SGIM Forum

Lessons from a Step behind the Frontlines: Providing Primary Care in New York City during the COVID-19 Pandemic 

07-30-2020 14:11

Sign of the Times

Lessons from a Step behind the Frontlines: Providing Primary Care in New York City during the COVID-19 Pandemic

Dr. Bosco (Joan.Bosco@mountsinai.org) is an instructor at the Icahn School of Medicine at Mount Sinai and an attending physician in the Division of General Internal Medicine, Department of Medicine at Mount Sinai Beth Israel. Dr. Amoruso (leonard.amoruso@mountsinai.org) is an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai and medical director for general medical associates and division chief for general internal medicine at Mount Sinai Beth Israel. Dr. Chow (desiree.chow@mountsinai.org) is an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai and associate medical director for general medical associates, the Internal Medicine faculty and residency practice at Mount Sinai Beth Israel. Dr. Cruz (christina.cruz@mountsinai.org) is an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai and the associate program director for ambulatory care for the Internal Medicine Residency at Mount Sinai Beth Israel. Dr. Weissman (matthew.weissman@mssm.edu; @drmweissman, Twitter; @drmattweissman, Instagram) is the site chair of medicine at Mount Sinai Beth Israel and an associate professor of internal medicine and pediatrics at the Icahn School of Medicine at Mount Sinai.

“I’m scared to go to the hospital but I’m scared to stay at home.”

These words are uttered in between labored breaths by my elderly COVID-19 patient. Over the telephone, she tells me she has been feeling progressively more ill. Yet, she is worried about getting sicker or infecting others by going to the already overburdened hospital, citing the NYC Department of Health and Mental Hygiene’s mandate to “Stay Home, New Yorkers.”

Our office staff assists her in enrolling in the patient portal and walking her through the process of initiating a video visit. I am then able to see my patient “face-to-face” and assess her respirations. I help her download a pulse oximeter smart phone app; her daughter texts me with updates. A nurse from our clinic calls the patient frequently to check in. During one of our video visits, we are able to conference in the patient’s rheumatologist, who, in real time, provides expertise on titrating her immunosuppressing rheumatoid arthritis medications in the setting of an active COVID infection.

While the common goal of primary care providers has always been to keep patients out of the hospital, flexibility, creativity, and interdisciplinary teamwork are required when the goal now entails keeping patients out of the office as well. During this period, there has been an amazing expansion of remote primary care in ways that, even in as recently as early 2020, many providers and patients were resistant to trying or did not think were possible. However, the idea of providing care in a “geographically unbound system” is certainly not a new one. A 2019 New England Journal of Medicine Case Study in Social Medicine describes a pregnant migrant farmworker who receives fragmented medical care as she moves from farm to farm.1 The authors utilize technology to attempt to bridge these gaps in her care, including text-message check-ins and video visits by “bridge” case managers not tied to a geographic location. In this way, when we begin to think of providing care that is not bound to a traditional medical office, the possibilities for patient outreach, as well as for the role of the primary care provider, become vast.

We are currently experiencing such an expansion in our roles as primary care providers. We are forced to think outside the box, such as hosting weekly video check-ins with a patient with schizoaffective disorder to ensure that she is not decompensating in the setting of social isolation. In some ways, we are also changing how we practice medicine. We are attempting to adhere to evidence-based approaches in a space where there is still little to no formal guidelines on best practices. In a cultural shift, we are prescribing empiric antibiotics for dysuria and evaluating patients’ volume statuses through a Smartphone screen. There is an increased sense of urgency—not to mention a government mandate—to keep patients out of the hospital and in their homes and to provide safe and effective care from miles away. We are not screening for cancer, administering vaccines, or checking A1Cs. Even semi-urgent issues cannot be prioritized. It is not safe for our elderly patient with postmenopausal vaginal bleeding to leave her home for an ultrasound. We cannot send our COVID+ patient with abdominal pain for a CT scan, as this would require the scanner to be shut down for hours while it is cleaned.

Our medical office staff has also taken on new and invaluable roles, rapidly enrolling our established patients onto the portal and troubleshooting any technical difficulties so that patients can engage in video visits. To make sure our most vulnerable patients are being contacted during the pandemic, we used population health data to generate a list of our highest risk patients. A team of medical students called these patients to ask about COVID symptoms, social concerns such as food insecurity, and medication refills, and to gauge interest in a televisit. Patients who had been resistant to telehealth are now enrolled and successfully completing video visits from the safety of their own home.

