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Thursday Jul 23, 2020

Art of the Pivot: Redeployment as a Family Physician

A few weeks before COVID-19 was even recognized as a pandemic, a team at Rush University Medical Center in Chicago gathered for the first of what would become daily meetings in the repurposed meeting room that eventually was dubbed the Command Center. Initial preparations focused on optimizing inpatient capacity and boosting personal protective equipment supplies, later evolving to ensuring the latest clinical guidelines were well communicated and being followed and focusing intensely on testing capacity and procurement of necessary supplies to keep up with the ballooning demand.

[Chicago Theatre and north State Street]

The Chicago Theatre and North State Street are dark during a shelter-in-place order. While the Chicago’s streets looked deserted, Rush University Medical Center was experiencing a surge of patients with COVID-19. This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

At one point, we were caring for 25% of the patients in Illinois who were critically ill with COVID-19.

Before we knew it, routine ambulatory operations and elective surgeries were on hold at our 697-bed hospital. Daily metrics tracked included the growing tally of more than 49,000 patients who were screened for COVID-19 and the wavering survival rate for hospitalized patients (an impressive 68% among those requiring mechanical ventilation). We heard about the scores of employees from our 10,000-person workforce who were out of work while recovering from COVID-19 or under quarantine awaiting testing -- and, importantly, about redeployment of existing resources to manage burgeoning volumes in the hospital and emergency department.

Redeployment as a concept was understood yet unfamiliar in the sense that many of us had never been a part of an emergency response plan that actually required it. Suddenly, the familiar currency of relative value units and specialized procedures had temporarily lost their worth -- supplanted by triage, testing and inpatient/critical care. Out of this emerged the distressing irony that each year of experience and competence in one's area of training represented an additional year distanced from the needed skills garnered in pluripotent residency training.

Hospitalist-led teams were organized with primary care and specialty-based attending physicians joining the effort on the floors and managing what they could while infectious disease, pulmonary and critical care specialists focused on COVID-19 management.

Enter family medicine. Before the pandemic, many in our department had already been participating in an on-demand virtual care pilot project, offering primary care services virtually during business hours. We were already a year into offering asynchronous "e-visits," a fee-based service providing patients treatment and advice for a handful of common primary care conditions. Consequently, we were well prepared for rescheduling full days of patients and seeing them via video platform or through phone-based interactions. We followed many of the best practices laid out by the AAFP in its toolkit for launching a virtual response to COVID-19.

When appointments for those visits began to decline, we saw an opportunity to proactively engage our older patients and began conducting virtual Medicare annual wellness visits, which allowed us to touch base on delayed care, check in on symptoms and ensure chronic illnesses were appropriately managed. Rush concurrently partnered with the mayor's office to make well-being calls and offer COVID-19 resources and education to seniors in high-risk ZIP codes on the south and west sides of the city, which aligned well with this initiative.

Meanwhile, our department chair organized a collaboration with the city and multiple service organizations for homeless people to provide PPE and hand sanitizer to shelters, arrange for expanded testing, and house symptomatic patients in a downtown hotel with medical staffing. Family physicians signed up early in the pandemic to staff the COVID tent, which was set up within days in the ambulance bay of our emergency department. This became a highly specialized area for COVID-19 screening that prioritized protecting staff and patients, similar to the response Rush led a few years ago when participating as an Ebola treatment center.

Additionally, a large atrium event space was converted into an ER overflow facility for lower-acuity patients, with 24/7 staffing organized across two teams -- family medicine and internal medicine -- paired so each shift had a family physician working to ensure adequate pediatric coverage.

Looking back on our surge plan, we learned many lessons. First, you can never be too prepared. Jumping in early and raising awareness across the organization was extremely important in being able to manage the volumes we saw during the early phases of the pandemic. We quickly grasped the value of having staff cross-trained in key areas, because it allowed more nimble redeployment. And although virtual care offerings had been limited by reimbursement before an emergency proclamation in Illinois required insurers to cover these services, we have a much greater appreciation for the importance of onboarding patients via these platforms more routinely as we move forward.

Like many of our peer hospitals, we continue to work through the recovery process with the intensity of managing more than 1,400 patients hospitalized with COVID-19 fresh in our minds. We now strive to serve similar volumes of patients in an era of social distancing with additional precautions in place to isolate and care for those with symptoms concerning for COVID-19. Physical restructuring, rethinking waiting areas, connecting with patients digitally and rethinking what meetings need to take place at all -- let alone in person -- have all been regular topics of conversation.

Preparations for future upsurges of COVID-19 infection have already begun during the breathing room created by a phased reopening plan and business-led masking policies following an unpopular, but seemingly effective, extended period of lockdown in the state. As cases begin to rise once more, the sense of pride in our initial response is as palpable as the tentative feeling that defines our current state of affairs. But, rather than see this through the lens of fear, I prefer to view it as a perpetual opportunity for growth. The pandemic has laid bare the inequities of our health care system for patients in our communities, while highlighting the consequences of our misguided valuation of primary care services and health education.

Beyond an organized front-line response, we must continue our advocacy to grow a primary care workforce dedicated to improving the very comorbidities that have exacerbated the mortality risk from this novel coronavirus: obesity, diabetes, respiratory disease and other chronic illnesses. Team-based care has never been more important as we seek agility in our care delivery and in our leadership response to an evolving set of challenges. The broad clinical scope and community awareness that family medicine encompasses is exactly what allows us to become masters of the pivot.

Michael Hanak, M.D., is associate chief medical officer for population health and an associate professor in the Department of Family Medicine at Rush University Medical Center in Chicago.

Posted at 02:17PM Jul 23, 2020 by Michael Hanak, M.D.

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