In March 2020, our practice implemented rapid changes to prepare for the COVID-19 pandemic. Among our first steps, we began shifting in-person appointments to tele-health visits, created a nursing phone triage algorithm to manage the high call volume from patients with questions about the novel coronavirus and concerns about getting tested, and launched an on-site respiratory symptoms clinic in one of our 5 suites. All of our residents were pulled to staff the inpatient and ICU services, and about half of our attendings entered a rotation to staff additional COVID and non-COVID ward services. Our Respiratory symptoms clinic was staffed by preceptors with a now available session and other MD and NP/PA volunteers from all 5 teams. Once patients started testing positive for the virus in our clinic and the hospital testing center, we identified the need to innovate a population management structure to help us manage our growing number of COVID-19 patients remotely.
Because our EMR system can receive the results of most diagnostic tests ordered throughout the hospital, we were able to identify many patients in our practice who had tested positive for SARS-CoV-2 by RT-qPCR. However, we needed a population management strategy to allow us to outreach to this cohort. We wanted a solution that would: 1) help us remotely manage COVID-19 patients recovering at home, 2) indicate when a visit to our respiratory symptoms clinic was required to answer clinical questions (oxygen saturation, chest x-ray for viral pneumonia, white blood count, e.g.) without taxing the Emergency Department, and 3) alert us in a timely fashion to instances when additional urgent interventions were required.
Based on published data regarding the clinical progression of the disease, we knew that some patients are more likely to rapidly deteriorate within one week after illness onset. Therefore, it was essential for our outreach program to identify not only patients with risk factors for severe illness but also increase monitoring during the days when they are most likely to worsen.1 With this knowledge of the illness, we designed a population management algorithm, an EMR component for entering important COVID-19 identifiers, and a population report. The algorithm (Figure 1) is used to guide triage decisions including how frequently to contact patients depending on symptom day and risk factors, and to identify clinical findings that indicate if the patient is safe to remain at home, the need for additional assessment, or emergency intervention. The component (Figure 2) is used to populate a twice daily report that allows us to tailor our outreach, and includes symptom date, age, comorbidities, last date of outreach, PCP, and whether a patient is currently hospitalized or had returned to baseline.
We run the population report (Figure 3) at 7:30 am each morning and distribute it by email to the five practice teams of MDs, NPs, PAs, and RNs who then reach out by phone to patients individually. Typically the primary care doctor, who knows each patient's history best, reviews their list and determines based on and their clinical schedule and patient complexity who they can outreach to themselves, with plans to turn outreach calls into telehealth visits when appropriate and the patient consents. The NP and PA on the team collaborate with all the PCP's on their team and reach out to patients they have relationships with and those the PCP's will not have time to reach. The report is run again at 3:00 pm and redistributed so that the primary teams can see who has not been contacted and the team working in the Respiratory Symptoms clinic, including RN's who have been triaging COVID patients and know some of those on the list, can supplement our calls and ensure that those who are particularly concerning are reached.
Since the COVID-19 outbreak began in Massachusetts, our practice has had daily leadership meetings and a daily email update to all working in the practice both at home and remotely. The clinical algorithm for the population management of COVID-19 patients was created by the Division Chief and Clinical Director of Nursing and reviewed by an Infectious Disease attending physician on the Infection Prevention Team. We then worked with our Manager of Applications and Analytics to build the EMR component and the population report. Once completed, we piloted the solution with our nursing team, and then rolled it out to the practice using our daily emails and our weekly practice-wide Zoom meeting to ensure all had a chance to learn the system and receive answers to their questions. The entire process, from design to implementation, took less than one week.