Post Hospital Follow-Up for COVID-19 Patients
Given the unpredictability of the COVID-19 disease, and with so much harm done by COVID-19 to one’s body and life, care of COVID+ patients does not end after discharge from a County hospital or ER. Leaders from DHS Population Health and the Office of Patient Access worked together to implement a new Expected Practice whereby all patients discharged with a COVID-19 diagnosis are contacted at least once, and often several times, after discharge.
Each DHS hospital created a detailed follow-up plan for their COVID-19 patients and, perhaps most remarkably, every patient is to be given a regular empaneled primary care provider and primary care medical home (PCMH) team (if they do not already have one) before they leave the hospital. Once a COVID-19 patient leaves the hospital, they receive a call from their primary care team within 72 hours. Patients are asked if they have a cough, fever, shortness of breath, chest pain or any other lingering effects of COVID-19, but they are also asked if they have access to food or have mental health or life concerns that need to be addressed while they recover. These post-discharge phone visits are essential to provide counseling and moral support to recovering patients as they try to restore their lives to normalcy.
Primary Care Drive-up Services
The World Health Organization states that during a pandemic, continued access to vaccination services is imperative to prevent concurrent outbreaks of other communicable diseases. Patients’ families at LAC+USC Medical Center were hesitant to come to our clinics to receive vaccinations for their children during the Covid-19 pandemic. To minimize exposure and risk to families, we designed a drive-up primary care service offering pediatric vaccinations. Patients are scheduled for an appointment, are greeted curbside by a clinic team member, and remain in their vehicle during the visit.
Additionally, we know that the economic devastation caused by Covid-19 disproportionately impacts the patients and families in our care. Therefore, those who screen positive for food insecurity are met with a box of fresh and non-perishable food at the curb when they arrive for their drive-up appointment. To date, the drive-up clinic has vaccinated over 110 children. One-third of families coming to the drive-up vaccine clinic have received food distribution due to food insecurity. We have received positive feedback from families, who noted that the visit was "quicker than coming to the clinic building" and they "felt safe coming to the drive-up clinic" for vaccines.
Psychological Support at LAC USC
When the pandemic started ramping up, the department of Psychiatry at LAC+USC Medical Center, sensing the weight of this challenge, put together a grand rounds series with the whole department to figure out what role the mental health providers could play in the crisis. There were a lot of reports of front-line health workers at the hospital feeling high levels of burnout because of the stress due to working during the pandemic so Jordan David, resident psychiatrist in the LAC+USC Department of Psychiatry decided to work with Tobi Fishel, head of GME Wellness and the leader of the Health and Healers Heal (H3) program and quality control officer, Laura Sarff to do something.
The outcome: resident physicians in the LAC+USC Department of Psychiatry conceived of, designed, and implemented a volunteer peer support hot line to support all medical center staff who have been impacted by the COVID-19 pandemic. Staff were provided a 30-minute conversation with a mental health provider to help deal with stress by speaking to someone who knows something about what they are going through.
Rancho Employee Childcare-We Are Family
During the pandemic, Rancho leadership has continued to show its strength by looking out for its ‘family’ of patients and employees. Rancho recognized the challenges many staff were encountering as school moved to virtual learning and parents were still trying to come to work. Rancho, in collaboration with Don Knabe Wellness Center (DKWC)/Rancho Research Institute and Rancho Los Amigos Foundation (RLAF), opened the Rancho Employee Childcare Center in late March 2020. Staffing was a kaleidoscope of Rancho clinical staff, Rancho KnowBarriers peer mentors, and disaster service workers from across Los Angeles County.
Children attended the childcare in the DKWC building, with craft supplies and snacks provided by RLAF. Childcare staff and children alike enjoyed our beautiful new outdoor campus; especially the weekly visits to the Rancho Therapeutic Garden. We made cardboard cars, celebrated a couple birthdays, made Rancho Hero posters to celebrate our staff and even created a YouTube video reminding us all to wash our hands and stay six feet apart. Rancho is grateful to the Los Angeles County family for providing us with the extra staffing we needed to provide this service to our employees!
Rancho Expands Telehelath Services
The COVID-19 stay-at-home order threatened the sense of community our patients enjoy at the Rancho Los Amigos National Rehabilitation Center (Rancho). In response, the Ambulatory Care leadership team immediately committed to expanding our telehealth services. In 2019, we averaged 165 telehealth visits per month. After pausing most in-person visits in March 2020, we averaged 400+ telehealth visits per week. Therapy and mental health providers started utilizing telehealth visits. We experienced a new commitment to work as a team to increase the number of patients enrolled and utilizing the MyWellness Patient Portal.
Rancho also wanted to enhance its current telehealth services by developing video telehealth visits via Zoom. The team created practice sessions between a KnowBarriers peer mentor and providers. The experience led to a new workflow utilizing clinic support staff, messaging utility, and Zoom. Today we are beginning to offer video telehealth visits in select clinics. Patients who are interested in a video telehealth visit are offered a video telehealth ‘video test call’ with a peer mentor. The peer mentor has a checklist of tasks to practice with the patient and provide feedback to the provider prior to the telehealth video visit. We are excited to expand & enhance our telehealth services for our patients.
Rancho Finding New Solutions During Pandemic
The team at Rancho Los Amigos National Rehabilitation Center (Rancho) discovered that sick patients recovering from COVID-19 couldn't do things that they used to be able to do – leading them to pull together a new service line for people who had been through COVID-19 and needed rehabilitation. The Rancho COVID-19 rehab team developed a database early on to collect information and track outcomes (ex. how well patients are able to function, how well patients were when they left), so that they could share best practices with the rehab community across the country.
