The CIP consists of two interrelated interventions: 1) A data sharing platform that disseminated COVID − 19 lab test results from the province’s public health system to local PC providers, and 2) A C1P that offers those providers guidance for patient care. In combination, the CIP’s interventions introduced a data integrated and standardized approach to care planning and delivery across the Calgary Health Zone. These system changes enabled a more coordinated and efficient response to the pandemic and ensured all patients received PC follow-up. We showed that during wave one of the pandemic, almost every patient was contacted through the AHS-run C4 hub clinic and, based on their risk, received timely follow up care – as structured by the C1P – either with a PCN-access clinic physician or their own FP. The median time from positive COVID-19 test result reporting to follow-up from the C4 clinic was 1 day, and from follow-up from the C4 clinic to a FP visit was a further 1 day.
The purpose of the CIP is to facilitate care of COVID-19 positive patients by PC teams in the community and to decrease the use of acute care. We showed that the rate of ED visits and hospitalizations within 30 days after C4 Clinic contact was 5.1% and 1.9%, respectively. We do not have a control group to compare these numbers to; however, Canadian data from the Public Health Agency of Canada and the Canadian Institute for Health Information on ED visits and hospitalization rates from April – September 2020 was 30.5% and 10.3%, respectively (Appendix A)15, 16. This could indicate that use of the CIP in the Calgary Zone may have decreased ED visits and hospitalization during wave one. However, we acknowledge that most new COVID-19 cases reported between April and September 2020 were in the provinces of Quebec and Ontario (79.81%) with only 11.25% of cases from Alberta14, which may be due to a lower proportion of older adults with COVID-19 in Alberta16, 17. In addition, the rate of ED visits and hospitalization in this data set is from patients in the community and did not include patients form LTC where most hospitalization and death occurred.
Literature evaluating community-based COVID-19 care pathways in the United States demonstrates similar findings5, 10. Patel et al. evaluated a remote monitoring pathway for high-risk COVID-19 patients discharged home in Colorado5. This pathway was delivered by new and established PC physicians, medical students, and nurses who conducted daily phone calls to patients and regularly monitored vital signs over eight days, or as needed5. Between April and June 2020, 422 patients were monitored through the pathway, with only 4% re-admitted to the hospital and 3% visiting the emergency department within 30 days5. Sherman et al. described a health information exchange pathway in the United States which alerts PC teams when veterans are diagnosed with COVID-19 in community facilities10. The health information exchange system integrated COVID-19 results from state reporting systems to identify and note COVID-19 diagnoses on patients’ electronic medical records, notifying their PC team for follow-up10. Over a three-month period, the information exchange pathway effectively facilitated clinician follow-up for 76% of Veterans diagnosed with COVID-19 in the community, with 63% receiving follow-up from their established primary care team10. The importance of information exchange between PC and central systems, emphasized by Sherman et al10, is confirmed by our analysis.
In addition, Ganesh et al. reported that among 849 COVID-19 positive patients engaged with a virtual care model, only 8.9% had an ED visit within 60 days, based on recommendations from care team physicians due to severe COVID-19 symptoms9. Of those, 40% were subsequently hospitalized, with 36% requiring admission to an intensive care unit9. Kerkhoff et al. similarly reported that a community-based care model for vulnerable COVID-positive Latinx patients resulted in 3 of 80 patients being directed to the ED due to severe COVID-19 symptoms, with only 1 hospitalized7. However, only 10% of patients engaged with this care model were connected to primary care within one month, which may be due to population and contextual differences7. The low levels of acute care use suggest such pathways may be useful in diverting patients from acute care settings. This is consistent with a study by Ye et al., which identified a trend towards reduced 14-day ED visits among COVID-19 patients referred to a remote monitoring pathway post-discharge, compared to those without remote monitoring6. These findings are aligned with our study that showed using CIP potentially decreased acute care visits in patients with COVID-19.
The CIP is an intervention developed in the Calgary Health Zone to facilitate the flow of data about, and provision of primary care to, patients with COVID-19, and it represents a model of collaboration between primary care, specialty care, and public health. Collaborative partnerships between distinct sectors allow for more effective action on an issue than if each sector were acting alone18. Specifically, collaborations between primary care and public health sectors have gained interest over the years, with the pandemic emphasizing their importance in Canadian contexts19, 20. Within Canada, primary care is often the first point of entry to the healthcare system, providing tailored and patient-centered care, whereas public health supports societal conditions that promote better health21. Though during the pandemic, public health has played a crucial role in COVID-19 identification, contact tracing, and information sharing22, and can thus facilitate primary care follow-up for illness management within the community23. Together, primary care and public health collaborations provide an integrated approach to improving both individual and population health21. Literature reports that successful collaborations are beneficial for community members and those involved in the collaboration21.
Our study has several limitations that should be considered. Additional data collected from PCNs to measure the time from a patient’s follow-up with the C4 clinic to follow-up by a PCN physician were incomplete and unable to be used. Secondly, this study did not have a control group to be able to definitively conclude that the CIP reduced ED visits and hospitalizations. Finally, we were not able to measure a number of social determinants of health that are not captured within our administrative data sources and could affect the continuity of care, ED visit and hospitalization.