Wither Primary Care, During and After the Virus

June 12, 2020 by David Nitkin | Categories: Healthcare Series Two: Futures | Tags: counselling, Health science

The Issue

Half of the primary care practices (face-to-face appointments at a doctor’s office) in Canada and the United States are small businesses. This means that they are battling the virus on the frontlines even as they are on the verge of going out of business. Use of virtual care has rapidly been rolled-out across Canadian provinces, most of whom have introduced a temporary fee code change that allows physicians to more flexibly bill for virtual (also called remote or distant) visits.

Primary care, which for years changed at a snail’s pace, has undergone a revolution in a few short weeks. Up to now, primary care has been driven by the face-to-face visit at the physician’s office. Today, this method has been rendered obsolete and harmful by the social and economic upheaval of the coronavirus pandemic. The number of distance visits—specifically defined as e-visits, phone visits, and video visits—has exploded, leading to a breathtaking change in primary care. But will we return to our old ways once the pandemic has played itself out?

This blog post considers three questions:

Why should distance visits become the new normal for primary care during the virus?
Can and should primary care change in the long term?
And what is the likely and desirable future of primary care?

Primary Care Was Already Under Stress

Face to face, in-doctor’s-office-care is in trouble. Over the past five years, pre virus, in the U.S., Canada and England, there are many reasons and grounds to conclude that all has not been well with primary care:

Family medicine burnout rates in the U.S. and Canada exceed 50 percent, leading clinicians to reduce their hours, thus further restricting patient access. Direct observation of 57 physicians found that 27 percent of their average day was spent face to face with patients; 49 percent was consumed in electronic health record and administrative work.
A Merritt Hawkins “secret shopper” survey in the U.S. found that primary care wait times grew by 30 percent from 2014 to 2017. With poor physician-office primary care access, patients are going elsewhere.
From 2002-2015, acute primary care visits per capita in the U.S. dropped by 30 percent while urgent care, retail clinic, and emergency department visits increased.
For clinicians, primary care is no longer “do-able.” According to Kimberly Hawblitzel Yarnall and colleagues, it would take (an impossible) 21.7 hours per day to care for a standard patient panel (case load) of 2,500.
To make matters worse, primary care in the US receives only 6–8 percent of health care expenditures compared with an average of 12 percent in other developed nations.
Many patient-initiated phone visits/e-visits/calls are hurriedly answered at lunch or after work. In fact, the percentage of primary care practices offering phone visits in the U.S. declined from 2008 to 2015.
Investment in primary care in the U.K. has fallen well behind investment in hospitals, despite increasing expectations of the work that should be done in primary care. Between 2003 and 2013, the number of hospital consultants increased by 48 per cent while GP numbers increased by only 14 per cent. Indeed, the number of GPs per head of population has declined since 2009, with major problems of recruitment and retention.
Nursing shortages is another area of serious concern, with an ageing workforce in general practice nursing and similar problems of recruitment and retention. Between 2001 and 2011, the number of community nurses in the U.K. fell by 38 per cent and there is a growing dependency on agency staff.

Ending the hegemony of the face-to-face visit and rebalancing the appointment template toward 50 percent distance visits are likely to improve patient access while reducing work and burnout. Studies are mixed but suggest that e-visits and phone visits:

(a) reduce the number of face-to-face visits,
(b) take less time for clinicians and staff, and
(c) for many procedures reduce demand for hospital visits.

When the Kaiser Permanente system in Hawaii massively changed its primary care model in 2004—with e-visits and phone visits increasing six-fold and eight-fold, respectively—office visits decreased 26.2 percent.

Responses for Progressive Primary Care Leaders

For physicians who are unable to see patients who require regular and ongoing care unrelated to whether they have or are suspected to have COVID-19, there are a number of steps you can take to help your patients.

