ANNUAL HEALTH CARE ISSUE

EPICENTER OF THE EPICENTER

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BY VINCENT SIASOCO, MD, MBA

Based on data from OPWDD and over 300 developmental disability agencies in NY State, a report revealed, "Individuals with intellectual and developmental disabilities (IDD) may be at a higher risk of severe COVID-19 outcomes due to their higher prevalence of pre-existing health conditions."

1. ONCOMING STORM

The new decade began with increasing reports of an unknown respiratory illness affecting large numbers of people halfway across the world. Information on this novel virus and the new condition it caused, COVID-19, was evolving by the day. It spread through cities, then across countries, and eventually reached almost every continent. By March, the storm had reached New York.

Located throughout New York City, Metro Community Health Centers (MCHC) is a network of five community health centers that specialize in providing primary care services along with multi-specialty services to patients with intellectual and developmental disabilities across the lifespan. Recognized by the National Committee for Quality Assurance (NCQA) as a Level III Patient-Centered Medical Home, MCHC provides high quality primary medical, dental, behavioral health and specialty services that are accessible, comprehensive, coordinated, continuous and accountable. The Patient Centered Medical Home (PCMH) is a primary care medical concept that refers to having a single source of responsibility for medical care for a patient. MCHC's comprehensive array of on-site services administered under the direction of a diverse team of primary and specialty care providers and nursing staff ensured access and appropriate and effective coordination of care. The facilities are wheelchair accessible and have specialized equipment, which accommodates a wide range of patient function and ability. MCHC cares for over 5,000 patients, a majority of whom live in congregate settings or group homes. These group homes pertain to certified residential facilities that include Intermediate Care Facilities (ICF) and Individual Residential Alternatives (IRA), and Community Residences (CR).

2. EYE OF THE STORM

"We are now the epicenter of this crisis," stated the Mayor of New York City at a news conference on March 13th. NYC hospital emergency rooms were being overwhelmed by a flood of patients. Calls to 911 saw an increase by 40% on some days during the height of the pandemic causing some callers to wait up to 3-4 for hours for help to arrive.

By March 16th, the patients at Metro Community Health Center had ceased to come on-site to the health centers. The once bustling waiting rooms full of patients, caregivers, and group home staff became eerily silent. Physicians and clinicians quickly became cut off from their patients.

Group home staff called Direct Support Providers (DSPs) and residential nurses were on their own front lines. Addressing the needs of the individuals they cared for in congregate settings posed multitudes of challenges. Lack of PPEs, lack of screening and monitoring guidelines, lack of space to isolate and quarantine individuals, lack of support to address the overwhelming emotional and financial toll. How does one explain to an individual with intellectual and developmental disabilities the need to isolate or quarantine and or to wear a restrictive covering as a mask? How does a DSP struggle to care for the individuals they serve and take care of their own health and families? How does one address receiving patients from a hospital discharge back to the congregate setting seemingly faster when they send them?

3. TRANSFORMATION, CONGREGATE SETTINGS AND COALITIONS

Telehealth: In these unprecedented times and in order to help address the needs of the patients and support the staff who care for them, Metro Community Health Centers quickly implemented a robust telehealth program. Staff were trained on how to schedule, set up appointments, and provide telephonic and video visits. Physicians who could not come onsite for work, were trained on how to work remotely and provide services. Within a week, Metro Community Health Center had completely transformed; providing primary care, psychiatry, psychotherapy, and neurology almost entirely through telehealth. MCHC's telehealth program was supported by both Federal and NY State improvements in reimbursement rates for these services and allowances that had not existed previously for federally qualified health centers.

RHIO: HEALTHIX, a regional health information organization (RHIO), is a health information exchange organization that facilitates sharing of patient information among hospitals and providers throughout NYC. Through HEALTHIX, Metro was able to continue to receive information and identify which of Metro patients were hospitalized, seen in the emergency rooms, and discharged. With this information, Metro staff was able to be proactive and ensure proper follow up with telehealth visits.

Chronic Care Management: Chronic Care Management (CCM) is a program through The Centers for Medicare and Medicaid Services (CMS) which provides extra care management for patients with two or more chronic conditions. This service is conducted outside typical office visits; staff connect with patients over the phone to develop individualized care plans and provide ongoing support to help patients stay on track with their health care goals in between office visits. This enhanced level of care allows Metro to provide more intensive services for some of our highest risk patients, which is critical during this pandemic.

Group Homes & Developmental Disabilty Coalitions: At the same time, health centers were transforming how services were being provided, developmental disability agencies were working together to address the needs of individuals living in congregate settings and the staff who support them. They purchased PPEs, developed plans to cohort those with Covid-19 or may have been exposed, and addressed staffing concerns. DSPs and residential nurses worked overtime to address the needs of the individuals they cared for. Emotional concerns of staff and individuals were addressed at each of the developmental disability agencies. Uniform Hospital and ED discharge protocols were developed by seven I/DD coalition agencies across NYS (collectively called NY Disability Advocates).1,2 The American Academy of Developmental Medicine and Dentistry shared sample ED transfer forms and other valuable tools and resources on their website.

4. LINGERING STORM CLOUDS

As the peak of Covid-19 has passed, NYC has begun to reopen with social-distancing guidelines. Testing and contact tracing capacities have expanded. MCHC's PCMH model of care and transformation to telehealth has been critical during the COVID-19 pandemic. The systems in place related to coordination and quality of care helped MCHC continue tracking diagnostic test results and ER visits, provide medication refills, and ensure continuous care during the pandemic. However, despite reaching the peak of Covid-19, challenges still lie ahead. Concerns regarding sustaining telehealth reimbursement and funding for developmental agencies remain. Efforts to improve communication and coordination between hospitals and group homes continue. Clinical guidance and cohorting efforts in the group homes needs to be addressed. Based on data from OPWDD and over 300 developmental disability agencies in NY State, a report revealed, "Individuals with intellectual and developmental disabilities (IDD) may be at a higher risk of severe COVID-19 outcomes due to their higher prevalence of pre-existing health conditions. A disproportionate percentage of this adult population resides in congregate settings, such as residential group homes, further increasing their risk of contracting COVID-19 and experiencing severe outcomes, including death."3 Therefore, this is an especially vulnerable population whose needs need to be given special attention during this pandemic. We need to remain vigilant, continue to be flexible, and advocate for the I/DD population and the group home staff who support them. •

ABOUT THE AUTHOR:

Vincent Siasoco, MD, MBA, is a Family Physician. He is the Chief Medical Officer at the Metro Community Health Centers, NY, NY, and an Assistant Professor in the Department of Family and Social Medicine and Pediatrics at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, N.Y.

References

(1) New York Disability Advocates (2020). Emergency Department discharge protocol for people who live in residential programs certified by NYS Office for People with Developmental Disabilities. (2) New York Disability Advocates (2020). Hospitalization discharge protocol for people who live in residential programs certified by NYS Office for People with Developmental Disabilities. (3) Landes, S.D., Turk, M.A., Formica, M.K., McDonald, K.E. $ Stevens, J.D. (2020) COVID-19 Outcomes among People with Intellectual and Developmental Disability Living in Residential Group Homes in New York State. Disability and Health Journal. doi.org/10.1016/j.dhjo.2020.100969.