Screening and Testing

The APPS were assigned to the RICs to screen patients for symptoms, travel history, and contact exposure, as well as perform nasopharyngeal reverse transcription polymerase chain reaction (RT-PCR) testing to confirm COVID-19 infection. Primary care providers would refer patients with minimal symptoms for testing only. Screening and testing visits were every 10 to 15 minutes depending on the proficiency of the APP. Ninety APPs were assigned to the RICs.  The majority came from primary care practices. Specialty APPs came from surgery, cardiology, neurology, urology, orthopedics, and women’s health.

The current recommended testing criteria was posted daily and reviewed with APPs in pre-shift huddles. Guidance on how to counsel patients who were not eligible due to availability of tests was shared, which included external resources when available. After screening, patients who required a test were seen by an APP who had demonstrated proficiency. The APPs performing RT-PCR testing received training through online videos and real-time learning from a preceptor.

Results Management

APPs assigned to results management were responsible for interpreting and relaying COVID-19 and other laboratory test results, most commonly streptococcal pharyngitis culture and respiratory syncytial virus (RSV) results. During telephone calls, APPs provided health education, counseling, and clinical guidance.

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Patients with positive COVID-19 results were contacted by APPs while other team members called patients with negative COVID-19 results. The APPs educated patients on self-isolation techniques for households that had COVID-positive and COVID-negative members, symptom management, and when to seek care for worsening symptoms. At the time, COVID-19 was an evolving disease with variable clinical presentations; APPs needed to rely on their clinical knowledge and communication skills to determine if a patient was safe to remain at home or needed to go to the emergency room.  APPs commonly helped patients facilitate coordination of private vehicle, public transportation, or an ambulance ride to the RIC or the ED.

Other patients needed an in-person assessment. In these cases, the APP coordinated with emergency medical technicians who could enter patient homes and report the patient’s vital signs and physical status to the APP remotely. This partnership permitted the APP to assess aspects of the patient’s clinical presentation, like a fever and hypoxia, which were not apparent over the phone.

Fifty APPs worked remotely 12 hours a day 7 days a week monitoring results in an electronic medical record, where 300 to 350 results were added daily into a shared pool. The team was led by 2 experienced APP leaders, a NP and a PA.

The team had daily huddles that were essential for team leaders to share new information, changes in guidelines that came from the daily Hospital Incident Command System meetings, and provide a forum for discussing new concerns, questions, or challenging patient care scenarios.

Case Management

Early in the pandemic, it became apparent that patients with active symptoms needed to be followed closely due to the risk of rapid deterioration. A separate team was assembled to call patients at 2, 5, and 8 days following an RIC visit with the intent of assessing symptom progression. Primary Care APPs were redeployed as case management APPs. Subtle changes in moderate and mild symptoms often indicated forthcoming clinical decompensation.

Recognizing symptom progression through a review of symptoms, past medical history, and possible exposure to infected individuals involved critical thinking and strong communication skills.  At the beginning of the pandemic, most patients did not have thermometers to provide information about the presence of fevers or pulse oximeters to assess hypoxemia in their homes. When the patient was stable, an important function of the case management APP was to transition them back to the primary care provider’s care, which required close communication and clear care plans.

The case management APPs worked 4 to 8 hours daily, 7 days a week. Peak volumes necessitated up to 22 APPs along with additional physician colleagues covering this role daily. The average daily volume at the RICs was 30 patients, ranging from 2 to 100 patients per day.

Training involved a 2-hour online module led by an APP/Physician team. The primary purpose of this training was to orient the APP to the EHR tools, resources for situations such as decompensation, need for interpreter, or referral to other resources for things like difficulty in self isolation or food insecurity.

Early on, Massachusetts General had partnered with an ambulance company that would provide home visits if needed to potentially avoid a trip to the ED. Given the lack of tools, such as a pulse oximeter or thermometer, this referral allowed the additional assessment needed. If a patient had a challenging home environment, without the ability to self-isolate (separate room and bathroom), a referral was placed for the Chelsea Hotel, which was secured and operated for just this purpose. Ideally the patient was referred directly from the RIC visit, but this was not always the case. Additionally, there were community case workers who were able to follow up with a patient.