“Innovation was a huge part of success in dealing with the pandemic,” said Michael Scott, Physician at Ranchos. The team also figured out how to do their jobs from a distance, using a video medical interpretation system, and found new ways to get the patients out of the room safely on short notice and in a very collaborative way. Physicians, speech and occupational therapists, psychiatrists, social workers and case managers all came together in a team effort, and the collaboration of the team was integral to every success story.
Rancho Provides Virtual Support During Pandemic
At the onset of the ‘stay at home’ order, Rancho recognized the potentially devastating impact to the large number of outpatients who utilize the many services at Rancho to meet their needs of community. The Rancho KnowBarriers Peer Mentor service stepped up to provide our existing support groups virtually. This was no small task! Establishing a Zoom account, coordinating with the various Peer Mentor support group facilitators to determine potential participants, and develop a system to help participants and facilitators adapt to using Zoom.
Keep in mind that many of the peer mentor facilitators and participants are recovering from a stroke or acquired brain injury; many have limited experience and access to technology. Today we host 9 weekly support groups, in English and Spanish languages, averaging over 100 participants per week! One man joins us from Colorado. The support groups are invaluable to share COVID related benefit programs, testing information, and provide the ‘Rancho community’ support our patients rely on. We would like to acknowledge Rancho Psychology and the Don Knabe Wellness Center/ Rancho Research Institute for partnering with us to provide Virtual support to our patients.
Rapid Transition to Telehealth During COVID-19
The COVID-19 pandemic has ushered in a period of unprecedented and rapid change in how we serve our patients at the Los Angeles County Department of Health Services (DHS). Before COVID-19, over 90% of our patient-provider visits were conducted in-person. By April, we had flipped the paradigm, with 90% of our patients now seen through telehealth encounters. Most of those patient visits were done by phone, utilizing adult and pediatric guidelines for how to conduct team-based provider phone visits. We have also ramped up our capacity to do video and drive-through visits at the same time.
In doing so, we haven’t just maintained access to care for our patients during this crisis, we’ve increased it: the average number of provider visits per day is now up compared to pre-COVID-19 benchmarks. As we shift our approach to serving patients, DHS has created new guidelines for providers on how they can best conduct team-based telehealth visits. It’s part of a broader effort within DHS to use the renewed sense of urgency and mission unleashed by this pandemic to rethink how we can best serve the changing needs of our patients amid a dramatically altered health care landscape. Telehealth has become a critical tool of care during the pandemic, and will certainly continue to be important after the pandemic has ended.
Safe @ Home O2 Program
To mitigate the risk of preventable mortality and optimize access to acute care during the Covid-19 pandemic, the Department of Health Services issued an expected practice whereby Covid-19 patients on low-levels of oxygen could be managed at home. Medical centers were instructed to develop their own, local processes, and LAC+USC Medical Center developed the SAFE @ HOME O2 Program. The program launched on April 3rd, and through mid-July it enabled over 400 patients to return home on oxygen. No patients died at home, no patients died in the field, and no patients died after leaving the ED with oxygen.
The few deaths that were observed occurred after return hospitalizations, with a resulting all-cause mortality of less than 1.5%. Readmission rate within 14 days of discharge was only around 10%, indicating that the program was overwhelmingly effective in preserving acute care access during the pandemic. Finally, patients reported positive experience with the program. Please refer to links below for further information on patients’ experiences.
Patient Education Video: https://lacusc.live/SafeAtHome
Administrative Briefing Video https://vimeo.com/444725266/fff50b538c
Strong Healthy and Resilient Kids (SHARK) Program
Through a multidisciplinary Olive View-UCLA, Rancho Los Amigos, and Ambulatory Care Network partnership, the Strong Health and Resilient Kids (SHARK) program launched in May 2020 to promote resilience and needed service linkages for children and families receiving care across Los Angeles County Department of Health Services. The program, through partnerships with First 5 LA and other community organizations, provides early screening and intervention services to children experiencing toxic stress in the setting of developmental, behavioral, mental health, and/or social needs.
Clinicians from across Los Angeles County can consult the SHARK team for assistance in management or service linkage for their patients. In addition to consultative services, the SHARK program offers a Primary Care Medical Home to pediatric patients with complex care needs and a multidisciplinary team-based inpatient service. With its launch at the start of the pandemic, the SHARK team—three pediatricians, a family medicine physician, a mental health clinician, physical therapist, occupational therapist, and social worker—has served many patients through telehealth visits.
TOC Post-Discharge Call Pilot Using CHWs
Transitioning from the hospital to home is a known high-risk transition period that can be associated with adverse patient outcomes including readmission. Performing timely outreach to recently discharged patients is a best practice and a National Committee for Quality Assurance requirement. However, this can be challenging during the pandemic when there are additional clinical priorities. Four Whole Person Care (WPC) Community Health Workers (CHWs) were assigned to Department of Health Services (DHS) primary care medical homes that had COVID-related staff redeployments.
Partnering the WPC CHWs with nursing, we developed a workflow for the CHWs to perform Transitions of Care post-discharge phone calls to recently discharged DHS-empaneled patients. The CHWs identified patients from a custom report and called them utilizing a phone script that has escalation pathways to nursing, pharmacy, scheduling and/or social work. The CHWs documented in Online Real-time Centralized Health Information Database and coordinated follow-up with multi-disciplinary team members. By the second month (July 2020) of the pilot, 74% of recently discharged patients received outreach within 7 days, up from a nadir of 31%. Given the success of this pilot and the valuable role that CHWs can play in post-discharge support, we plan to expand to additional sites.