Houston family practice encounters COVID-19

Lessons learned: A conversation with Clive Fields, MD, of VillageMD

By Jonathan Nelson

In late February, a patient came in to Village Medical in Houston for her annual exam. She had just returned from Egypt. She presented with mild respiratory symptoms and received appropriate treatment. Three days later, she was notified that some of her travel companions had tested positive for COVID-19. Village Medical referred her to the health department, which in turn referred her to the emergency room where she was hospitalized. Four days later, the CDC confirmed the patient had the new coronavirus. The family physician and nurse who cared for her are now quarantined at home for 14 days and others who came in brief contact with her are being monitored for symptoms, including persistent fever.

The experience has caused Clive Fields, MD, chief medical officer and co-founder of VillageMD, to think a lot about how the country’s frontline physicians should be prepared to handle this potential pandemic.

“It’s a little bit more real for us,” he says.

In the past several days, Village Medical has posted a set of frequently asked questions and a patient risk assessment tool from the CDC. And they’ve established a set of protocols and decision trees to help them triage calls. Their call volume is up 20%. Here is how Fields summarizes their process.

• Anyone who calls the office and wants information on the CDC is directed to https://www.villagemedical.com/covid-19-coronavirus.  
• All patients who want to schedule an appointment are screened with the risk assessment.
• If they screen positive, they are urged to stay at home and then are contacted by one of their health care professionals.
• If negative, they are scheduled for an appointment.
• Patients who come to the clinic instead of calling in are screened at the front desk with the same risk assessment, and if the risk assessment is negative, they are scheduled to see a provider.
• If the risk assessment is positive, they are placed in a designated room where they are evaluated by a provider who has all the personal protective equipment needed to appropriately evaluate that patient.
• If the evaluation leads to another reasonable cause for their symptoms, they are treated appropriately.
• If no other cause is identified and they have no life-threatening symptoms, they are educated on how to quarantine at home. (This is important: quarantine means they don’t leave the house. That’s not an easy concept for most Americans to take seriously.)
• If they have life-threatening symptoms, they are sent to the emergency room, and the emergency room is alerted to their impending arrival.

“You just heard exactly what every family doctor needs to have in place in this state, which is how to make sure people who are sick don’t come to their office and that those who come to their office and are sick are triaged quickly and appropriately.”

Here is the patient self-assessment tool Village Medical uses. You can access it and all their other coronavirus resources at https://www.villagemedical.com/covid-19-coronavirus.

COVID-19 Coronavirus Patient Self-Assessment Tool

If you have symptoms of respiratory illness (e.g., fever, cough and/or shortness of breath), answer the following questions:

1. Have you recently traveled outside the country? Current countries at high risk include all Asian countries, Italy, and Iran.
2. Have you been in close contact with anyone known or suspected to have the COVID-19 coronavirus illness? Close contact is defined as within 6 feet for 3 minutes or more.

If you answered yes to one or both of these questions and have respiratory symptoms:

• Stay home and call [your medical practice]. A patient representative will take your information and have a health care provider contact you to discuss next steps.
• If you believe your symptoms are life threatening, go to the nearest hospital emergency department. We recommended that you call the emergency department immediately so the staff can provide you with arrival instructions.
• If you do not have respiratory illness symptoms, please refer to information below or contact your local health department.

Fields spoke with TAFP about their preparations and process, and about how this outbreak demonstrates the need for robust investment in primary care. Here is an edited version of our conversation.

Jonathan Nelson: Dr. Fields, you've had a an interesting few days.

Clive Fields: Yeah, you know we have. It turns out that we had one of the first two confirmed positive coronavirus infections in Harris County and needless to say, until it’s actually on your doorstep, your planning is inadequate.

The reality of what’s happening is far different than what I think people would like to believe so there are two things I’m happy to help you with; one: the real need to prepare in a much more concrete checklist-type fashion, and two: how this brings out the lack of investment in community-based physicians over the last 50 years. This is exactly why the country needs to invest in its primary care base, because it’s only with a high-touch and high-tech approach that you can really allay patients’ fears and anxieties and deliver the kind of education and health care they need.

JN: Other than the protocols (described above), what are some other actions you’ve taken?

