key: cord-0774978-ahz6jzm1
authors: Matenge, Sethunya; Sturgiss, Elizabeth; Desborough, Jane; Hall Dykgraaf, Sally; Dut, Garang; Kidd, Michael
title: Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature
date: 2021-10-06
journal: Fam Pract
DOI: 10.1093/fampra/cmab115
sha: 4583c703f4711eb6699a4aa4c6cacb593a93192b
doc_id: 774978
cord_uid: ahz6jzm1

BACKGROUND: The COVID-19 pandemic has resulted in the diversion of health resources away from routine primary care delivery. This disruption of health services has necessitated new approaches to providing care to ensure continuity. OBJECTIVES: To summarize changes to the provision of routine primary care services during the pandemic. METHODS: Rapid literature review using PubMed/MEDLINE, SCOPUS, and Cochrane. Eligible studies were based in primary care and described practice-level changes in the provision of routine care in response to COVID-19. Relevant data addressing changes to routine primary care delivery, impact on primary care functions and challenges experienced in adjusting to new approaches to providing care, were obtained from included studies. A narrative summary was guided by Burns et al.’s framework for primary care provision in disasters. RESULTS: Seventeen of 1,699 identified papers were included. Studies reported on telehealth use and public health measures to maintain safe access to routine primary care, including providing COVID-19 screening, and establishing dedicated care pathways for non-COVID and COVID-related issues. Acute and urgent care were prioritized, causing disruptions to chronic disease management and preventive care. Challenges included telehealth use including disparities in access and practical difficulties in assessing patients, personal protective equipment shortages, and financial solvency of medical practices. CONCLUSIONS: Substantial disruptions to routine primary care occurred due to the COVID-19 pandemic. Primary care practices’ rapid adaptation, often with limited resources and support, demonstrates agility and innovative capacity. Findings underscore the need for timely guidance and support from authorities to optimize the provision of comprehensive routine care during pandemics.

The COVID-19 pandemic has placed significant demands on health systems globally, resulting in the diversion of health resources away from routine primary care delivery to address the pandemic. [1] [2] [3] [4] [5] This disruption of health services has necessitated new models of care to ensure continuity of regular care provision. [6] [7] [8] Although several studies have examined primary care responses to COVID-19, [9] [10] [11] there is limited evidence regarding adaptations to models of care and challenges associated with reconfiguring service delivery. This review aimed to identify and summarize practice-level strategies used to ensure the provision of routine primary care during the COVID-19 pandemic response in order to inform current and future practice.

We conducted a systematic search for relevant peer-reviewed literature to 15 December 2020 using PubMed/MEDLINE, SCOPUS, and Cochrane Library. A combination of key terms was used including the following: physicians, general practitioner (GP), family, registrar, doctor, primary, health, care, general, practice, usual, regular, routine, COVID, SARS-CoV-2, "model of care," "models of care," the MeSH term "organizational models," "family practice," "primary health care," "primary care," and "general practice." Terms were grouped according to key concepts-primary care, COVID-19 pandemic, and models of care using truncation and Boolean operators "AND" and "OR." The search string was developed and refined in PubMed and adapted for the other databases (refer to Supplementary Material). Searches were supplemented by hand searching of reference lists of eligible studies and by recommendations of additional articles from team members some of whom are primary care clinicians as well as primary care researchers. Gray literature sources and non-English publications were not included in the review.

Title and abstract screening was conducted by 2 independent reviewers (SM, ES) as was full text screening of relevant articles (JD, SM). Conflicts were resolved in consultation with a third reviewer (JD or ES). Peer-reviewed publications were included in the review if they were based in primary care and described practice-level changes to the provision of routine care in response to Publications were excluded if they were commentaries and guidelines on models of care, related to hospital or community care or allied health services, and specific to education and training. Publications that focused only on the use of telehealth without describing adaptations and strategies from a practice standpoint were also excluded.

Included papers were assessed for methodological quality or risk of bias (SM, JD, ES, SH, GD) using the Mixed Methods Appraisal Tool. 12 Data were extracted from studies by all team members (ES, JD, SM, GD, SH) using a data extraction form that addressed changes to delivery models, impact on primary care functions, and challenges encountered in reorganizing services. Narrative synthesis, an approach used to summarize, compare, and integrate findings from included studies, 13 was used to classify strategies adopted by primary care providers (PCPs) to facilitate provision of routine care, and identify challenges to adaptation. Results were framed and interpreted using Burns et al.'s framework for primary care provision in disasters, 14 which compares characteristics of primary care response across disaster and nondisaster scenarios. We equated COVID-19 with Burns' theory of disaster-related care and compared this with nondisaster usual or routine primary care (see Table 1 ).

