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Primary Care Population Management for COVID-19 Patients
Deborah Blazey-Martin1, Elizabeth Barnhart2, Joseph Gillis2
1Division of Internal Medicine and Adult Primary Care, Tufts Medical Center, Boston, MA, USA. dblazey-martin@tuftsmedicalcenter.org.
Journal of General Internal Medicine
|July 29, 2020
Summary
A new remote population management strategy effectively monitored COVID-19 patients at home. This approach identified individuals needing hospitalization, optimizing care and reducing severe illness outcomes.
Area of Science:
- Primary care
- Infectious disease management
- Health informatics
Background:
- While most SARS-CoV-2 infections are mild, up to 20% require hospitalization.
- Primary care practices can leverage population management tools for remote patient assessment.
- Early identification of deteriorating COVID-19 patients is crucial for timely intervention.
Purpose of the Study:
- To develop and implement an innovative remote population management approach for COVID-19 patients.
- To optimize at-home care and identify patients requiring inpatient medical support.
- To integrate an algorithm, EMR component, and daily reports for efficient patient monitoring.
Main Methods:
- A large urban academic medical center primary care practice implemented the strategy in April 2020.
- The system managed a panel of 40,000 patients, with 305 testing positive for SARS-CoV-2.
- Multidisciplinary teams conducted remote outreach and patient management.
Main Results:
- Out of 305 COVID-19 patients, 196 returned to baseline.
- 54 patients required hospital admission, with 6 fatalities.
- 40 patients were discharged after inpatient care.
Conclusions:
- The population management strategy successfully optimized at-home COVID-19 care.
- The approach enabled timely identification of patients needing inpatient medical care.
- This model demonstrates effective remote management of infectious diseases in primary care settings.
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