Abstract
Although significant attention has been allocated to hospital management of COVID-19 patients during this pandemic, less discussed is the management of ambulatory patients. This has resulted in a challenge for ambulatory care providers in the management of COVID-19, particularly in areas with high disease prevalence. In this article, the authors share a pragmatic approach to ambulatory management of COVID-19 at Northwell Health, a large health system that employs approximately 300 primary care providers in the New York metro area. This includes guidance on various COVID-19 management topics: clinical assessment algorithms, guidance on patient tracking, and the importance of engaging in partnerships with other provider types. Sharing these experiences in the clinical management of COVID-19 may benefit other ambulatory providers in earlier stages of the COVID-19 pandemic.
The spectrum of patients affected by COVID-19 include those hospitalized because of infection and its sequelae, as well as those managed in the community by primary care and subspecialty providers. Significant attention has been allocated to acute care management of COVID-19 patients during this pandemic. It is equally important to discuss the management of nonhospitalized ambulatory patients, given the collation of multiple processes and workflows. This article describes a process improvement initiative that led to a pragmatic approach to COVID-19 ambulatory care from the perspective of the primary care and subspecialty providers of Northwell Health, one of the largest health systems in New York State. Sharing these experiences and practical tips for managing ambulatory patients as “lessons learned” may benefit ambulatory providers in earlier stages of the COVID-19 cases in their respective settings. The guidance is presented in 3 major sections: (1) clinical practice considerations, (2) operational considerations, and (3) leveraging collaboration between patient services.
Given the likely persistence of infection across the nation, primary care and subspecialty providers play a leading role in the management of COVID-19.
Clinical Practice Considerations
At the time of COVID-19 emergence in the New York area, there was no standard approach to clinical care and little evidence-based guidance available for the management of COVID-19. There is a range of both illness presentation and severity of COVID-19 infection in the ambulatory setting. Thus, ambulatory management of COVID-19 is based on clinical judgment, experience managing other viral syndromes (such as influenza), and outcome data available on hospitalization outcomes/mortality from other regions 1 and the study health system. 2
Triage Assessment
In the ambulatory practices discussed in this article, patients were triaged largely over the phone or through telehealth. Triage focused on 4 main considerations: (1) days since symptom onset, (2) tally of current symptoms, (3) comorbidities that may increase risk of poor outcomes, and (4) demographic concerns (Table 1).
COVID-19 Triage Assessment in Ambulatory Care.
Onset and Duration of Symptoms
COVID-19 symptoms were present for 7 to 14 days in many patients, and up to 21 in some. Cautionary guidance for known clinical decline between days 5 and 8 in many hospitalized patients was highlighted in the clinical algorithm, especially for patients with higher risk for decompensation. 2 In addition, a “honeymoon period” was experienced by some patients: a 1- to 2-day period of seeming clinical improvement and decrease in temperatures in the middle of their illness, with resumption of symptoms soon thereafter.
COVID-19 Contacts History
Early in the outbreak, evaluation of patients included assessment of travel and/or contact with a known COVID-19 case, both of which were considered differentiators. However, the rapid expansion of infection in the New York area eventually meant that most patients lived in an outbreak area. COVID-19 contacts, while important to understand, became a less reliable indicator of likelihood of disease.
COVID-19 Testing
A positive COVID-19 polymerase chain reaction (PCR) test was initially a diagnostic luxury given the limitations on PCR testing during the early stages of the outbreak in New York. Therefore, in many cases clinical assessment was used to make a presumptive diagnosis of COVID-19.
Triage Algorithm
Clinical decision-making focused on the presence of respiratory symptoms based on the overwhelming evidence of respiratory failure in hospitalized patients. Assessment was done by ambulatory physicians over the phone or via telehealth visit.
Respiratory symptoms were graded and placed in the context of patient age and comorbidities, with an algorithm suggesting next steps: frequency of monitoring, providing oxygen support, or changes to the location of care (Figure 1). 3
COVID-19 ambulatory clinical algorithm.
Operational Considerations
Patient Tracking System
Patients with COVID-19 symptoms presented to ambulatory practices through various modes: calls or portal messages from patients with questions/concerns, notifications from local urgent care visits or emergency room (ER) visits, or close contacts of other COVID-19 patients in the practices’ care.
Given the long duration of COVID-19 illness and the large number of patients who may need to be followed, it is imperative to develop a reliable tracking system for COVID-19-suspect patients in the ambulatory setting. This could take varied forms, from a simple spreadsheet to an electronic health record (EHR)-based tool. Given the disruption to health systems and practices during COVID-19, an easily transferrable tracking system for clinicians and teams is essential. Ambulatory clinicians were sometimes deployed to inpatient settings, or in some cases, out with illness themselves, necessitating transfer to other clinicians. The tracking system should include day of symptoms, with a highlight of the high-risk period (days 5-8).
The authors leveraged the available tools: EHR (Allscripts Touchworks 17.1) notes and patient-specific tasks. A templated EHR note was created, highlighting date of onset of symptoms with a prompt for “Caution at day 5 to 8,” alerting clinicians to the potential for decompensation in this period. Once an initial EHR note was created, the note triggered the creation of a “task.” This task would then be updated during future dates when follow-up evaluations for COVID-19 were completed and reflect any escalation in care such as referral to the ER or urgent evaluation center. While this is an EHR-embedded tracking system, even a simple tracking system outside of the EHR system would suffice.
