Primary care practices should adopt the Centers for Disease Control and Prevention (CDC) pandemic interval framework to create a more agile and responsive first-line of defense against the next COVID-19 wave or new pandemic, according to a study published in Annals of Family Medicine.

The study authors outline how primary care has reinvented itself during the COVID-19 pandemic based on their firsthand experience with community-based primary care practices, which are grounded in the core principle of protecting clinicians, staff, and patients while adhering to the needs of the patient population.

The CDC Intervals Framework was created in 2014 following the influenza pandemic. The framework describes 6 intervals: 1) investigation of cases of novel influenza; 2) recognition of increased potential for ongoing transmission; 3) initiation of a pandemic wave; 4) acceleration of a pandemic wave; 4) deceleration of a pandemic wave; and 6) preparation for future pandemic waves.

During the pre-pandemic intervals, primary care clinicians maintain practice as usual while preparing for a possible pandemic by participating in public surveillance programs and monitoring and reporting outbreaks. Primary care practices should also maintain readiness for an outbreak such as keeping adequate supplies for testing, protective gear for clinicians and patients, and treatments for those who could get sick.


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Although offices are open and functioning normally during the recognition interval, cases may begin to appear in sentinel communities. At this time, primary care practices must enforce social distancing by separating healthy patients from those with symptoms, minimizing the number of patient in waiting rooms, and spreading chairs 6 feet apart. Hand washing before and after each patient encounter is essential and rooms must be thoroughly disinfected after patient visits. Patients who may be presenting with respiratory illness must wear a face mask. To minimize spread, virtual and telephone-based visits should be implemented. Testing is essential; through testing and contact tracing, primary care clinicians can identify patients who need to be quarantined.

The pandemic intervals of the framework include initiation, acceleration, and deceleration. Initiation is marked by confirmation of human cases and global spread. In primary care practices, patients begin showing signs of illness and fear and anxiety is heightened in the community. Primary care clinicians must become leaders in promoting physical distance, hand washing, and limiting contact; this can be implemented by converting to virtual care.

Clinicians may be able to see a patient in-person but only after triaging symptoms through virtual care. To remain in contact with patients, practices can implement proactive population care in which practices shift registry functions to identify vulnerable patients, those at risk for chronic infection, those with uncontrolled chronic disease, or those experiencing social needs. Staff should call these patients frequently to assess and address symptoms as needed.

Acceleration occurs when there is an increasing rate of infection. For primary care practices, this means more patients are infected, have become acutely ill or experience complications that require hospitalization, and/or begin to avoid care for noninfectious conditions. A key goal of this interval is to limit patient contact with hospitals; this will allow patients to remain unexposed and hospitals to focus on patients who need their services.

Primary care practices and health systems will need to coordinate on criteria for emergency assessments, criteria for hospitalization, and overflow care when hospital capacity is exceeded. Outpatient clinicians should be ready to provide inpatient care. Primary care should also be well-positioned to provide home hospital care in which patients are treated at home who normally would be hospitalized.

During deceleration, rates of infection in the community are decreasing. Primary care practices transition from virtual care to in-person care. Practices need to engage with nursing homes, rehabilitation centers, and home health agencies to help care for their convalescing patients. Primary care must play a key role in accepting patients who need rehabilitation care if centers and home health agencies are overwhelmed and cannot accept patients who are post-infectious. Primary care should follow public health authorities to decide when to re-open. Throughout the reopening process, primary care will need to monitor the health of their clinicians, patients, and community. If infections spike, the reopening process may need to be modified.

The final stage of the interval is preparation. This interval is a return to normal where infection activity is low but outbreaks are possible. Before considering the future, primary care will have to address the direct and indirect consequences of the pandemic. Practices will also need to address pent-up demand and adverse consequences from delayed or deferred care. Additionally, practices will need to help patients improve health behaviors, address mental health needs, and improve social risks.

“Primary care of the future must learn from [the COVID-19] experience and be ready for the next pandemic; and policy makers and payers cannot fail primary care and must ensure that funding and policies allow primary care to do what it does best—care for people,” concluded the authors.

Reference

Krist AH, DeVoe JE, Cheng A, Ehrlich T, Jones SM. Redesigning primary care to address the COVID-19 pandemic in the midst of the pandemic. Ann Fam Med. 2020;18(4):349-354.