Accept the realities that providing care during a pandemic has the potential to alter how we understand the standard of care.
Avoid as much as possible simply redirecting patients to the Emergency Department of your local hospital. Hospitals are also being overwhelmed and finding means for providing care in the community as much as possible helps the entire system respond to this public health emergency. Instead, do your best to help patients navigate the system to find the care they need while you’re unavailable to them.
Try implementing virtual care to provide that care directly and ensure they get the care they need or to help triage patients, thus helping them problem-solve their issue, and re-direct them as needed.
Participate in triage systems that have been set up across most health-care organizations that involve front-desk staff, nurses, and doctors to manage incoming calls and determine which patients need to be seen in clinic.
Try coordinating with colleagues to provide coverage. This may include associates whose scope of practice and time availability are different than yours, but who are able to provide assistance either virtually or in-person.
While pharmacists are also currently experiencing the pressure of delivering care during the pandemic, they may be able to assist in some instances, like extending of renewing prescriptions.

During this crisis, primary care providers are particularly well-positioned to demonstrate the value of accessible, comprehensive and well-organized care based on existing established relationships of trust with patients. A helpful five-stage care delivery strategy (Women’s College Hospital, Toronto) based on variations in patient care needs in this COVID period looks like this:

1. Triage and remotely manage minor acute illness: The first phase or step, which continues today, is to limit in-person care, cancel non-urgent patient visits, and shift other appointments to phone or video calls. “This step was and remains essential,” said Dr. Bhattacharyya. “It’s clear, though, that this triage system could be improved by using a more algorithmic approach through AI, for example. This approach could also include classifying patient requests and determining whether patients are best suited to phone, text or video for assessment and advice, only escalating to face-to-face care when needed.”

2. Remotely manage chronic disease: As COVID-19 continues, primary care providers will need to shift their approach towards remote management of chronic disease, principally to help reduce complications that can result in hospitalization. “There are many different options to make remote monitoring of chronic disease work in the primary care setting,” Dr. Agarwal explained. “For example, clinics can e-mail patients’ symptom scores or online questionnaires. Patients with one central chronic disease, such as diabetes, could be prescribed an app that could track symptoms and provide analysis and targeted patient education.”

3. Provide virtual care for patients with severe acute illness: Should a virus surge occur, primary care providers will need to use remote management for severely ill patients who would normally be admitted to hospital. Use symptom scores and basic vital sign collation at home to be called or e-mailed in. Alternatively, more robust monitoring systems could be set up. Use Bluetooth enabled devices with automated alerts and the ability to dispatch staff to homes when necessary.

4. Provide virtual home-based palliative care: If the health system does become overburdened, transferring patients with life-limiting illnesses to hospital may become impossible. In that scenario, primary care providers would need to undertake a rapid scale-up of home-based and remote palliative care for patients with severe COVID-19 or other conditions that are not responsive to treatment. “In this difficult scenario, primary care providers would need to discuss advanced care directives with their patients and then partner with palliative care experts and home care agencies to monitor patients and provide ongoing symptom management support,” said Dr. Agarwal.

5. Consolidate the primary care system of the future: Primary care can be deeply engaged in every phase of the COVID-19 response and, by developing a range of primary care-based initiatives, the health system can more quickly move patients out of the hospital and back into their communities. “The extensive use of virtual care will allow us to reflect on where it has been most effective and develop new models of primary care that will continue after the pandemic has been addressed,” said Dr. Bhattacharyya.“

New Normal Primary Care Strategies During COVID

The following practices are drawn from a Trends, Forecasts and Outlooks workshop offered by EthicScan, as strategies that would help to relieve pressure on the system and support access to care more generally.

(a) Define a new normal “care in person” standard by:
- i. conducting a risk assessment in advance of resuming primary care services,
- ii. implementing a hierarchy of hazard controls, and
- iii. redesigning your practice structure to implement public-health guidance regarding, for example, social/physical distancing and proper hand hygiene.

(b) Exercise judgment regarding the appropriateness of providing in-person care. This means:
- i. continuing to make decisions that are proportionate to system capacity,
- ii. minimizing harm and prioritizing services that mitigate the greatest risk of harm,
- iii. being equitable in facilitating access to care, and
- iv. supporting those burdened the most as a result of the recent restriction in access to care.

(c) Make virtual care the default modality. Doing so helps to minimize the spread of the virus, conserve PPE, and save your in-person capacity for those instances where it is most needed.