CF: What we’ve seen out of China is the death rate in people over 80 is almost 15%. You’re talking about effectively wiping out the last of the Greatest Generation if we don’t risk-stratify and take care of those patients. So we’ve identified all of our patients over 65 and we communicated with them in a far more concise and specific way about how to protect themselves, given that the current recommendations are for the general population and not the high-risk population.

We tell the high-risk patient to picture yourself in the middle of three large concentric rings the coronavirus being on the outside of the third ring. The first ring is what we call personal protection — handwashing, making sure you are personally clean and practicing good hygiene. The second is what we call environmental protection, which is avoiding areas that are frequently used by others like computer pads and phones and desks and mass transit and things that clearly are out of your control. And then the third ring is a what we call community-based protection, which is avoiding people who are clearly ill.

We’re also advising our high-risk patients to make sure they have all necessary medications for a period of at least 30 days, to not go down to your last pill because of potential disruption to the drug supply. We’re also recommending that people be prepared to be quarantined at home for 14 days. We’re not recommending a run on the stores but for high-risk patients that may have issues with access to both pharmacies and groceries, we’re asking them to plan for 30 days of medicine and 14 days of potential incubation.

We are classifying high risk at this time as anybody over 65, and those at highest risk are those over 65 with comorbid conditions, like heart and lung disease. We have dedicated communications going to those high-risk patients giving them advice above and beyond what is currently being recommended for the general public.

JN: How are you communicating with them?

CF: In our model, all of our high-risk patients have an assigned care management team. So those care managers are reaching out and letting those patients know that we are available 24/7 because in these situations, what I’ve recognized is that the panic and the anxiety is far worse than the disease. And that panic and anxiety is not limited just to lay people. It also affects health care professionals up to and including physicians.

JN: You said your call volume has gone up 20%. How are you dealing with that?

CF: You’ve got to have scripts for your call center. You’ve got to have a patient self-assessment tool because you’re not going to be able to manage all your calls. So if you call our office today, you’ll get a message up front that says if you have questions about coronavirus, please refer to our call center. If you have additional questions, please hold the line and then during the hold time, you’ll hear us actually drive home those three self-assessment questions so when it's time to make the appointment, they know that. Because if you’re positive for the self-assessment, we don’t want you coming to the doctor’s office. We have nothing to help you. We want you to either quarantine at home and be reassured by us or if you’re having life-threatening symptoms, we want you to go to the emergency room. 

JN: This situation has you thinking about family physicians and other primary care providers in the community. Make the case for investing more in primary care.

CF: This is a disease that is going to travel through our communities and for the vast majority of patients, be managed by community-based physicians through testing, education, and the reduction of anxiety associated with the unknown. Nobody is better prepared to do that than those doctors who have a relationship with patients that has been trusted and built over years.

The additional ability that those doctors have is the ability to risk-stratify their patients. They understand which of those patients is high-risk either based on age or comorbidity, and when given the appropriate technology like telehealth in a non-regulatory confined way, they can deliver appropriate care to patients in the community or their home. To send people in this type of situation to a health care system that is effectively being built to manage acute and traumatic injury is not helpful.

Those are the three legs that we should be thinking about: community-based physicians, risk-stratified patients, and technology to assist in reaching those patients. That’s the angle that I want to drive home.

Those are all the kinds of things that an organization like mine can do because of our commitment and access to capital, but it can’t be done by small practices in rural America and certainly not in rural Texas, because they don’t have the regulatory relief and they don’t have the access to data.

We need to make a serious investment in community-based physicians, technology, and analytics that allow us to reach and manage our most vulnerable patients in the site where they’re most comfortable, their home. That’s the message we should be bringing as family docs.

This is our moment. This is a moment for family physicians to take the lead and show their value throughout not just their neighborhoods and their communities, but the country at large when it comes to managing large scale disease that is neither acute or traumatic.

There’s no group of physicians that have the kinds of relationships that family physicians have with their patients in every community in America. And this is the time for us to leverage that trust, use analytics and technology to reach those patients at highest risk. And if we do that, then the death rate in this country will be far less than what would be predicted.

1 Comment

• Juan E. Vargas said 4 years ago

  Thank you Dr. Fields for making this argument for more investment in Primary Care and specifically, Family Medicine. As a fourth year medical student matching into Family Medicine, I am encouraged by doctors like yourself that affirm my decision to go into such an important and necessary field of medicine going into the future.