Oregon and Virginia physicians create start of a “road map for how primary care should respond to a pandemic”

July 21, 2020
From the Virginia Commonwealth University press release by Jackie Kruszewski

Primary care doctors were not prepared for COVID-19 and have to reinvent how they practice, say physicians in a paper published this month in the Annals of Family Medicine. The paper is coauthored by Department of Family Medicine Chair Jen DeVoe, M.D., D.Phil., and Assistant Professor Anthony Cheng, M.D. Alex Krist, M.D., a professor in the Department of Family Medicine and Population Health at the Virginia Commonwealth University School of Medicine, is the lead author.

The authors write that primary care practices have a crucial role to play during a pandemic — namely, keeping people out of the hospital.

When COVID-19 hit, primary care providers struggled with a lack of testing and supplies, a lack of unified operations, and financial systems not designed to proactively help communities. Many practices shut their doors and furloughed staff.

“But 75% of Americans have primary care physicians, and 54% of all doctors’ visits are made to primary care physicians," Krist said in an interview. “If you shut your doors, patients are abandoned. They go to overwhelmed emergency rooms, or they avoid the health care system and get sick.”

On the other hand, primary care practices can’t operate as usual during a pandemic. Inviting vulnerable patients into shared waiting rooms endangers patients and staff.

“There’s no road map for how primary care should respond to a pandemic, and the paper outlines the beginnings of one,” said Krist.

Using a model established by the Centers for Disease Control and Prevention to address outbreaks of flu, “Redesigning Primary Care to Address the COVID-19 Pandemic in the Midst of the Pandemic” recommends several actions for primary care providers at each stage of the outbreak.

Recommendations include early and widespread testing done in the primary care setting and a virtual-first approach to triaging patient care to determine who needs to be seen in person. As hospitals become busy and care for more patients, primary care physicians need to be ready to provide “home hospital care” through virtual monitoring and home visits for sick patients who want to avoid the hospital or cannot go because it’s at capacity. And as a pandemic begins to subside, primary care practices should transition to rehabilitation and support for survivors, tend to the secondary health impacts such as declining mental health and worsening social needs, and address pent-up demand for other health care.

Authors developed the paper in response to the transformations they've seen at practices over the past four months. While much media attention has focused on hospitals and intensive care units, primary care clinicians were working hard on the front lines to protect their patients.

“The pandemic was a crisis for primary care,” said Krist. "Physicians needed to redesign their practices overnight.”

COVID-19 brought three groundbreaking changes to rules around medical care in March. Technology requirements for telehealth were relaxed. Cross-state treatments were allowed. And pay structures were updated to accommodate virtual care.

Primary care practices, though, weren’t prepared for these changes. And if the changes stick around, which the authors hope they will, physicians need to adapt, especially as COVID-19 infection rates are increasing again. 

The paper isn’t just for other doctors. Policymakers, insurers, and communities need to continue to support primary care as the first line of defense during a pandemic.

“Primary care is the backbone of our health care delivery system,” Krist said. “And it’s a place where people need to be able to go to have questions answered and needs taken care of, especially during a pandemic.”