key: cord-1023507-wphuf7f3
authors: Zhang, Annie; GoodSmith, Matthew; Server, Steven; Uddin, Sophia; McNulty, Moira; Sherer, Renslow; Lio, Jonathan
title: Providing support in a pandemic: A medical student telehealth service for ambulatory patients with COVID-19
date: 2022-01-14
journal: Healthc (Amst)
DOI: 10.1016/j.hjdsi.2022.100612
sha: 877f1cc44328c40efa275245293135a32cb7b752
doc_id: 1023507
cord_uid: wphuf7f3

During the early months of the COVID-19 pandemic, when health systems were overwhelmed with surging hospitalizations and a novel virus, many ambulatory patients diagnosed with COVID-19 lacked guidance and support as they convalesced at home. This case report offers insight into the implementation of a telehealth service utilizing third- and fourth-year medical students to provide follow-up to ambulatory patients diagnosed with COVID-19. The service was evaluated using medical student surveys and retrospective chart review to assess the clinical and social needs of patients during the spring of 2020. Students assessed symptoms for 416 patients with COVID-19 from April 8 to May 20 and provided clinical information and resources. Eighteen percent of these patients sought higher levels of medical care, in part from student referrals. Three key implementation lessons from this experience that may be relevant for others include: 1) Vulnerable patient populations face unique stressors exacerbated by the pandemic and may benefit from intensive follow-up after COVID-19 diagnosis to address both medical and social needs; 2) Medical students can play value-added roles in providing patient education to prevent the spread of COVID-19, assisting patients with escalating care or resource connection, and providing emotional support to those who have lost loved ones; 3) Continuous re-assessment of the intervention was important to address evolving patient needs during the COVID-19 outbreak. Future work should focus on identifying high-risk patient populations and tailoring follow-up interventions to meet the unique needs of these patient populations.

Since March 2020, the COVID-19 pandemic has overwhelmed health systems across America. 23 While significant clinical and research efforts were directed early on to the care of hospitalized 24 patients with COVID-19, epidemiologic data revealed that the majority of patients diagnosed 25

with COVID-19 never require hospitalization. 1 In response to these challenges, we designed a structured service-learning opportunity for third-41 and fourth-year medical students to provide clinical and social support for ambulatory patients 42 diagnosed with COVID-19 through longitudinal telephone follow-up. This program highlights 43 the role that high-intensity follow-up played in the management of complex clinical and social 44 needs experienced by patients early on during the COVID-19 pandemic during a period of state-45 wide lockdown and limited access to care. 46 47

This program was implemented at an academic medical center located on the south side of 49

Chicago. This academic medical center is an 811-bed tertiary care hospital with more than half a 50 million outpatient visits, 75,000 adult emergency department visits, and 34,000 hospital 51

admissions a year. 5 The hospital cares for a predominantly underserved African American 52 community that is disproportionately affected by chronic disease and socioeconomic inequality, 53 including a sizable proportion of patients insured by Medicaid. 6 Through the Urban Health 54

Initiative, the hospital's dedicated community health division, the institution aims to address 55 structural health inequities that affect its surrounding community. 7 Predictably, the pandemic has 56 heightened the long-standing health disparities in cities across America. In Chicago, the rate of 57 COVID-19 deaths has been two times greater for Blacks compared to Whites. 8 58 59

Removed from in-person educational experiences, many medical students led grassroots efforts 61 to assist the hospital and community. One such initiative grew out of collaboration with 62

Infectious Disease faculty to provide support to ambulatory patients diagnosed with COVID-19. 63

Initially, three student leaders volunteered to spearhead the development and execution of the 64 program; a fourth student leader was added as the project expanded. Given their available time, 65 dedication, and the clinical skills required to communicate effectively with newly diagnosed 66 patients, third-and fourth-year medical students were offered the opportunity to participate in 67 J o u r n a l P r e -p r o o f this service-learning initiative. Faculty from the Section of Infectious Diseases provided 68 mentorship and guidance on COVID-19 health education, frequently evolving hospital testing 69 guidelines, and knowledge on available clinical trials. 70 71 Problem 72