• COVID-19 pandemic has necessitated new models of care. • Primary care providers adopted innovative, flexible, and integrated models of care. • Challenges included telehealth use and diversion of primary care resources to other settings. • Acute and urgent care were prioritized disrupting chronic disease management. • Greater efforts are needed to optimize comprehensive routine primary care.

We defined primary care as the first point of health care access, with a focus on general practice, family practice, or officebased medical care. PCPs refer to medical or nursing practitioners who provide care in this setting including family doctors, GPs, family physicians, primary care physicians, nurses, and nurse practitioners.

One thousand six hundred and ninety-nine publications were identified, of which 17 studies were included in the review (see Fig. 1 ). These included 16 empirical studies, [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] including 8 case studies, [23] [24] [25] [26] [27] [28] [29] [30] and 1 review. 31 The evidence base was generally low in quality with many studies having a high risk of bias based on study design and methodology. Tables 2 and 3 provide summaries of included studies and study characteristics respectively. A matrix of usual nondisaster care functions covered by the studies is provided in Table 4 . 14

Five key strategies were adopted to facilitate provision of regular health care: (i) Integrating telehealth; (ii) Limiting in-person care; (iii) Adopting public health measures; (iv) Enhancing surge capacity; and (v) Proactively contacting vulnerable patients.