Notifications of Visits to Urgent Care, Emergency Rooms, or COVID-19 Testing Sites
As already mentioned, many of the COVID-19 patients came to the attention of the ambulatory teams via the patient notifying the team of symptoms. However, other COVID-19 patients were identified through notifications of admission to hospitals, ERs, and urgent care centers. Notifications included electronic alerts or paper communication (including faxes). This was an essential tool to identify patients, especially those at higher risk and who had not proactively reached out to the practice. This allowed tracking of these COVID-19 patients to ensure that each patient is clinically monitored until recovery. Automated notifications are used to ensure that patients are reengaged with the primary care practice, enrolled in necessary services (eg, home care, physical therapy), and have access to treatments/medications on discharge.
Telehealth
Telehealth technology has rapidly become important for care of both COVID-19 and non-COVID patients remaining home per public health guidance. Telehealth encompasses care delivered using telephone, secure messaging portal, or video technology. Telehealth added to the ability to perform patient assessment; video capacity allowed a more detailed assessment of general appearance and breathing status. Telehealth technology was leveraged in a few ways: (1) for initial diagnosis of COVID-19, (2) for follow-up visits or “check-ins” for COVID-19 patients, (3) for follow-up or routine visits for medical illnesses other than COVID-19 (eg, hypertension, diabetes, heart failure), and (4) for post hospital discharge evaluation and management. The process for establishing telehealth services requires aligning distinct team members, including clinicians, office staff, billers, coders, audio/visual technologists, administrative support, as well as patients. In this vein, the practice teams were offered standardized workflows specific to the technology being used: telephone, secure messaging portal, or audio/visual communication. Each workflow was delineated into 4 main aspects of a patient visit: (1) before the patient visit, (2) beginning of the patient visit, (3) during the patient visit, and (4) completion of the patient visit. It is critical to identify a workflow for each aspect of the patient visit to distribute responsibilities appropriately and allow for team members to perform at the top of their license. EHR notes were reconfigured to allow easier documentation of patient consent, to offer separate notes for COVID-19 symptoms and clinical decision support, as well as to capture time-based billing within the note as appropriate.
Leveraging Collaboration Between Patient Services
Primary care has been largely an office-focused discipline for the past few decades. Northwell Health has moved to team-based care through the patient-centered medical care approach; creating or strengthening partnerships with other providers and services, particularly outside of the office, becomes imperative in times of crisis.
Home Care Services
Home care delivery partners should be identified. Though staff frequently engage with home care services in the postdischarge period, patients are eligible for home care when these criteria are met: homebound, under care of a physician, and in need of intermittent skilled nursing care. 4 Many COVID-19 patients at home have met these criteria, needing skilled nursing assessment (delivered in person or through telehealth service) for respiratory symptoms caused by COVID-19 infection or presumed COVID-19 infection. This can include durable medical equipment (eg, pulse oximeters, home oxygen concentrators) to treat COVID-19-related hypoxemia.
In the practices discussed in this article, referral to home care services for respiratory symptoms related to COVID-19 allowed for more accurate assessment of oxygenation status, the ability to treat mild hypoxia at home, and a clinical registered nurse (RN) partner to expand the monitoring capacity of the care team. The RN team provided regular telehealth visits to enrolled patients, identified home needs, reviewed temperatures and pulse oximetry readings, and reported back to the primary provider as another source of clinical data for COVID-19 management decisions.
Hospice Services
In the authors’ experience, hospice programs are often underutilized in normal practice. The COVID-19 pandemic has pushed goals of care conversations to the forefront in many institutions, along with a tremendous increase in the need for medical services in ERs, hospitals, and intensive care units (ICUs). This has been compounded by the necessary restrictions on visitors to hospitals, which has changed the patient and family experience of hospitalization. In the ambulatory setting, it has become imperative to speak with patients and caregivers of those with advanced illness to identify goals of care while patients are at home. It is helpful to remind providers that hospice referrals can be made from the ambulatory setting. For those ambulatory patients with advanced illness where COVID-19 infection was suspected, and hospice care was appropriate, hospice partners were able to be engaged quickly. Hospice care was delivered in 2 settings: hospice at home programs, which were able to provide care for patients with COVID-19 infection, and in a small number of COVID-19-specific hospice beds. This allowed the needs of patients and families to be met in the appropriate setting, and avoided overutilization of acute care services (ER, hospital, ICU).
Conclusion
COVID-19 infection has challenged the current state of ambulatory primary care in many aspects. The clinical and operational management of the response requires collaboration in novel ways between clinical, informatics, and the wide spectrum of patient services. Although within the walls of a hospital such teams have aligned on previous initiatives, COVID-19 has challenged outpatient primary care services to swiftly align needs and solutions. The ambulatory primary care COVID-19 response continues to evolve as cases progress from diagnosis to management, recovery, and even potentially chronic illnesses. Thus, continued research and data reporting are needed to further enhance the readiness and adaptability of outpatient services to serve communities and patients in the best possible manner.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
