It is suggested that primary care physicians and nurses built chronic disease registries for patients at high risk of COVID complications and develop a protocol, along with frontline staff for medical assistants and other staff calling those patients. Callers should provide basic education about COVID, then ask some simple questions to help find out if a patient’s disease is poorly controlled - for instance, if a patient with diabetes is having symptoms of low blood sugar. All chronic disease patients should be offered telephone appointments with their primary care provider. People with concerning symptoms should be routed more urgently to a nurse. Extensive outreach is second crucial innovative piece to this, and suggested with patients who have heart failure, diabetes, asthma, chronic obstructive pulmonary disease and HIV, patients with other immune- compromising conditions, kidney disease and children with chronic illnesses.

The key is to keep a check on those people who are high risk and vulnerable, including those patients who don’t speak English or have low literacy levels.  Many primary care practices, Federally Qualified Health Centers (FQHCs), safety net clinics serve patients that are highly vulnerable  also need housing and food – which can be offered via strong outreach.

If pandemic was seen coming, health centers would have equipped many patients with a glucometer and a scale, for example. This was not the possibility, as health professionals could not predict it, but if patients are interested in, say, getting a home blood pressure monitor, health centers can easily arrange to have one shipped to their house. This is much easier to do since lot of community health centers and primary care centers already are good in disease management and education and many already have done a lot of work with hypertensive population, in general –such as teaching patients to use blood pressure cuffs  etc, and have laid the foundation. On a population health level, it may be too early to tell what kind of effect outreach will have, but it is promising. In addition, there is a strong financial case for both telephone visits in general and outreach in particular. Federally Qualified Health Centers are struggling for revenue as they cancel outpatient in-person visits, and telephone visits are one of the only remaining sources of revenue. While providers don’t bill for the outreach, they are able to bill for the phone visits, which helps prevent a drastic shortfall in revenue.

A critical part of this effort has to be towards creating electronic chronic disease registries and teaching front-line staff how to use them. Population health management tools are now available on most of the electronic medical records in primary care practices today. This is the time to advance them, use analytics tool embedded in EHRs, train to change clinical workflows for chronic disease and high risk vulnerable patients. Population health tools can have real value in COVID-19 when trying to reaching large number of such patients, in less time.

It is important to know that flattening the curve of a pandemic means prolonging the emergency restrictions, and eventually people with chronic illnesses are going to suffer, no matter what. The longer normal healthcare operations are disrupted, the more likely chronic illnesses will be exacerbated. It is imperative that primary care health centers, FQHC's continue to check in on people to make sure they are proactively protecting the high risk, vulnerable and chronic disease patients. These are the patients that can add health care costs due to mortality, but more importantly will surely add to long term morbidity costs of health care in weeks to come.