The shift to remote care was necessitated by the need to prevent the spread of COVID-19 and to ensure continuity of care while protecting providers and patients, especially vulnerable individuals such as the elderly, and those with chronic illness. [15] [16] [17] 19, 20, 22, 23, 25, [28] [29] [30] [31] Telehealth was widely used to facilitate this, with most studies (n = 15) describing its integration into routine care. [15] [16] [17] [18] [19] [20] [21] [22] [23] 25, 26, [28] [29] [30] [31] For many primary care settings, the transition to telehealth occurred rapidly, aided by legislative changes in response to the pandemic. 19, 20, 22, 25, 28, 31 In the United States, for example, the temporary easing by most states of regulations governing telehealth licensing and reimbursement requirements for health care providers accelerated its adoption and expansion. 25, 28, 31 Similar payment mechanisms were provided in the Netherlands, France, and Belgium to promote telehealth services. 19, 20, 22 Other facilitators included technical and organizational factors such as existing telehealth infrastructure (e.g. internet access, digital platforms, and devices), 20, 23, 26, 28, 30 training of providers and patients in the use of telehealth, 26, 30, 31 enabling organizational funding models, and provider incentives for telehealth adoption (e.g. pay for performance). 15, 30 Telehealth was provided through a variety of ways including telephone, [15] [16] [17] [18] [19] [20] [21] [22] [23] 25, 26, [28] [29] [30] [31] video consultations, [15] [16] [17] [18] [19] [20] [21] [22] [23] 26, [28] [29] [30] email, [18] [19] [20] 22, 23, 29 text messaging, 23,28,30 online patient portals, 22, 23, 28 and smart phone apps. 19, 25, 29 Telephone was the primary means of care delivery in many practices and reportedly constituted the majority of remote consultations. 18, 20, 22, 23, 30 Telehealth was adapted to support the provision of a range of routine care functions including disease management [15] [16] [17] 19, 22, 23, 25, 26, 28, 30, 31 and coordination of care. [15] [16] [17] 19, 22, 26, [28] [29] [30] Telephone and video consultations were commonly used for triaging patients and treating acute and chronic conditions that did not require in-person management including nonurgent presentations and stable chronic conditions. [15] [16] [17] [18] [19] 22, 23, 25, 26, [28] [29] [30] [31] Two studies described the use of medical home monitoring devices such as Bluetooth-enabled blood pressure monitors, pulse oximeters, and glucose meters to support chronic disease management. 25, 30 Telehealth enabled care coordination between PCPs and other health care providers including allied health and hospital-based specialists. [15] [16] [17] 19, 22, 26, [28] [29] [30] Telehealth facilitated the screening, triage, and management of suspected cases of COVID-19, 16, 19, 22, 23, 30 and in certain contexts such as in Belgium, this was done in collaboration with designated COVID centers or triage posts so as to maintain safe access to routine primary care. 16, 22 Other reported uses of telehealth included aiding the provision of essential services (e.g. immunization and abortion services), 21 assessing and addressing patient needs, [15] [16] [17] 22, 29 electronic prescribing, 22, 23 and issuance of medical certificates or laboratory and imaging requests. 22, 23 Limiting in-person care Practices balanced remote and in-person care in response to the pandemic, limiting the latter to help contain the spread of COVID-19. Nine studies from Canada, 15 United States, 17, 26, 28, 30, 31 New Zealand, 23 South Africa, 24 and Belgium 22 reported measures taken (other than telehealth) to limit direct patient care. These included canceling or deferring appointments, 22, 23, 31 suspending intake of new patients, 17 advising patients against in-person care when possible, 23, 30 and avoiding in-person group activities including social support programs. 15, 24, 26, 28 In-person consultations were undertaken either onsite, 23, 30 or through home visits, 17, 24, 26 or both 15, 22, 28 and were usually reserved for acute and urgent presentations 15, 22, 23, 28, 30 and management of at-risk patients. 15, 17, 22, 24 Adopting public health measures As part of promoting safe access to routine care, PCPs adopted public health measures, which commonly included screening patients for symptoms of COVID-19 and establishing dedicated care pathways for non-COVID-and COVID-related problems. 16, [18] [19] [20] 22, 23, 25, 30 Patient screening was usually conducted remotely, and in some of the practices examined, this was aided by receptionists trained in identifying suspected cases of COVID-19. 20, 23 Other infection control measures taken included having dedicated clinic hours 19, 20 and onsite areas for symptomatic patients, 19, 20, 23, 28 reorganizing patient waiting areas to make them safer (e.g. limiting number of patients, removing unnecessary material to prevent contamination), 18, 21, 22 personal protective equipment (PPE) use by staff, [18] [19] [20] [21] [22] [23] 28, 31 widespread wearing of masks and maintaining appropriate hygiene, [20] [21] [22] and environmental cleaning. 18, 21, 22 Enhancing surge capacity Practices took steps to strengthen their capacity to meet increased care needs during the pandemic. Experiences from the United Sta tes, 17, 26, 28, 30, 31 South Africa, 24 Belgium, 22 and Canada 15,18 described a range of strategies, which included expanding staffing (e.g. recruiting temporary employees or retired physicians), 18, 24, 30, 31 increasing work hours, 15, 22, 30 staff training and prioritizing PPE, 16, 22, 26, 28, 31 as well as redeploying staff to meet the increased demand in care. 15, 17, 18 Proactively contacting high-risk individuals Some primary care practices took a proactive approach to identify and engage with high-risk individuals. [15] [16] [17] 22, 26, 31 These included the elderly, individuals with chronic diseases, the homeless and those of lower socioeconomic status, essential workers, as well as racial and ethnic minorities. [15] [16] [17] 22, 26, 31 Risk stratification and active follow-up of vulnerable patients was aided by electronic medical records, 15, 16 15, 17, 26 and by practitioners' intimate knowledge of such persons. 16, 26 Proactive care was provided through various means including telehealth [15] [16] [17] 22, 26 and in-person visits, 16, 17 in coordination with other health care providers and social support services. Proactive care comprised an holistic, integrated, and communitybased approach to the provision of routine care during the pandemic. Providers engaged in community outreach to provide services and support, with an emphasis on vulnerable and underserved patients, through traditional and innovative strategies including home delivery of medications and food 15, 24, 26 ; provision of addiction and harm reduction services as part of outreach 15 ; drive through vaccine schemes 21 ; and mobile COVID-19 testing and vaccination sites to overcome barriers to access. 21, 31 Challenges encountered in adapting new practice models of care delivery A range of challenges experienced by patients and practitioners were reported across the studies. Difficulties encountered by patients mostly related to the shift to telehealth. [15] [16] [17] 19, 22, 23, 25, 26, [28] [29] [30] [31] These included barriers to access due to low-technology literacy, 17,23,26,30,31 aversion to telehealth, 23 and inadequate internet connectivity or access to devices such as smartphones and laptops, especially among under-resourced and underserved patients. 15, 26, 30, 31 This raised concerns about disparities in access to care during the pandemic. 15, 26, 31 Other issues related to the use of telehealth included language and cognitive barriers, 17, 22, 30 privacy and safety concerns, 26, 29 lack of access to home monitoring medical devices such as thermometers, blood pressure monitors and pulse oximeters, 25, 30 and loss of a sense of community and connectedness with fellow patients which in-person group activities engendered. 26, 28 Similarly, practitioner challenges revolved around the adoption of telehealth. [16] [17] [18] 22, 23, 25, 26, [29] [30] [31] These included infrastructure limitations (e.g. internet connectivity), 23,25,28,31 regulatory barriers, 17, 26, 31 concerns regarding patient confidentiality and safety, 26,29 digital literacy issues, 16, 30 reluctance to provide care virtually, 16 practical limitations on the ability to examine patients, 16, 22, 23, 30 communication barriers, 22, 26, 30 and loss of financial revenue due to reductions in in-person consultations. 16, 18, 22, 23, 25 Other challenges included staff shortages or redeployment to other settings, including acute and hospital-level care, [15] [16] [17] [18] [19] 21, 31 and shortages of products including PPE, [18] [19] [20] [21] [22] 31 logistical challenges providing respiratory specialist support to PCPs such as availability of to lengthy sessions and lack of nonverbal cues; patients did not always answer or return phone calls from physicians although they did respond to calls from the promotoras who were known and trusted community members 27 increased workload and work-related stress, [16] [17] [18] [19] 22, 31 and limited support and guidance from authorities on response measures. 17, 19, 20, 22 

