In this installment of "COVID-19 health equity initiatives," we see how COVID-19 and systemic racism have impacted the lives and health of essential workers in Massachusetts.

Cambridge Health Alliance

Our outpatient COVID-19 response was designed as a centralized strategy guided by Cambridge Health Alliance’s dedication to “most lives and life years saved.” We knew that primary care was uniquely positioned to both prevent and mitigate COVID while continuing to provide care that would decrease the risk to patients of health consequences from lack of access to preventive medical care and care for chronic conditions. In the context of the pandemic, the need to take an approach that was even more equity-focused and patient-centered was paramount.

Our response to community COVID spread was coordinated but also proactive, with a focus both on a population health strategy to continue to provide important preventive care and care for chronic medical conditions and an intensive outpatient COVID management strategy designed to emphasize mitigation strategies and programs to support patients with COVID or suspected COVID.

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Continued provision of preventive care and care for chronic medical conditions

We transitioned in March 2020 to a 95% telemedicine-based primary care structure, with limited in-person visits available for the evaluation and management of acute needs as well as the provision of important preventive care like early childhood vaccines.

This strategy allowed us to keep patients and staff safe while minimizing the unnecessary use of personal protective equipment. Additionally, with an eye to mitigating the downstream consequences of inattention to chronic medical conditions, a rapid transition to telemedicine allowed us to continue providing non-COVID care to patients during the first pandemic surge. We additionally created a registry of approximately 30,000 patients with risk factors for severe outcomes with COVID, and proactively reached out to these patients to provide education and counseling on hand washing and social distancing, as well as confirming that they had adequate refills of their medications and offering televisits with their providers to discuss their medical conditions.

One feature of our system that increases the value of this type of outreach is that our employees often come from the various communities we serve, with many having language and cultural competencies that allow them to be trusted sources of information.

A COVID strategy focused on mitigation and patient support

Our COVID outpatient management strategy, developed in March 2020, consists of a central triage center for our 12 primary care practices to address all COVID-related complaints, a dedicated respiratory center for in-person evaluation as needed, and a longitudinal telephonic community management strategy designed to follow patients throughout the course of their illness.

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We additionally deployed our considerable presence in the community to engage in broader educational efforts, including unconventional means like church gatherings and Facebook Live sessions, to reach populations in ways that were meaningful to them. These sessions also served to provide us with information about what our communities felt they needed most, and about perceived or real barriers to care. Our strategy also included a focus on “planned redundancy” in counseling of patients about social distancing, self-isolation, and self-quarantine, as well as concerted efforts to address barriers to these edicts, for instance by working with partners to provide alternative housing, or food delivery.

Finally, we embedded an understanding of the need to understand our own “microtrends” early on, which allowed us, among other things, to realize early on that our Hispanic/Latinx community was disproportionately represented in COVID-related hospitalizations, and to tailor our response accordingly.

"A coordinated outpatient approach to COVID should be informed by the strengths of primary care, including a focus on population health and prevention."
—Jessamyn Blau, medical director, COVID Outpatient Management

As COVID spread to Massachusetts, it was clear that our patient populations would experience the brunt of the surge in cases in our state. Many of our patients are essential workers and/or live in crowded housing or have unstable housing, increasing their risk for COVID. Additionally, many members of our population have chronic medical conditions, compounded by historic and continued systemic racism, which predispose to severe complications of COVID.

Our COVID strategy was developed in March 2020 and is ongoing.

  • Decreased unnecessary use of key resources, including PPE and emergency department visits
  • Improved access to key resources for vulnerable populations due to adequate conservation
  • Improved patient satisfaction and trust in the health care system
  • Public health departments from the cities of Cambridge, Somerville, Malden and Everett
  • Transportation coordination with Cataldo Ambulance Service
  • CHA Community Health Improvement team worked with CHA’s volunteer health advisors to liaise with a variety of community partners

As we emerge from this first surge, we have focused on 1) rapid re-expansion of primary care services with a population health approach designed to provide much-needed care for target populations of children needing vaccines and screenings, frail older adults, and access to reproductive health services and 2) ensuring continued excellence in outpatient COVID care and process improvement within our existing structures while creating a sustainable model that can adapt rapidly in the setting of future surges.

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A coordinated outpatient approach to COVID should be informed by the strengths of primary care, including a focus on population health and prevention, patient empowerment, and an equity lens. By putting primary care at the center of our approach, we were able to design a pandemic response system that used these tools to guide our COVID-specific care, while simultaneously being able to identify and prioritize care gaps that would otherwise have gone unaddressed.

Finally, we were able to leverage and further develop our existing community partnerships to ensure that we not only reached members of our communities at higher risk for poor outcomes, but that we provided the care and education our patients actually felt they needed.

For more information about the Cambridge Health Alliance initiative, please contact: Jessamyn Blau, medical director of COVID Outpatient Management at [email protected].

Visit the COVID-19 health equity initiatives main page for additional information.

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