Primary Care Population Management for COVID-19 Patients

Abstract

Background: Most patients infected with SARS-CoV-2 have mild to moderate symptoms manageable at home; however, up to 20% develop severe illness requiring additional support. Primary care practices performing population management can use these tools to remotely assess and manage COVID-19 patients and identify those needing additional medical support before becoming critically ill. Aim: We developed an innovative population management approach for managing COVID-19 patients remotely. Setting: Development, implementation, and evaluation took place in April 2020 within a large urban academic medical center primary care practice. Participants: Our panel consists of 40,000 patients. By April 27, 2020, 305 had tested positive for SARS-CoV-2 by RT-qPCR. Outreach was performed by teams of doctors, nurse practitioners, physician assistants, and nurses. Program Description: Our innovation includes an algorithm, an EMR component, and a twice daily population report for managing COVID-19 patients remotely. Program Evaluation: Of the 305 patients with COVID-19 in our practice at time of submission, 196 had returned to baseline; 54 were admitted to hospitals, six of these died, and 40 were discharged. Discussion: Our population management strategy helped us optimize at-home care for our COVID-19 patients and enabled us to identify those who require inpatient medical care in a timely fashion.