Redesigning Primary Care to Address the COVID-19 Pandemic in the Midst of the Pandemic

Alex H. Krist, MD, MPH; Jennifer E. DeVoe, MD, DPhil; Anthony Cheng, MD; Thomas Ehrlich, MD; Samuel M. Jones

Disclosures

Ann Fam Med. 2020;18(4):349-354. 

In This Article

Abstract and Introduction

Abstract

During a pandemic, primary care is the first line of defense. It is able to reinforce public health messages, help patients manage at home, and identify those in need of hospital care. In response to the COVID-19 pandemic, primary care scrambled to rapidly transform itself and protect clinicians, staff, and patients while remaining connected to patients. Using the established public health framework for addressing a pandemic, we describe the actions primary care needs to take in a pandemic. Recommended actions are based on observed experiences of the authors' primary care practices and networks. Early in the COVID-19 pandemic, tasks focused on promoting physical distancing and encouraging patients with suspected illness or exposure to self-quarantine. Testing was not available and contract tracing was not possible. As the pandemic spread, in-person care was converted to virtual care using telehealth. Practices remained connected to patients using registries to reach out to those at risk for infection, with uncontrolled chronic conditions, or were socially vulnerable. Practices managed most patients with suspected COVID-19 at home. As the pandemic decelerates, practices are now preparing to address the direct and indirect consequences—complications from COVID-19 infections, missed treatment for acute problems, inadequate prevention, uncontrolled chronic disease, mental illness, and greater social needs. Throughout, practices bore tremendous financial burden, laying off staff or even closing at a time when most needed. Primary care must learn from this experience and be ready for the next pandemic. Policymakers and payers cannot fail primary care during their next time of need.

Introduction

In normal times, 75% of adults report 1 or more illness or injury per month. Most manage symptoms on their own, but 25% consult a clinician.[1] Our health system is right-sized to meet that demand. During a pandemic, demands and needs completely change. More patients need infection-related care, but there is also a decreased number of patients seeking non-infection–related care, potentially with adverse consequences. Stress rises as do mental health needs and substance misuse, and new financial burdens cause greater social needs for patients and burdens for primary care. A pandemic is a time when people need primary care more than ever and primary care needs to know how to help them.

In 2014, the Centers for Disease Control and Prevention (CDC) issued a framework to address the influenza pandemic.[2–4] They describe 6 intervals: (1) investigation of cases of novel influenza, (2) recognition of increased potential for ongoing transmission, (3) initiation of a pandemic wave, (4) acceleration of a pandemic wave, (5) deceleration of a pandemic wave, and (6) preparation for future pandemic waves (Table 1 and Figure 1).

Figure 1.

The Centers for Disease Control and Prevention interval framework for influenza pandemic—hypothetical cases as a function of pandemic interval.
CDC = Centers for Disease Control and Prevention.
Note: This is a hypothetical depiction of the number of infectious cases as a function of the Centers for Disease Control and Prevention's pandemic intervals. Reprinted from Qualls et al.4

The CDC's framework is a strong public health strategy, but it does not address the specific needs of primary care nor the patients and communities they serve. As the most common place for first health care contact,[5] primary care is the health system's first line of defense, able to reinforce critical public health messages, help patients manage infections at home, and identify those in need of hospital care. Done well, this can reduce the spread of infection and protect hospitals from being overwhelmed.

This manuscript considers how primary care practices can rapidly and continuously reinvent themselves during a pandemic using the CDC's pandemic framework. The recommendations are based on the experiences of the authors' community-based primary care practices during the COVID-19 pandemic. Recommendations are grounded in the core principle of protecting clinicians, staff, and patients while remaining available and connected to meet patient needs.

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