Originally published in Patient Engagement HIT
Driving chronic disease management during the coronavirus pandemic has proven challenging, but telehealth is emerging as a key tool to push continuity of care.
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April 29, 2020 - Starting the week of March 9, California-based Primary Medical Group knew it needed to pivot. Like so many primary care providers across the country, the clinician team was growing increasingly concerned about ensuring quality chronic disease management and patient care access as the rest of the nation shuttered its doors in response to the coronavirus pandemic.
“As COVID-19 cases started to pop up in our area, we very quickly, within a matter of five to 10 days, converted to telemedicine,” said Maria Barrell, DO, a family medicine physician at the clinic. “We had no telemedicine capabilities prior to the outbreak, but we have a phenomenal CMIO who was able, with her tech whiz husband, to come up with a platform for telemedicine visits and get I'd say 90 percent of our workforce to operate in a telemedicine platform from home while maintaining open offices.”
Employing a strong telehealth strategy, fueled by technology from AristaMD, not only made good business sense — although that was important — but it was essential to keeping the patient at the center of care.
“There are a lot of primary care offices that are already furloughing employees, and there are a lot that are at-risk for financial compromise and closure,” Barrell told PatientEngagementHIT. “We wanted to make sure that doesn't happen to us. Because if our lights aren't on, then we can't take care of our patients.”
And taking care of patients, paradoxically, became extremely complicated once the coronavirus pandemic began ravaging the United States. While hospital beds began to fill with patients sick with COVID-19, primary care clinics, specialty clinics, and elective surgery sites emptied.
“What we saw initially was a sharp drop off in any visits at all, telemedicine or otherwise,” Barrell recalled. “There was a fairly steady flow of patients with concern about COVID coming through the drive thru clinic, but otherwise people just buttoned down and we weren't seeing much of anything.”
And that trend became visible nationwide. As states established stay-at-home orders and patients began practicing social distancing and self-quarantine, their engagement with other areas of the healthcare industry dropped off.
In some cases, this was an important step forward. In the middle of March, CMS called for a pause in all elective surgeries and other non-urgent care. This move intended to keep patients out of hospitals to free up space and personnel to care for COVID-19 patients, as well as tamp down on coronavirus spread.
But in other areas, it was a little alarming. An April 2020 report from Evidation showed that about half of patients with a chronic illness are worried about visiting their provider office for a non-coronavirus healthcare need. Ten percent of those respondents said they were so concerned they would forego care altogether.
This spelled out a potentially disastrous healthcare landscape should patients continue to forego their chronic disease management check-ins, Barrell explained. Patients with a chronic illness who do not continually make key wellness checks could see their disease states deteriorate, launching into an acute care crisis.
And in a time where coronavirus spread looms large, this could be a catastrophe.
“We have this entire health workforce in the US distracted by their response and really important questions about how to contain COVID,” Barrell said. “Now, it's been five weeks of this, and it's created this really audible gap in care for those with chronic diseases, who are ironically at highest risk for complications and deaths from COVID.”
“I've got diabetics and patients with COPD who are terrified to go into the doctor, see a specialist, or even go to the ER, because everyone has clearly said to stay home. So they're all staying home, but then they're getting worse,” she continued. “And then they have to go to the hospital in a very compromised position. And their risk of being admitted is much higher and then paradoxically, their risk of exposure to COVID, which is what they're hoping to avoid, is higher than it was in the first place.”
As time as pressed on, however, Barrell has noticed an uptick in patients accessing non-COVID treatment. Patients are realizing that they need to take care of their chronic conditions and other healthcare needs, and are open to working around some of the risks in order to connect with a provider.
“As we realize this is a new normal and not just a temporary blip, the patients are realizing they need to seek care,” Barrell said.
And essential to that transition to a new normal is the use of telemedicine, she explained.
As noted above, Primary Medical Group has been live on its telemedicine platform since the beginning of March, all as a part of its effort to keep caring for its patients.
