Primary Care Population Management for COVID-19 Patients.

Deborah Blazey-Martin,Elizabeth Barnhart,Joseph Gillis,Gabriela Andujar Vazquez

doi:10.1007/s11606-020-05981-1

Deborah Blazey-Martin, Elizabeth Barnhart + Show 2 more

Open Access

https://doi.org/10.1007/s11606-020-05981-1

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Abstract

BackgroundMost patients infected with SARS-CoV-2 have mild to moderate symptoms manageable at home; however, up to 20% develop severe illness requiring additional support. Primary care practices performing population management can use these tools to remotely assess and manage COVID-19 patients and identify those needing additional medical support before becoming critically ill.AimWe developed an innovative population management approach for managing COVID-19 patients remotely.SettingDevelopment, implementation, and evaluation took place in April 2020 within a large urban academic medical center primary care practice.ParticipantsOur panel consists of 40,000 patients. By April 27, 2020, 305 had tested positive for SARS-CoV-2 by RT-qPCR. Outreach was performed by teams of doctors, nurse practitioners, physician assistants, and nurses.Program DescriptionOur innovation includes an algorithm, an EMR component, and a twice daily population report for managing COVID-19 patients remotely.Program EvaluationOf the 305 patients with COVID-19 in our practice at time of submission, 196 had returned to baseline; 54 were admitted to hospitals, six of these died, and 40 were discharged.DiscussionOur population management strategy helped us optimize at-home care for our COVID-19 patients and enabled us to identify those who require inpatient medical care in a timely fashion.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-05981-1) contains supplementary material, which is available to authorized users.

Highlights

80% of laboratory-confirmed COVID-19 patients have had mild to moderate disease that can be managed without hospitalization.[1]
Our patient panel consists of 40,000 people (~ 8000 per team), Blazey-Martin et al.: Primary Care Population Management for COVID-19 Patients including patients participating in both Medicare and Medicaid accountable care organizations (ACOs), patients who are dually eligible, and patients who are commercially insured in risk contracts as well as PPOs
We leveraged our experience with existing electronic medical record (EMR) tools and workflows developed for population management of patients with conditions such as diabetes and opioid addiction when we realized that responding to the COVID-19 pandemic would require a similar approach

Summary

Introduction

80% of laboratory-confirmed COVID-19 patients have had mild to moderate disease that can be managed without hospitalization.[1]. Received April 30, 2020 Accepted June 11, 2020 Published online July 27, 2020 reports of patients dying at home for failure to recognize the severity of their symptoms. It is critical for COVID-19 patients to receive remote support and monitoring so that they can recover successfully at home when possible and be advised when in-person evaluation is needed. Most patients infected with SARS-CoV-2 have mild to moderate symptoms manageable at home; up to 20% develop severe illness requiring additional support. Primary care practices performing population management can use these tools to remotely assess and manage COVID-19 patients and identify those needing additional medical support before becoming critically ill. DISCUSSION: Our population management strategy helped us optimize at-home care for our COVID-19 patients and enabled us to identify those who require inpatient medical care in a timely fashion

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