Clearly, the routine services that used to fill our days (annual physical exams, wellness checks, condition management appointments, or even routine acute care visits) now seem so inconsequential as we face the progression of COVID-19. (And, at the request of health authorities, we have called our members to cancel all such “non-essential” care services). While you won’t be reading much about primary care now that the appropriate focus is—and should remain—squarely on available health system capacity (ICU beds, ventilators, hospital PPE, medical staff at these facilities, etc.), we still have a vital role to play in ensuring our members are cared for, while we also preserve capacity for those with the most critical needs.
We call this Pandemic Primary Care. What follows is an outline of how we are flexing our core capabilities and inherent competencies to meet new and emerging challenges.
Relationships. Having an established relationship with the entire care team is invaluable in highly uncertain times. This foundation of trust allows for rapid communications and decision-making.
- Trust. Our entire business is based on trust. There has never been a more urgent need than right now for reassurance around what we can offer our patient members —where to go, what to expect, and how to get vital health information. Knowing that your personal care team knows you, has access to your personal health information, and is available to you, is critical in maintaining trust and building confidence in these uncertain times.
- Truth. Getting accurate, factual information is critical, particularly in the age of the personal printing press and “Aunt Gina” sharing what she’s heard about how ibuprofen increases the risk of Coronavirus or that tanks are rolling into Chicago which is being put under martial law to enforce the quarantine. You want someone who can help you vet health-related truth with simple, factual updates. At Crossover, we are redirecting our marketing machinery from monthly campaigns and launch efforts to mass communications with members, timely client updates, and pushing reliable, real-time content as the situation evolves.
- Time. Both of the above rely on having previously invested time—which cannot occur at the point of crisis—into building a relationship where trust and truth have already been established. Because that previous deposit is going to be withdrawn from (and relied upon) at this time; providers are going to be direct and to the point as they provide guidance and recommendations, with the expectation that this direction will be definitively and decisively acted upon.
Communication. The ability to remain in contact with your care team is essential. Accurate information-sharing through all channels provides critical connectivity despite travel limitations.
- Phone. Our care team is organized as such that we can answer the phone, are available for questions, and can get back to individuals. This is where our hosts, our care navigators, and even other members of the care team (like Acupuncturists, Optometrists, etc.) can be deployed in new ways to be helpful. And since we function as a single care team, we can be redeployed and rotated to new assignments like answering phone calls. This is why cell phone and direct text connection is part of our care model.
- Video. While we don’t love synchronous video, being able to connect in this manner is a viable channel that is increasingly valued during a time of social distancing. This capability is an important extension, and I would argue a necessary bridge, that will help people make the full conversion to digital-first, asynchronous forms of communication in the future.
- Messaging. Most healthcare providers don’t have your email address, let alone a direct way to share information with you. Words of comfort or administrative follow ups (like ensuring lab results are processed or referral information shared) can be processed by non-clinical staff (or performed by “non-essential” clinical staff rotating into “all hands on deck” roles). This back and forth is vital—helping members and our teams stay connected and get questions answered when everyone is working uneven and odd hours.
- Asynchronous. Given the natural queuing that overwhelms synchronous phone and video channels, you also need to have asynchronous channels that allow responses from the entire care team, including responses during non-business hours (⅔ of each day!). This is why we are so bullish on asynchronous messaging, structured question sets, and the ability to store and forward health data, vetted condition information, and related articles to our members.
Capabilities. As primary care providers, we are capable of providing leadership, organization, and direction in times of crisis. The ability to redirect capabilities to meet new needs is a hallmark of a flexible, relevant, and valuable long-term partnership.
- “Chief Medical Officer as a Service.” Each one of our physician leaders is in a position to provide leadership and direction for, and on behalf of, our clients. They also have the ability to tap into local and national physician leadership who collectively bring hundreds of years of experience with large health systems and population health critical thinking, and can apply that knowledge into planning for issues like the ones we are facing now. Being able to provide this “service” to our clients as we all think through large-scale business issues like closing campuses, reducing exposure, considering new policies, etc. is invaluable.
- Virtual. The ability to go fully virtual is now so obvious in retrospect, but until now, it felt like “crying in the wilderness.” As we have mentioned previously, we are all remote now. What is even more interesting to consider is what happens post-COVID-19. Do we return to the way things were, or is this the catalyst to move to a brave new world of “digital-first?”