On March 9, the state of Illinois was declared a disaster area by the governor in response to 73 COVID-19 outbreaks. By April 1, healthcare facilities in the state were ordered to cancel or 74 postpone elective surgeries and procedures. 9 A "stay-at-home" executive order was initiated less 75 than a week later. 10 As disease testing and contact tracing ramped up during this time, hospitals 76 were focused on maintaining bed access, securing adequate PPE for staff, and ensuring access to 77 equipment such as ventilators for critically ill patients. Due to limited testing supplies, guidance 78 around who was eligible to be tested for the virus was frequently evolving. At the time of this 79 project's implementation on April 8, during the "first wave" of cases in the state, the number of 80 daily new COVID-19 cases was over 1,500 and would reach nearly 3,000 at the wave's peak. were overwhelmed by their diagnosis and unable to process additional information during a 89 single phone call. Other patients continued to have questions about their disease even after the 90 initial phone call. As much of the city ground to a halt during the stay-at-home order, many 91 primary care clinics closed temporarily. For this and other reasons, patients had few resources 92 they could turn to in these early months of the pandemic. Furthermore, little was known about 93 the experience of ambulatory patients diagnosed with COVID-19 and the clinical trajectory of 94 the disease at the time. Thus, it was important to closely monitor these patients and triage more 95 severe cases in the emergency department (ED). Based on these initial experiences, it was clear 96 that there was a need for more extended follow-up and support for ambulatory patients diagnosed 97

The pandemic produced a series of unprecedented social stressors in our patient population, and 100 many of these stressors were particularly acute for those who tested positive for COVID-19. In 101 hard hit areas, surveys show higher rates of essential workers and others unable to work 102 remotely. 13 Frequently, workers faced uncertainly about how and when to safely return to work 103 while others required documentation of their test result in order to return. Many lived in 104 multigenerational homes or crowded living quarters that made social distancing impossible while 105 others struggled with the social isolation brought on by the stay-at-home order. As the economy 106 plummeted with record unemployment, many patients experienced financial challenges and food 107 insecurity. Others faced housing insecurity, and some patients even lost housing as a direct result 108 of their COVID-19 diagnosis. 109 110 Given these challenges, it became apparent that a new workforce was needed who could spend 111 the necessary time with ambulatory patients who had tested positive for COVID-19 and address 112 their needs. By developing a program to help track patient symptoms, disseminate information 113 about the disease, and aid with various social needs, we hoped to address these challenges 114 initially observed during the pandemic. Furloughed medical students, with the proper training 115 and guidance, were identified as an ideal group to staff this project. Given the stay-at-home 116 order, it was ideal to implement the program as a telehealth model, which was also aligned with Developing Team Structure 127

The program was urgently implemented and evolved extensively over the course of weekly 128 rapid-cycle improvement meetings. Initially, three student leaders each directed a team of 129 approximately 12 volunteers. Each team assigned patients to volunteers using a three-day 130 rotating call schedule, excluding weekends. However, as the hospital increased its testing 131 volume, this system was overwhelmed. As such, the service was expanded after two weeks to 132 include four teams accepting patients on a four-day call schedule, including weekends. A total of 133 53 student volunteers and three faculty volunteers were involved in the program. A summary of 134 the team structure is illustrated in Figure 1 . for clinical stability, the next priority was to provide patient education on topics including safe 172 self-isolation practices, "red flag" symptoms warranting an escalation of care, supportive care, 173 return to work precautions, and COVID-19 testing for exposed family members. Emphasis was 174 also placed on assessing patient psychosocial needs, providing emotional and mental health 175 support over the phone, and referring patients to resources to address unmet housing, food, and 176 other needs. Students also offered information regarding emerging clinical trials to patients who 177 expressed interest. A summary of the process for identifying patients and follow-up is illustrated 178 in Figure 2 . followed patients for 4.5 days, with 41 (10%) patients requiring follow-up for greater than 10 205 days. Thirty-two (8%) patients went to the ED but were not hospitalized. Of these, nine (28%) 206

