How the pandemic transformed primary care for seniors

During the Covid-19 pandemic, companies focused on primary care for seniors have been faced with the Herculean task of caring for an extremely vulnerable population.

Not only did the deadly virus more acutely affect seniors, but also routine care for this population — especially necessary primary care — was widely disrupted. A survey conducted last April, which polled more than 1,000 elderly Americans, showed that nearly a third had canceled or delayed primary and preventive care since lockdowns took effect.

Such a seismic event necessarily meant that companies focused on caring for seniors had to scramble to find new ways to operate and deliver care. Not surprisingly, many of them adopted virtual care and remote monitoring — as did the healthcare industry en masse —  but several groups also began fulfilling specific social needs of this population.

Miami-based Cano Health had to quickly pivot to digital solutions to ensure continuity of care for their patients. Prior to the pandemic, only about 1% of patient visits at Cano Health’s 70-plus centers were conducted virtually. By early April 2020, north of 90% of patient encounters were conducted via telemedicine, said Dr. Marlow Hernandez, co-founder and CEO of Cano Health.

“During this pandemic, we at first had huge uncertainty — not having testing, not fully understanding the virus, having no accepted treatment, certainly no vaccine, and thus, the need to protect our patients,” Hernandez said in a phone interview. “That combined with stay-at-home orders required a much higher utilization of technology in order to continue to provide routine services.”

Luckily, Cano had telehealth technology already in place, so it was able to ramp up virtual visits quickly and allow its staff to work remotely.

“We reminded our patients to stay home, stay calm and call Cano,” Hernandez said.

But since all care cannot be provided via digital solutions, Cano Health kept its offices open across three states and Puerto Rico, with the necessary Covid-19 protocols in place. Any patient who wanted in-person care was welcomed to come to a facility.

In addition, physicians could ask their patients to come in if they were displaying symptoms that indicated an urgent need for medical attention, like acute shortness of breath in a patient with cardiovascular conditions and patients with skin abscesses, Hernandez said. 

Like Cano Health, another provider group dedicated to older Americans also employed a hybrid virtual and in-person clinic strategy last year. Oak Street Health, a national network of primary care centers serving Medicare enrollees and those eligible for both Medicare and Medicaid, leaned heavily on telehealth while continuing to provide in-person services at its 80 clinic locations.

To do so, Oak Street Health made a big investment in personal protective equipment and infection control protocols. The latter included conducting thoughtful symptom screening, isolating patients properly, turning over rooms safely and making sure there was appropriate ventilation in its centers.

The company, based in Chicago, used while continuing to provide in-person services when needed. It was able to pivot from 0% telehealth visits to 94% in 10 days, said Dr. Ali Khan, executive medical director, in a phone interview.

Further, Oak Street initiated a large remote monitoring program through which it checked in on some patients daily. They gave home-bound patients necessary medical equipment, like pulse oximeters and thermometers, and went a step further by also delivering prescriptions and food.

The company was able to care for its patients in this way because of the large community engagement teams staffed at all of its centers, said Khan. These teams screened for social isolation and monitored for behavioral issues as well as helped identify the patients who would need home visits.

Oak Street Health’s business model — which involves a fixed payment amount per patient, per month and is not based on fee-for-service — allowed it to easily flex and tweak its care delivery model, Khan said.

“We were able to continue to deliver care where it was needed most — be it virtually, in the home or in the center,” he said. “[Our business model allowed us] to make logical investments around like [getting] food to people because that may keep [patients] safer than the alternative.”

Similar to Oak Street Health, Conviva Care Centers also used home care services to identify and address social determinants of health. The senior-focused primary care physician group, with headquarters in Miami, cared for certain patients in their homes. This allowed clinicians to address the social factors that were negatively affecting their patients’ health, said Dr. Steve Lee, president of the physician group, in an email. 

“Our senior patients faced real struggles when it came to transportation and the ability to get to or receive food,” said Lee. “Many Conviva centers became food distribution centers to ensure patients and the community was receiving food that they desperately needed.”