- Testing. As the ordering and prescribing physicians, we are first in line to make the diagnosis and confirm with testing. We are now adding screening capabilities (phone questionnaires and online question sets) to help prioritize testing due to limited supplies. What’s even better, given our integrations with LabCorp, is that our ordering/resulting process is automated so we can match mass lab processing with mass lab reviewing. This allows us to push negative results automatically (after MD review), and then concentrate all of our communication efforts toward members with positive tests.
- Navigation. One of the biggest issues in normal times is referring to competent, cost-effective, and high-quality secondary care providers. Now that capability is being used as a function to find available testing facilities, number of open hospital beds, and related systems capabilities. Having an entire care team, and a bank of care navigators, working on behalf of members to find these critical resources is incredibly powerful. We have hacked together these lists quite quickly, making the old, outdated, and static information on most health providers sites feel anachronistic, given the dynamism of constantly changing pandemic conditions.
Capacity. Managing care team capacity is critical during disaster situations. We are unable to help everyone; but we can help our own patient members, and ensuring how we are serving our members reserves system capacity for others.
- Disaster Principles. One of the first rules of first aid is that the responder needs to assess the situation and not create further issues by becoming a victim as well. There is also the harsh reality of having to triage individuals in disaster situations with quick judgement and ruthless prioritization (this often feels cold and callous, but is absolutely necessary). In this setting, you have to realize that if you are out of the battle, you are ineffective; that if someone is beyond help, you must move on; and that every decision you make has multiple unintended consequences. These are the harsh realities and ethical decisions that are going to be decided in the days and weeks ahead. The kindness, compassion, and judgement of providers is relied upon to do the right thing with little context, backup, or solace.
- Response Levels. A critical decision point is how to best deploy resources, particularly when those resources are likely to “go down” in the fight. For this reason, we rapidly deployed response levels that both anticipated, as well as communicated, how we saw our position changing with the likelihood that more of our team would be infected over time. This resulted in the creation of six service levels that go along a continuum from full, to limited, to essential in-person, to heaven forbid, none at all. This created a “roadmap” that allows us to both plan as well as predict where the crisis is likely to go.
- Rotations. To avoid the “none at all” service level, we rapidly moved our care teams to virtual (to avoid exposure and preserve capacity while still providing the service), with specific teams rotating in-person to continue to serve. This allowed everyone shared “battlefield” time, as well as time off the front lines (and to be virtual only). As described earlier, we also rotated “non-essential” providers into new roles to serve as support for the more limited services. While this may introduce some conflicts of the relative value of various services at times of crisis, we have been able to maintain a “TEAM” (Together Everyone Achieves More) mindset where everyone is only focused on the higher cause.
Resources. Sourcing and obtaining supplies was once a basic capability that has now become a core competency. Our ability to aggregate hundreds of thousands of members means we can obtain priority sourcing for much-needed basic PPE and related supplies. Resourcefulness in obtaining resources is a critical differentiator during a pandemic.
- Supplies/PPE. Our scale allows us to have priority relationships with a variety of suppliers—particularly valuable now for hard-to-get items like N95 masks, gloves, gowns, and other basics. Without PPE, our teams are unavailable to provide any in-person care. We never thought these would be rate limiters and have had to get creative in pooling with clients to order 100K units of materials at a time.
- Medications. We have been grateful for the long-standing relationship with AS-Meds, who has been both innovative and responsive to new medication orders and processing of requests. Shifting to all mail orders has been seamless as we ensure our members’ medication needs are met. We are looking to expand capabilities to address an even wider array of medication needs, including specialty pharma, to address sourcing issues we anticipate for members.
- Labs. We have maintained a relationship over the course of several years with LabCorp who has been excellent at providing us rapid turnaround times on our tests, worked with us to ensure both orders/results are efficiently processed, and now during this crisis has been able to supply us with testing supplies and media. We are also actively working on a variety of home-based testing capabilities (beyond just COVID-19) and will be bringing that forward in the near future.
Pandemic Primary Care is definitively a new concept for us, but highlights the resiliency and robustness of the care model. In fact, it is this flexibility and anti-fragility that allows this model to thrive in a time of chaos as we move to digital-first (or digital only), redeploy our care teams to meet emerging needs, and continue to serve our members and our clients in urgent new ways.