were advised to go to the ED directly by volunteers and 5 (16%) presented to the ED for a 207 COVID-19 related reason after follow-up was completed. The remaining 56% of patients who 208

presented to the ED during the follow-up period received anticipatory guidance from volunteers 209 on "red flag" symptoms and were thus, likely better attuned to their disease progression. Overall, 210 41 (10%) patients were hospitalized, 11 (27%) of whom were advised to seek a higher level of 211 care by volunteers and 4 (10%) of whom presented after follow-up. The four patients who were 212 hospitalized after follow-up may have entered the inflammatory phase of COVID-19 after a brief 213 period of symptom improvement. Thirteen (32%) of the hospitalized patients experienced an 214 ICU stay, and 2 (5%) died. 215

The majority of patients that presented to the ED or were hospitalized did so during volunteer 217 follow-up. A significant portion of these patients were determined by volunteers to have 218 symptoms that necessitated a higher level of care, suggesting the program was effective in 219 identifying high-risk patients. All other patients were educated on "red flag" symptoms that 220

should prompt them to seek further care. 221 222

Volunteers also provided clinical and social resources during follow-up (Table 2) . Patients 224 frequently requested information about clinical trials and primary care. Many patients lacked 225

PCPs or reported challenges in communicating remotely with their PCPs. Volunteer-provided 226 primary care resources included contact information for local free clinics and federally qualified 227 health centers and direct referrals to a hospital clinic designated to serve COVID-19 patients. 228

Volunteers provided work notes directly to 39 (9%) patients and instructed patients on how to 229 obtain a work note later if desired. Four patients were referred to housing or shelter resources, infections, and high infection rates will likely perpetuate until vaccines and nonpharmaceutical 256 interventions are widely adopted by the public. This next wave of infections is heavily impacting 257 our patient population, which includes many individuals from historically disadvantaged 258 neighborhoods in the city at high risk of hospitalization from COVID-19 due to underlying 259 chronic disease such as obesity, hypertension, and diabetes. 1 As virus outbreaks and resource 260

constraints intensify, future interventions should continue to focus on identifying high-risk and 261 underserved populations that could maximally benefit from follow-up services. Furthermore, 262 future interventions must be tailored to specific populations. For example, although phone 263 interpreter services were available as needed for our volunteers, the program would have been 264 enhanced with additional bilingual providers to communicate more effectively with our limited-265

English proficient patients. While some hospitals have relied more heavily on patient health 266 portals or cell phone apps to facilitate symptom monitoring and patient education, it is unknown 267 how effective this type of intervention would be in communities where access to technology and 268 health literacy is more limited. 22,23 As we have shown, there is significant value to longitudinal 269 relationships formed through follow-up phone calls. These calls can be performed by many 270 healthcare providers, including medical students, nurse practitioners, physician assistants, and 271 physicians. Robust, comprehensive training and support for providers on topics such as evolving 272 public health guidance, telehealth best practices, access to local resources, and preventing 273 emotional exhaustion are critical for sustained engagement. Further, to tackle the long-standing 274 health disparities exacerbated by the pandemic, hospitals and public health departments must 275 come together to mobilize both medical and social resources especially in the most 276 socioeconomically disadvantaged communities. In particular, future interventions should plan to 277 address major unmet needs in housing, food security, and mental health resources among others. The authors wish to thank the medical students who participated in this study for their time and 292 dedication to supporting patients impacted by the COVID-19 pandemic. We also wish to thank 293 the patients who taught us and made this experience possible and the patient navigator team for 294 their support. 295

This research did not receive any specific grant from funding agencies in the public, commercial, 298

or not-for-profit sectors. 299

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☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:J o u r n a l P r e -p r o o f