Evolving strategy amid uncertainty
One of the biggest challenges of the pandemic last year was uncertainty. The constantly evolving medical science and understanding of the new coronavirus made it hard for health centers to ensure they were following appropriate protocols.

“Staying connected to medical societies, hospital systems and all of our great clinicians is one of the ways we continue to overcome that ongoing challenge,” Lee said.

And when providers thought they had landed upon a good solution with remote and virtual care tools, even that threw up some challenges. Uneven internet access among seniors was one of the biggest barriers to technology-driven care, said Renee Buckingham, president of Humana’s Care Delivery Organization. The Humana division includes Louisville, Kentucky-based Partners in Primary Care, a national senior-focused primary care company with 158 health centers.  

“We had to overcome some of the disparity gaps with the patient population,” she said in a phone interview. “Around 70% of our total centers are located in healthcare shortage areas. These are communities that don’t have access to good healthcare.”

So, Partners in Primary Care started conducting drive-by visits. This type of visit involved patients staying in the parking lot of the centers, and medical assistants bringing iPads to the cars so patients could connect with their clinicians virtually, Buckingham explained. Patients who were not comfortable coming into a center and also did not have reliable internet access could avail of this option.

Cano Health faced similar issues, with video adoption presenting a particularly intractable challenge. Not only were the technical aspects of telehealth difficult for seniors to figure out, but many were also reluctant to appear on a screen, said Hernandez. So, Cano Health focused on getting their patients comfortable with voice-enabled telehealth.

“[Video] is helpful, but it’s not like we’re a dermatology practice,” Hernandez said. “While you can get information from looking at a patient, unless you can put your stethoscope [on the patient], and palpate…it is sub-optimal. I would say 90% of telemedicine visits could be accomplished using just audio.”

But it wasn’t just the patients’ welfare that senior leadership at these various primary care companies had to contend with. Another was provider burnout. 

The healthcare workforce, while running a veritable marathon at work, was also facing some of the same problems plaguing other Americans during the pandemic — child care, for example.

Oak Street Health and Partners in Primary Care extended paid time-off benefits and worked closely with their staff to make sure their schedules were flexible, so staff could meet the needs of their families as well as care for patients.

“Keeping people sane while schools were closed, and ensuring we were paying attention to our providers’ needs was really crucial,” said Oak Street Health’s Khan.

Looking ahead to 2021
The new year brought with it a new phase in the course of the pandemic: vaccination.

States are slowly starting to vaccinate the elderly. This provides a host of new opportunities — and poses new challenges — for senior-focused primary care organizations. They are now coordinating with state health agencies to get vaccine supplies and play their part in the rollout.

Even with supplies, these organizations may still have to contend with a more obstinate issue: vaccine hesitancy. According to a poll of more than 1,500 older adults, conducted last October, 46% said they want to wait to get a Covid-19 vaccine until others have received it, 20% were unsure about getting it and 14% did not want to get it.

Oak Street Health is addressing potential hesitancy issues head-on. The organization is cultivating trusted messengers, among its own staff and within the communities it serves. The Oak Street Health staff is diverse and looks like the patients they care for, which helps them build trust more easily, Khan said.

Further, the group is working to vaccinate unaffiliated healthcare workers, he said. For example, in Illinois, Oak Street Health has vaccinated over 13,000 individuals, of which 8,000 were seniors over the age of 65, and 5,000-6,000 were home health workers, behavioral health therapists and private care physicians or nurses who were not affiliated with a hospital, health system or large physician group.

“What we uncovered was that, for many, institutional affiliation became a huge health disparity because without being associated with an Oak Street or big health system, you might not have access to a vaccine,” said Khan.

Vaccine access, ongoing Covid-19 hospitalizations, and deaths, new coronavirus variants — there is still much to overcome before the pandemic is fully curbed. But senior primary care companies are hopeful about finding opportunities amid the challenges.

“It’s amazing how crises can drive so many good things while you are dealing with some of the challenges,” said Partners in Primary Care’s Buckingham said. “Like the rapid adoption of virtual capabilities by our providers and our patients [which] I think will have a really long positive impact. I’m really proud of how quickly we pivoted.”

Photo: Tempura, Getty Images

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