Pursuing Patients During COVID-19 Pandemic: A Novel Approach to Maintaining Continuity in a Rural Resident Clinic

Osteopathic Family Physician | Volume 12, No. 4 | July/August, 2020

Pursuing Patients During COVID-19 Pandemic: A Novel Approach to Maintaining Continuity in a Rural Resident Clinic

To the OFP Editor,

We are facing a problem in my rural-resident run clinic on how to maintain continuity with patients when the number of visits has been greatly reduced during the COVID-19 pandemic. We were up against the challenging possibility of not monitoring our patients with high- risk comorbidities, which is a significant problem with substantial consequences.

Nationwide, outpatient providers have encountered dramatic decreases inpatient visits. There are many plausible reasons. The social distancing mandates have made it difficult for patients to come to the clinic office. Patients may not realize telehealth is a viable option at their clinic. In accordance with public health and government recommendations, patients are attempting to stay home if possible, Patients may wait too long to call for emergency health care and ignore red flag symptoms due to fear of hospitalization and exposure to COVID-19. Regardless, the bottom line is patient visits are down-trending and the impact is hitting the health care system.

For example, our resident clinic felt the negative impact by having practice visits down 22% in March 2020 as compared to March 2019. Fifty percent of the visits completed in March 2020 were telehealth appointments due to the COVID-19 pandemic. Individual residents’ schedules were noted to have decreased the amount of telehealth or office visits. Patient volumes varied widely, and some clinics only had zero to three patients scheduled per half-day. No-shows and not reaching patients for telehealth visits was also an all-too-common occurrence. Hospital admissions lessened and patients appeared afraid to call 911 for emergency care even when in dire health. Patients may unknowingly be at high risk for poor clinical outcomes and even death. This has enormous ramifications for both patient care and clinic revenue.

The problem is apparent. If high-risk patients with chronic illnesses are not monitored appropriately, detrimental outcomes are sure to follow. We believe that clinics nationwide are experiencing this difficulty and could benefit from a strategic approach to this problem. In our resident-run clinic, we needed a method to blunt these undesirable ramifications.

Initially, we collected a list of patients seen by each resident within the previous year. The lists were provided through our billing company’s assistance to produce specific reports within the requested date ranges. We procured the list through an encrypted file share and a securely managed physical document to fall into HIPAA guidelines. This could also be obtained from the electronic medical record system. The lists were distributed to each resident for review and comment. The lists may also be distributed to any office staff member to review and stratify patients using protocols established by the patient’s physician.

Then, each list was filtered by a chart review to determine the need for follow-up visits. The necessity for the follow-up visit was determined by reviewing the follow-up plan in the last note or by stratifying patients with a past medical history of a chronic illness that would benefit from a follow-up visit. These chronic illnesses included: hypertension, diabetes type I or II, depression, anxiety, congestive heart failure, COPD, asthma, chronic pain, headaches, frailty, etc. All of these conditions are known to have increased patient morbidity and mortality if left unmonitored for extended periods.

Next, consideration was taken to determine the appropriateness of a telehealth visit versus having the patient come into the office if an exam was essential. Patients were slotted for an office visit if labs were needed. An option for a nurse visit for labs post-telehealth visits was available to patients as well.

Finally, the front office staff was sent patient lists of those needed follow-up visits with essential information, including patient identification and type of visit needed (telehealth versus office).

The front office staff would then contact the patients to have them scheduled for a follow-up visit. They also were able to make sure they did not have any immediate needs in the setting of the COVID-19 pandemic. If the patient did have needs for refills or questions for the provider, these messages would be securely sent to the resident from the front office staff.

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Using the flowchart below (algorithm for method), physicians can improve patient contact during the COVID-19 pandemic, and other seasons of visit stagnation.

There is an innate value to reaching out to patients. The patients get the message, “I care about you.” There is a therapeutic element to someone making sure you are doing well and simply checking in, and this is an incredibly powerful gesture from physicians. This proposed workflow allows providers to enhance the physician-patient relationship. This relationship has the potential to play an active part in healing and patient well-being.

Furthermore, we had the personal experiences of watching patient schedules go from zero to four, then to a full load. The more we reached out to patients, the more they responded. This is not only beneficial for revenue but for residents to provide the best care for patients. This approach promotes practice sustainability in these unprecedented times.

In our experience, patients responded well to this invitation and pursuit. This workflow provided an opportunity to answer patient-specific questions and/or refill needs that could be taken care of before the official visit. The overwhelming response was positive and one of gratitude.

In the future, we will have time to reflect on this pandemic, our flexibility, and our response to the

difficulty it brings. What will we say to future generations of physicians when they ask about our pandemic experiences? Can the challenge be reframed as an opportunity for growth and improvement in patient care and workflow of a practice? We argue this is possible and is occurring before our eyes as history is made.

At the core, this strategy benefits the patient and improves care. It was so rewarding that we plan to utilize it yearly or quarterly to engage our patients and enhance patient continuity and quality of care. It is a useful strategy not only now, but in other times when visits are at a low volume. We, as physicians, can use what we learn from this challenging crisis to enhance our ability to pursue our patients in every-day practice purposefully. What an opportunity this situation has presented to us. The newness of COVID-19 is forcing us to rethink medicine. That might be a good thing!

Brianna Buchanan, DO, PGY-2; Ryan Hudson, DO; Regina Bray-Brown, MD