This review identified key strategies adopted by PCPs to cope with changes in routine care during the pandemic. Providers were quick to adopt innovative, flexible, and integrated models of care delivery to ensure continuity and safe access to care. Burns et al.'s framework for primary care provision in disasters comprehensively covers the functions of primary care and served as a useful lens to study and reflect on the changes to routine primary care during the COVID-19 pandemic. 14 Practices examined in the included studies considered these functions to varying degrees, giving greater consideration to aspects such as acute and chronic disease management, biopsychosocial or holistic care, and coordinated care within the community context, while there was less consideration of functions such as preventive care and health promotion (refer to Table 4 ). Primary care remained the first point of contact, supported by the use of telehealth to address acute non-COVID and COVID-related presentations that did not require in-person management. Similarly, a holistic, coordinated, and community-based approach to the delivery of care was maintained with an emphasis on vulnerable patient groups. Practitioners collaborated among themselves and leveraged existing partnerships with other providers, such as COVID centers, hospital-based specialists, and community services to coordinate care. However, there was little evidence on linkages with public health or government entities, with some studies suggesting suboptimal coordination and guidance on response measures. Previous research [32] [33] [34] [35] [36] has similarly highlighted the lack of collaboration between public health and primary care in planning and response, which has important implications for maintaining safe access to regular care during a pandemic.

Disruptions to chronic care delivery during the pandemic are well recognized and were highlighted across some of the studies covering this function of routine care. 16 capacity to reorganize chronic care. 16, 19, 22 Disruptions to chronic disease management were worsened by public health containment measures (e.g. lockdowns and physical distancing), and the reluctance of some patients to seek care due to fears of becoming infected. 16, 19, 22 Consequently, these conditions were often dealt with inadequately, which is concerning given the potential for increased illness and death due to delayed care. Equally concerning was the lack of attention given to preventive care and health promotion (such as screening activities and immunizations), which were substantially impacted due to the cancelation or suspension of services in certain contexts including low-and middle-income countries. 21, 22, 31 As with chronic care, disruption to these lifesaving activities has important health implications including avoidable illness and potential resurgence in vaccine-preventable diseases. 5, [37] [38] [39] Interruptions to routine care during the pandemic have been reported by other studies, 1, 4, 40 which underscores the need to strengthen primary care capacity to promote access to a broader range of regular health services during pandemics, and to reduce the potential harmful effects of delayed care on patients, providers, and primary care systems.

The limitations of this review include a focus only on peer-reviewed literature and exclusion of non-English publications; as such we may have missed relevant adaptations and strategies discussed in the gray literature and in languages other than English. Due to time constraints, we excluded telehealth publications that did not discuss adaptations from a practice standpoint and consequently did not explore its use beyond these changes. The strength of our study lies in demonstrating the application of the framework by Burns et al. to reflect on practice-level adaptions and impacts on functions of routine care during the COVID-19 pandemic.

The COVID-19 pandemic resulted in substantial disruptions to the provision of routine primary care. This review demonstrates the agility and innovative capacity of PCPs, who rapidly adopted new models of care delivery to ensure continuity and safe access to care. While practitioners rose to the occasion, they encountered substantial challenges, not least being limited guidance and support with adaptations. Our findings underscore the need for enhanced efforts including timely and adequate investment by authorities to optimize the provision of comprehensive routine care during pandemics. These lessons are also important as many PCPs again shift their model of care delivery to support national COVID-19 vaccination programs. Changes to routine primary care delivery are likely to continue as the pandemic evolves; supporting primary care practices with response measures and in maintaining new models of care, including telehealth integration, is critical to ensure care continuity. While our review identified key strategies used to maintain the provision of routine primary care during the pandemic, further research is needed to evaluate the effectiveness of new models of service delivery, including PCPs' experiences and perceptions, patient reported outcomes, and costs. In addition to determining best practices to ensuring continuity of routine care during the COVID-19 pandemic, such research will help broaden the evidence based on primary care response to infectious disease outbreaks for future reference.

Supplementary material is available at Family Practice online.

No funding to declare.

Pandemic threatens primary care for long term conditions

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The authors are employed by or seconded to the Australian Government Department of Health. There are no additional interests to declare.

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