In the weeks since the primary care clinic launched this model, Barrell said she and her team have learned a few key lessons.
Foremost, primary care clinicians need to be flexible in how they actually deliver telemedicine. Many in the clinic’s chronic illness population are seniors, Barrell noted, and although there is a growing proportion of older patients who are familiar with technology, she has encountered barriers here.
“We are noticing that especially with some of our chronic disease population, a large percentage of whom are seniors, that they lacked the technical ability to have the video conference,” Barrell pointed out. “It's much easier if you have a smartphone or a computer with a video capability. And many of them don't.”
And even when that older patient may have an adult child or a grandchild who could usually help get them set up on telemedicine, social distancing protocol is making that an unrealistic ask.
“So we're just talking to them on the phone, because so many of these things with diabetics or COPD patients, you can talk to them about their diseases without necessarily listening to their lungs or checking their feet for neuropathy,” Barrell said.
What’s more important, she continued, is thinking of the different things a patient might need during the coronavirus pandemic specifically, like conducting a chronic illness check using accessible digital formats or checking for social needs.
“We're trying to think outside the box in terms of what really needs to happen,” Barrell stated. “What is the basic level of care that needs to be provided? Are patients taking their medicines? Do they have someone who can go pick them up for them, because they may be 80 years old and have multiple comorbid conditions?”
Checking in simply on how a patient is doing in the holistic sense is another core component to Barrell’s current chronic disease management strategy. A lot of chronic care management cases have a comorbid depression element that often stems from the burden of having a chronic illness and the unfairness of that, she said.
“And now we’re socially isolating everyone,” she pointed out. “I've seen a big increase in terms of people just feeling really lonely, and that can have a poor effect on your motivation to take care of your health. So honestly, it sounds really simple and basic, but we're just trying to call and reach out and tell patients we care. And it has been phenomenal.”
More logistically, Barrell and her colleagues have found telehealth to be a boon for care coordination, one of the key components of being a primary care physician, she said. The telehealth platform allows her to consult with the specialist who is a part of the chronic care management team, helping her to make care decisions with the patient and document it in the medical record.
“It pulls together this kind of this remote care team in a way that's really streamlined and efficient. It helps keep patients out of the hospital and help make sure that our chronic condition patients are taken care of,” she said.
“Telehealth really empowers the primary care provider to be the complete custodian of the patient and reduces the risk of hospitalization and ultimately reduces the risk of morbidity and mortality associated with their underlying chronic disease.”
These efforts are grounded in Primary Medical Group’s pre-COVID chronic disease management strategy, Barrell noted. The clinic has long had quality measures in place to track and manage patients with chronic illness, tipping off providers to when patients need a nudge, a test, or a check-in. These haven’t gone away, despite the pandemic, acting more as a guiding tool than burdensome reporting.
“We're trying to proactively give each of our 30 providers and their managers and medical assistants a list of patients who are outside of the buffers that we tend to set for ongoing medical care, or who might be due for an appointment,” Barrell explained. “Then we're actively seeking out to engage with those patients to make sure that they don't fall into the abyss.”
The use of medical devices at home, like blood glucose monitors or blood pressure cuffs, is helping to empower patients in tracking their own illness and engaging with the providers.
However, as a preventive strategy moving forward Barrell did note the utility of widespread use of Bluetooth-enabled remote patient monitoring tools that feed data directly into the patient record. Healthcare is still lagging in this area, and that caused the industry to be woefully underprepared for delivering chronic disease management even during a health crisis.
But ultimately, the shift to telemedicine use for chronic disease management is a great step forward, with or without coronavirus concerns, Barrell said. The convenient care option is a boon for care access and patient experience.
“It’s really interesting to me because in a lot of ways patients are even happier,” she concluded. “So many patients who come in to see me, like for a blood pressure recheck or to see how they're doing with their depression medications, see that it doesn't need to be in the office. Most people have been totally blown away at how much can be done by telemedicine.”