(d) Implement innovative office design respecting physical (social) distancing. Set up your physical workspace and manage your practice in a way that enables staff and patients to observe physical (social) distancing (e.g., barriers at screening points, limited/separated seating in waiting rooms, assigning in/out routes with signs and/or visual markings, limiting the use of some examination rooms, having patients wait in their cars (if possible), reducing appointment availability, and staggering shifts within group practices.

(e) Have appropriate hygiene systems in place, including disinfectant for the office, support hand hygiene among staff (e.g., before/after every patient) and make hand-sanitizing stations available to patients.

(f) Screen all patients in advance (when possible, through video or telephone consultation), and at the point of entry for care. If you are unable to safely isolate and/or provide care to symptomatic patients, redirect them to appropriate access points (for example, emergency room if care is urgently needed).

(g) Report cases of COVID-19 to your local public-health unit.

(h) Encourage patients in advance to bring and wear their own mask for their own safety and the safety of others, especially in instances where social/physical distancing cannot be maintained. If patients do not have a mask, provide them with one or keep them isolated from other patients, and/or reschedule their appointment if necessary.

(i) Consider using services of senior retired or semi-retired colleagues, retired or currently inactive, out of province physicians, and trained residents who may wish to help out temporarily.

(k) Empower patients with minor conditions or in an emergency to provide self-care for themselves, family members, or persons close to them to ease strain on health-care system, especially if another qualified health-care provider is not readily available.

Primary care in Canada, the U.S. and the U.K. needs to change. An overall vision of primary care going forward post COVID for individual practices arguably could or should feature:

A stronger patient needs focus that is still based around the GP practice but holding responsibility for the care of its registered patients.
An expanded workforce. Many existing healthcare professionals will develop new roles, and patients will be seen more often by new types of health-care professional such as physician associates.
Clinical staff will have access to better administrative support and, when needed, healthcare professionals will be able to spend more time with their patients to discuss and plan their care.
Staff will also be able to better communicate with patients and with other health professionals by phone, e-mail, electronic messaging and video-conference.
Triage logic IT systems will become joined up across providers of primary care.
Primary and community care staff will also work closely with secondary care and social services.
If administrative staff (such as medical assistants) took on half of necessary administrative work, this would be equivalent to 1,400 more full-time GPs in England.
Premises in Canada and the U.K. should be upgraded, making better use of existing community facilities in order to support closer working with hospitals and with social services, and to provide a wider range of diagnostic facilities.
Increase recruitment and retention of GPs.

New Normal Primary Care Practice Principles After COVID

In the longer term after COVID, here are some ideas drawn from discussions that created a Scenario Development and Testing framework developed by EthicScan.

(a) Do not arbitrarily limit the number of issues that can be addressed in an appointment (that is, one issue per visit). Doing so leads patients to self-triage, which introduces risks as patients are not trained to identify what is or is not most pressing or concerning.

(b) Enhance compatible distance visit services. Ending the hegemony of the face-to-face visit and rebalancing the appointment template toward 50 percent distance visits is likely to improve patient access while reducing work and burnout. Studies are mixed but suggest that e-visits and phone visits reduce the number of face-to-face visits and take less time for clinicians and staff.

(c) Re-direct certain medical conditions more appropriately. Several medical conditions are best diagnosed, treated and monitored in other settings and/or through e-visits with home monitoring. The list includes:
1. diabetes,
2. hypertension, and
3. common musculoskeletal problems.

(d) Offer more multi-disciplinary group capitation schemes. Fee-for-service reimbursement with its time-consuming documentation is increasingly inappropriate.

(e) Explore better and smarter ways of networking such as hospital doctors working more closely in community settings.

(f) Encourage e-mail communications with patients as is the case in countries such as Denmark. If 5 per cent of GP consultations could be dealt with by e-mail, this would save 17 million face-to-face consultations a year.

(g) Make better use of after-hours communications platforms. There should be a single point of access to out-of-hours services to avoid patients needing to make more than one call to get advice. Software solutions should have full access to electronic medical records including care plans.

The Issue

Primary Care Was Already Under Stress

Responses for Progressive Primary Care Leaders

New Normal Primary Care Strategies During COVID

New Normal Primary Care Practice Principles After COVID

Further Reading