The Covid-19 pandemic is overwhelming hospital and emergency response systems in the U.S., much as it did in Italy. Even with current efforts to increase the number of inpatient beds, some communities will fall short of having enough beds to manage all of the patients with Covid-19. The community-based approach that our hospital has implemented can help.
Perhaps in even greater shortage is personal protective equipment, which is used at high rates in inpatient management — in our experience, 25 to 50 gowns per patient per hospital day.
Communities of color are hardest hit by the pandemic and face many barriers to care, placing them at particularly high risk of being unable to access inpatient care when needed. And rural areas face capacity challenges with hospital closures and aging populations at high risk of complications.
The most successful model available for managing Covid-19 comes from China. In it, patients with symptoms are evaluated in person at a fever clinic. The goal of this clinic is to identify all patients who have Covid-19 and refer them to the hospital to both quarantine them and manage their disease. In this model, everyone is admitted to the hospital, whether they have a mild or severe case.
But while this approach successfully quarantines people and provides care to all with Covid-19, it uses hospital care for many patients who do not need it because their symptoms are mild. It also brings all patients into clinics for in-person evaluations, increasing exposure risk to health care workers and patients who do not have Covid-19.
Like Italy, the U.S. does not have the inpatient resources to implement this model. Even if the U.S. could significantly increase the number of hospital beds, limitations in access to personal protective equipment would continue to place health care workers at risk, and shortages of health care workers would persist.
Some U.S. outpatient health systems have rapidly adapted to the Covid-19 crisis by expanding the availability of telemedicine, creating an opportunity to manage care at home. Yet to optimally care for patients, telephonic-based patient management needs the availability of coordinated in-person evaluation.
To address the shortages of inpatient beds, personal protective equipment, and health care workers, we believe that states and cities need to develop a coordinated community Covid-19 management strategy.
Community management model
One example of a community management system has been developed by Cambridge Health Alliance, a Harvard-affiliated community teaching public hospital system just outside of Boston where we work. It was designed to provide a low-resource management strategy that could affect a large number of patients. Its goals are to provide patient-centered care across the continuum of Covid-19 disease, avoid exposing healthy individuals seeking primary care to Covid-19, reduce the strain on emergency and hospital systems, and conserve personal protective equipment by managing patients at home.
This primary-care-based model includes telephonic primary care, a telephone triage system, a community management group, and a respiratory clinic.
Primary care teams identify individuals who might have Covid-19 and refer them to a telephone triage center. This center is staffed by a team of trained nurses who identify and stratify possible Covid-19 cases based on symptoms. They also provide coaching about methods for preventing the spread of a highly infectious disease like Covid-19. Patients at low risk for Covid-19 are managed by primary care teams over the phone with telehealth visits, while moderate- to high-risk patients are managed by a community management group.
This group consists of a group of primarily primary care clinicians who have taken on panels of patients with suspected and confirmed Covid-19 who are at higher risk for severe disease. The community management group manages patients longitudinally from their first call to the triage center, scheduling follow-up calls at points in the disease process known to be associated with sudden changes in clinical course, such as the fourth, seventh, and 1oth days after the first day of symptoms when respiratory symptoms, difficulty breathing, and severe difficulty breathing can often begin.
Clinicians pay careful attention to evaluating respiratory symptoms over the phone by listening for changes in breathing patterns when patients speak, asking about changes in breathing and activity levels that might indicate low oxygen levels and, when appropriate, administering a breathing test over the phone.
Patients who require in-person evaluation are referred to a dedicated respiratory clinic within the Cambridge Health Alliance system. It provides supportive therapies such as medications to manage symptoms and treat alternative or concurrent illnesses; connection to resources such as housing, crisis counseling, domestic violence counseling, and the like; and creates appropriate follow-up plans.
This continuum — primary care, triage center, community management, and respiratory clinic — then follows patients through a combination of telephonic and in-person management as necessary, monitoring for signs of worsening disease, providing ongoing education and support, and transitioning patients to the hospital at a point in the disease course when inpatient management would have the greatest impact.
Discussions about goals of care are embedded into both longitudinal community management and respiratory clinic visits, thus reducing the likelihood that patients will be faced with difficult decisions down the road without having had a chance to reflect on them.
This community management system for Covid-19 has yielded a few key insights:
First, it has allowed us to manage most patients without hospitalization. Although half of our first 1,100 respiratory clinic patients had moderate to severe symptoms of Covid-19, 92% of them were managed in the outpatient setting, and only 8% were subsequently seen in our emergency departments or admitted to our hospitals.