Therefore, if this idea of providing remote care is not a new one, and our goal as primary care providers has always been to keep patients out of the hospital, why do things feel so different now? On the inpatient floors, our colleagues constantly ask: “Where are all the non-COVID patients?” Our sentiments were echoed in an April 2020 New York Times article entitled “Where Have All the Heart Attacks Gone?”2 As discussed in the article, some of the reduced admission rates may have to do with cancelled elective procedures. Expansion of telemedicine may also account for some, but would not necessarily account for the acutely ill. Are people staying at home and suffering, or worse, dying, rather than coming to the hospital? Is social distancing—less eating out, less alcohol, less physical exertion—removing many of the acute triggers for, say, an acute myocardial infarction or congestive heart failure exacerbation?

Perhaps outpatient physicians are doubling their efforts to keep patients at home. For example, a patient at our clinic who self-catheterizes is frequently sent to the emergency department (ED) to treat multi-drug resistant urinary tract infections. However, during the COVID pandemic, we worked to set up home antibiotic infusions for this patient. Similarly, a woman with type I diabetes, admitted a few months ago for diabetic ketoacidosis, confessed in a telephone call that she had run out of insulin and felt similar to how she did before her prior admission. Instead of sending her to the ED, we were able to arrange for the patient to receive IV fluids in the office. Stat labs were drawn and the patient was able to be seen by endocrinology the same day, with daily monitoring via telephone thereafter.

So, why aren’t we always doing things like this? Why are our EDs and hospitals usually full even when there is not a pandemic? We believe there are many reasons for this. General resistance to telemedicine, on both the part of the patient and the provider, has long been an issue.3 There is also likely concern about keeping patients in unmonitored settings, or fears that we are simply delaying patients from getting the appropriate tests or treatment. Many providers may not know how to set up, for example, home infusions, especially in areas that aren’t as resource-rich as New York City. Time, an already limited resource in the primary care setting, is certainly a factor; the process of setting up antibiotic infusions for our aforementioned patient took the better part of an afternoon. Coupled with concern that the patient may decompensate, this may not always be a feasible option.

We must maintain this current emphasis on keeping patients at home even as the pandemic subsides. But to do so, the following factors will need to be addressed first:

  1. Currently there are many Smartphone apps for home vital monitoring, but they vary in accuracy. Before we can safely and reliably use them to guide at-home treatment, there needs to be more data on their use, and perhaps even safety trials and/or the development of healthcare app standards.
  2. We need an expansion of accessibility to home medical equipment such as pulse oximeters, blood measure cuffs, and diabetic testing supplies, even for people without uncontrolled medical problems. While expensive, the ability to reduce in-person office and ED visits and forestall decompensation should make this program financially self-sustaining.
  3. Should Smartphones themselves be considered necessary medical equipment? Should phone plans be covered by insurance so that patients can participate in telehealth? Should providers also be universally given technology so that their patients can reach them when it is safer for both provider and patient to remain at home?
  4. We need to reduce disparities in telehealth accessibility through better spoken language and American Sign Language (ASL) interpretation resources.
  5. The process of prescribing home blood draws and infusions should become streamlined and easier for the provider to access. Navigating multiple agencies makes ordering home services a daunting task with potential significant cost for the patient.

We have all become more creative primary care providers because of this pandemic. As we look to the future, we must work to advance these accomplishments while remaining cognizant that it is precisely the most vulnerable of our population who are most likely to fall through the gaps of a geographically unbound healthcare delivery system. That way, we will be best prepared for the next pandemic—and also for the endemic diseases that we face every day.

References

  1. Madaras L, Stonington S, Seda C, et al. Social distance and mobility—A 39-year-old pregnant migrant farmworker. N Engl J Med. 2019 Mar 21;380(12):1093-1096. doi: 10.1056/NEJMp1811501.
  2. Krumholz HM. Where have all the heart attacks gone? The New York Times. https://www.nytimes.com/2020/04/06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html. Published April 6, 2020. Updated May 14, 2020. Accessed July 15, 2020.
  3. Tepper DL, Weissman MA. Can we live-stream primary care? Challenges in the adoption of e-consults and video visits. SGIM Forum. https://www.sgim.org/File%20Library/SGIM/Resource%20Library/Forum/2020/SGIM-February-2020-Web.pdf. 43(2);2:15-16.

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