testing in any capacity. While our ID Now machines sit idle, we do not expect point-of-care tests to be made available to us anytime in the foreseeable future.

]While the pandemic has laid bare the glaring disconnects in supply and demand across economic sectors, this is also true in healthcare. As hospitals and emergency departments post record census numbers, inundated with demand, the majority of community physicians and surgeons have seen a significant decline in patient care. The Commonwealth Fund notes that the volume of ambulatory office visits in the U.S.dropped steeply by almost 60% in mid-March of this year.

Why does this matter? Medical practices are no different from the millions of small businesses across the country and our fate should be no different. Yet there is opportunity here. As states roll out strategies for re-opening, community medical providers may yet play a critical role that seems to be overlooked thus far in the national discourse.

In National Coronavirus Response: A Road Map to Reopening, Mark McClellan, Director of the Duke-Margolis Center, and his colleagues comprehensively outline the four phases of action needed to eliminate the current threat and to prepare for future pandemics. Essential steps in Phase 1 include increasing nationwide testing capacity, implementing a COVID-19 surveillance system, and mass scaling of contact tracing.

In order to implement an effective contact tracing system across the nation, a recent Johns Hopkins Center for Health Security report estimates that an initial 100,000 contact tracers will be required.For perspective on the scale of this workforce mobilization, the U.S. Census employed under 42,000 in April. State and local public health entities that are already strapped for funds and resources are assigned the daunting task of building this infrastructure. How about as a first step, do what you can with what you’ve got?

Engage the Medical Home

For a national test and trace program to be successful, engendering trust and confidence is critical. This requires partnership with medical providers who have established relationships with their patients and communities. According to the CDC, 84% of American adults in 2018 had an encounter with a healthcare professional in the preceding year. For children, this figure was almost 94%. As noted by the CDC’s expanding list of COVID-19-related symptoms, the presentation can be varied, especially for mild cases that do not require hospitalization. These symptoms could potentially be due to a number of illnesses or conditions, not just COVID-19. Seeking care and evaluation from a medical provider, who knows your history and risk factors and will guide you through your illness, is fundamental to good medical care.

Leverage Existing Public Health Partnerships

Community medical providers have a longstanding history of evaluating, testing, and reporting communicable diseases in partnership with local health departments and the CDC. These relationships and workflows already exist. From seasonal flu, to chlamydia and Hepatitis A, community medical providers provide essential frontline diagnostic and reporting services on a daily basis to protect the public’s health.

Rely on Available Expertise

While COVID-19 is very much a public health crisis, we must not overlook the need to safeguard the privacy rights of individuals, as with any other medical condition. Community medical providers and their staff are already trained in HIPAA compliant practices. Primary care providers and medical homes also possess experience in patient education and care management needed to help individuals navigate the course of illness.

Support Community-Drive Action to Address Disparities

Socioeconomic and racial disparities are clearly coming to light as the pandemic evolves. The CDC reports that racial and ethnic minorities disproportionately bear the burden of illness and death from COVID-19. Social determinants of health are complex and challenging to recognize or understand for those not familiar with affected communities. For this reason, it is imperative that public health measures to implement an effective test and trace strategy be rooted in partnership with community-based organizations and medical providers who are of the community.Where you are.

While community medical providers can by no means be expected to fill the gap for all test and trace needs, they can be a powerful ally in quickly scaling and complementing the endeavors of public health departments. Empower us to do what we do best—care for our patients and communities. This collaboration will require clear communication from public health leaders and prioritized access to resources such as testing supplies and PPE in order for community providers to implement wide scale testing and reporting. For medical clinics that have the capacity and desire to contribute to contact tracing, they should be recruited in this effort. In order for this partnership to be successful, training will be required, as well as a creative payment model that captures the value of the work being performed.

As a nation, we have more reserves than we realize in combatting this pandemic. Do what you can, with what you’ve got, where you are. Effectively deploying these resources to where they are needed as we build and expand capabilities will be key. We are here.