Second, only about 5% of patients initially seen in the respiratory clinic required subsequent evaluation in our emergency departments, and half of them were discharged to their homes after emergency care with respiratory clinic follow up. This suggests that patients can be successfully triaged by telephone.
Third, in its first three weeks, the community management system avoided a significant number of hospital visits. Because most patients spend several days to weeks in the hospital, this means that patients initially treated by the community management model stayed in the hospital for fewer days on average. In a review of the first 20 patients of ours who met the criteria for in-patient admission at other area hospitals, nine avoided hospitalization completely and one was managed at home for three days before admission. Based on the average length of stay for Covid-19 patients at Cambridge Health Alliance who do not require admission to the intensive care unit, we conservatively estimate that 39 hospital days were saved for these 20 patients.
Since we use one gown per patient, compared to at least five per patient evaluated in the emergency room and 25 to 50 per patient per hospital day, we estimate this model saved thousands of gowns in just a few weeks.
Based on the Cambridge Health Alliance experience, we share these policy recommendations:
States and cities should develop community Covid-19 management strategies
Once community transmission of Covid-19 is occurring, health systems need to be able to respond to patients presenting with a wide variety of symptoms. Outpatient management strategies should adopt the management approach that everyone has Covid-19 based on clinical presentation rather on testing. Waiting for testing misses the opportunity to support patients in the outpatient setting and increases the risk that patients will transmit the virus to healthy individuals.
Community management strategies should use telehealth and/or home health management to manage symptoms while reducing the possibility of exposure to others. These systems should also include palliative care and hospice as appropriate. Palliative care is an added layer of support that improves quality of life by managing pain and symptoms and ensuring that patients receive care that is consistent with their goals. If patients prefer comfort care management at home rather than hospitalization, hospice teams can help ensure patients and families are comfortable at home. By supporting patients in the home when they want to be, this will reduce the burden on hospital systems while providing more treatment choices for patients.
Community Covid management strategies should leverage primary care and public health
Primary care provides a natural base for community Covid-19 management. As the spread of the virus in the community becomes chronic, patients will seek care in primary care systems. Primary care providers are often the most trusted source of health information, and already understand the family and personal context. Because community management and prevention strategies for Covid-19 are so dependent on understanding patients in the context of their lives, primary care providers are uniquely poised to counsel and manage low-risk patients.
Public health systems also have a key role to play. One-quarter of U.S. adults do not have a primary care provider, a proportion that is increasing over time. Public health systems already have community management systems for other public health concerns, such as sexually transmitted diseases, that can form the basis for community Covid-19 management.
While both primary care and public health systems are a necessary base for any community management system, they are not sufficient. Both primary and public health systems need to be integrated with hospital and emergency care to escalate care for individuals with increasing risk of complications and worsening disease.
Eliminate insurance requirements for patients with symptoms
Removing insurance barriers to care allows patients who have symptoms of Covid-19 to access the community management system at the right time. To minimize community spread of the virus, access is essential early in the course of illness — before confirmatory testing — when viral spread within the community is most common.
Eliminating insurance requirements based on symptoms will reduce the spread of Covid-19 by allowing patients to access community management early in the course of their illness. It is also likely to be cost effective by avoiding costly inpatient care. Because communities of color are hardest hit by Covid-19 and also have high rates of uninsured individuals and families, elimination of insurance requirements is essential for health equity.
As the Covid-19 pandemic continues to engulf U.S. health care systems, the time for community Covid-19 management systems is now. It is not too late to establish these. We built our system within a month of recognizing that Covid-19 was coming to our community and within two weeks of deciding we needed a community management strategy. Though glimmers of hope in flattening the curve have begun to appear, nearly 30,000 new cases are diagnosed daily, reminding us that we have a long road ahead. In fact, experts believe the U.S. and other countries are likely to be managing Covid-19 for years to come.
As health systems struggle to provide care to those affected, community management systems for Covid-19 can optimize care for patients and the use of resources, allowing our nation to ensure that care is available when people need it.
Janice John is the medical director of the respiratory center, chief primary care physician assistant, and associate medical director of the Cambridge Health Alliance’s Assembly Square Care Center. Leah Zallman is a primary care physician at Cambridge Health Alliance, the director of research at the Institute for Community Health, and an assistant professor of medicine at Harvard Medical School. Jessamyn Blau is a primary care physician, medical director of the intensive Covid Community Management Program and medical director of the Cambridge Health Alliance’s Broadway Care Center, and an instructor of medicine at Harvard Medical School.