Outreach, prevention efforts key to mitigating latest COVID-19 spike
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November 14, 2020 01:00 AM

Outreach, prevention efforts key to mitigating latest COVID-19 spike

Alex Kacik
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    An ad showing a man wearing a mask with the slogan: "I'm protecting those who protect me. Mask up to protect others."
    PRESBYTERIAN HEALTHCARE SERVICES

    Presbyterian Healthcare Services commissioned public service announcements illustrating COVID-19 protection measures. It shared them with universities, community organizations and other providers.

    Presbyterian Healthcare Services has been reaching out to high-risk individuals and families to try to get ahead of complications stemming from COVID-19.

    The Albuquerque-based integrated health system has analyzed electronic health record and health plan data to identify older populations, people with chronic diseases as well as families that don’t have access to quality food, among other social barriers. It has contacted more than 30,000 health plan members since March to make sure they were taking their medicine, keeping appointments, eating well and to ask if they had any questions about accessing care.

    A Presbyterian Health Plan community worker recently reached out to a family of three—a 2-year-old who tested positive for COVID-19; his grandmother; and mother, who is out of work. They are now getting meals delivered to them, financial aid for their utilities and guidance on how to use transportation and telehealth services, helping them stay healthy and out of the hospital, said Dr. Gray Clarke, medical director for Presbyterian Health Plan. 

    “We have delivered almost 3,000 meals to date, with the help of Meals on Wheels,” she said, noting that the nutrition program was part of a social determinants of health effort implemented prior to the pandemic. For the cost of meals, the health plan pays $207 per member; it also provides 14 days of meals for one caregiver.

    New Mexico’s three biggest systems, like many across the country, have been over capacity—both for inpatient and intensive-care beds—for the past two weeks. But lessons learned from the first wave, along with data analysis, have helped providers revamp outreach efforts and streamline treatment pathways, resulting in shorter stints in the hospital and fewer readmissions, as well as better resource allocation.

    “We hope to get an outpatient remdesivir infusion clinic up and running by Dec. 1, which should make a huge difference,” said Dr. Jason Mitchell, chief medical officer of Presbyterian Healthcare Services. “We stratify who is highest risk and make sure they have their refills done, switch them to mail order, convert appointments to video visits and that they are managing their chronic conditions. That has had a profound impact.”

    In New Mexico, the number of COVID-19 cases has nearly doubled in the past month, requiring another all-hands-on-deck response, per Johns Hopkins University data. Most states have fewer than 30% of their ICU beds available, according to HHS data, although those are often conservative estimates since hospitals may have added capacity and often don’t have the staff to manage additional beds, Mitchell said.

    Presbyterian Health Plan has lifted the prior authorization requirement of some medication refills, which has improved adherence and lessened clinicians’ paperwork. Administrators have halted nonurgent surgeries, and trained and redeployed outpatient workers as well as back-office employees in their hospitals. Hospitals in Illinois, where cases have been ballooning by more than 10,000 a day, are also starting to roll back elective procedures. Similar scenarios are playing out across the nation.

    Hospital leaders say they are better prepared for the latest spike, in part thanks to their data analysis. 

    Acute COVID-19 patients commonly have underlying chronic conditions. Providers hope that new data from FAIR Health showing which comorbidities present the most risk could help them hone their risk-stratification, and help prioritize interventions and vaccination distribution.

    “It is tremendously important to say this is the stratification of patients that we need to take a hard look at to try to keep them out of the hospital, or if they are in the hospital, optimize treatment as soon as possible,” said David Pearce, president of research and innovation at Sioux Falls, S.D.-based Sanford Health, who lauded FAIR Health’s research and noted that it matched up with Sanford’s.

    When a high-risk individual is COVID-19 positive and does not require acute care, Sanford sets them up with a blood-oxygen level home-monitoring kit. Once those levels hit a certain threshold, they should see their doctor, hopefully heading off complications that would require hospitalization, Pearce said.

    AdventHealth, which is based in Florida, where cases have increased by about 20% over the past month, has mobilized nursing teams that have helped treat around 8,000 patients in their homes.

    FAIR Health’s analysis of more than 467,000 private insurance claims from April through August revealed that developmental disorders present the most risk across all age groups. Those who had disorders involving speech and language, scholastic skills, central auditory processing, among others, were three times more likely to die from COVID-19 than patients who had the virus but did not have developmental disorders.

    Individuals in the U.S. who are currently hospitalized with COVID-19

    COVID-19 patients with lung cancer were a little less than three times as likely to die compared to COVID-19 patients who didn’t have lung cancer. The mortality odds ratio was 2.75 for COVID-19 patients with intellectual disabilities; 2.48 for those with spina bifida or other nervous system anomalies; and 2.2 for patients with leukemia and lymphomas. Higher mortality rates could stem from exposure to group residential settings, working in essential services or the likelihood of having multiple comorbidities, which significantly increases risk, researchers found.

    Among those who succumbed to COVID-19, 83% had an underlying condition, FAIR Health found.

    “Stratifying comorbidities will give us a public health road map,” said Robin Gelburd, president of FAIR Health. “The provider community and other community outlets and social service agencies can (implement) prioritization based on the most vulnerable, which would presumably translate into policies that allow certain individuals to advance to the front of the line.”

    Providers and public health experts can drill down into why certain populations may not be adhering to recommended practices, and make a concerted outreach with education, assistance and optimal treatment plans, she said.

    Athenahealth has compiled county-level EHR and billing data to identify counties with the most high-risk individuals. Nearly half of Sumter County, Fla., residents are both over age 65 and have been diagnosed with underlying chronic conditions associated with severe illness in COVID-19 patients.

    Males were somewhat less likely to be diagnosed with COVID-19, but much more likely to die from the virus, FAIR Health’s data show. While patients 69 or older accounted for only 4.82% of COVID-19 diagnoses, that demographic accounted for 42.43% of total deaths.

    Those findings aligned with research at Santa Clara Valley Medical Center in California, which developed its own risk-assessment tool. If COVID-19 patients are male, over age 60, have a body-mass index of at least 30 and have comorbidities, they are more likely to get sick. Lower scores of less than two of those criteria were associated with a mortality rate of zero, according to the medical center’s analysis from March until August.

    “As we head into the challenging winter months, there will be additional strain on resources as the pandemic continues and non-COVID related illness require hospitalization,” said Dr. Sanjay Kurani, medical director of inpatient medicine at the San Jose, Calif., facility.

    The medical center is examining which risk factors are driving racial disparities in COVID-related morbidity and mortality.

    “Some of these risk factors could be modifiable,” Kurani said.

    While COVID-19 patients with underlying medical conditions have a harder time fending off the virus, much is still unknown. Even patients with mild symptoms can experience neurological, cardiovascular or other long-term issues, researchers said.

    “Sometimes those with mild symptoms have the most persistent issues, which is worrisome,” Gelburd said.

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