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As regional stay-at-home orders sweep across California amid growing ICU shortages, community health centers find themselves in a bind.
“We’re not hospital-based, and we don’t have treatment to prevent severe disease, so our hands are tied,” said Dr. Jerry Douglas, the Chief Medical Officer at Mendocino Community Health Clinic, Inc (MCHC) in Northern California.
Though primary care facilities like MCHC don’t have the resources to treat critically ill patients, they may have a role to play in averting Covid-related hospital admissions: “Our aim is prevention and early detection,” said Douglas.
The health center has been focused on minimizing transmission to help patients avoid illness altogether. While non-pharmaceutical interventions have been shown to be effective, widespread adoption is a challenge. “Some people are still skeptical,” said Douglas. Throughout the pandemic, Douglas has been stressing the importance of standard public health measures: social distancing, frequent hand-washing, and masking. “I just try to educate them that this is something that can be very serious,” he said.
While Northern California has the highest remaining ICU capacity out of all five regions being tracked by publich health officials, it has the fewest hospital beds. “We’re worried in a week or two we’re not going to be in as good of a place,” said Douglas. Once a region’s ICUs reach 85% capacity, it triggers a three-week stay-at-home order per the Office of the Governor.
Since December 1, 14% of patients tested for Covid-19 at MCHC were positive. If a patient presents with respiratory symptoms, the health center “sorts” to prevent unnecessary hospital visits. “These days we have to think, ‘Could this be flu? Could this be COVID? Could this just be a really bad upper-respiratory infection?’” explained Douglas. Depending on the assessment, providers funnel patients into the appropriate course of treatment. For those diagnosed with Covid-19, close monitoring is crucial, particularly for those at risk of complications.
“Those who are are older and those with chronic conditions are typically at higher risk,” explained Dr. Edward Liao, the Chief Medical Officer at QueensCare Health Centers (QHC) in Los Angeles. Providers at QHC schedule follow-up visits with high-risk patients to ensure they aren’t experiencing shortness of breath or a secondary infection, such as pneumonia, due to the virus. And, they make sure their patient’s chronic condition is under control. “We don’t want them to have hyperglycemic episodes while they’re trying to recover from Covid,” said Liao.
But controlling these chronic conditions can be difficult. At Northeast Medical Services (NEMS) in San Francisco, Dr. Kenneth Tai has seen a trend in patients delaying chronic care. “Some of our patients are still refusing to come into the clinic for assessment or evaluation,” said Tai, the health center’s Chief Medical Officer.
Most chronic conditions can be managed with a prescription, but patients do occasionally need to see their doctor for blood work and diagnostic testing. “There’s only so much you can do through video or telephonic visits,” he explained.
While the Bay Area’s ICU capacity has yet to reach the 85% threshold, five counties, including San Francisco, have pre-emptively ordered residents to stay home. “Now, I think, with a stay-at-home order in place, more patients are really not coming back into the clinic for care,” said Tai.
To help patients manage their chronic conditions at home, NEMS is sending prescriptions to patient’s doorsteps. “That service has actually been very well received by our patients,” said Tai, whose patients primarily fall into the 65-and-up category.
By keeping these conditions in check, the health center is also reducing the burden felt by hospitals. When left unmanaged, a chronic condition like heart disease can quickly turn into a heart attack or stroke, landing a patient in a hospital’s emergency department or ICU.
At L.A.’s QueensCare Health Centers, providers are seeing a similar trend. “There are a number of people who will not seek out preventative services because they are scared of going out or coming to the health centers in general,” said Liao. During the pandemic, screenings for diabetes and cancer at QHC have dropped.
To keep patients on track, staff are reaching out to those who have missed routine appointments. If a patient with heart disease needs a diagnostic test, they call to order the lab work and schedule a visit. “We are proactively reaching out to patients to prevent an emergency,” said Liao. “We don’t expect heart attacks to go away during the pandemic.”
Direct Relief’s Response
In addition to providing ongoing medical support – Direct Relief has provided more than $24 million in medical aid, including PPE, to health facilities in California since the beginning of the pandemic – the organization has been sharing information and insights to inform public health responses.
Direct Relief is collaborating with Facebook’s AI Research Team to forecast the projected growth of Covid-19 across the United States. These projections, based on a number of variables including mobility patterns, local-level policies, and previous rates of transmission, allow Direct Relief to target health facilities in the nation’s hardest-hit zones, ensuring medical supplies and funding are effectively allocated.
According to the research model, California is expected to see a 30% increase in cases across 17 of its 58 counties over the next three weeks. “California is seeing a massive surge of Covid-19 across almost every corner of the state,” said Andrew Schroeder, Direct Relief’s Vice President of Research and Analysis. The counties likely to see the highest rates of growth include Los Angeles, Alameda, San Bernardino, and Riverside.
“One of the really troubling dynamics in California right now is that areas of the state which had previously been doing a reasonably good job of controlling the pandemic at earlier stages are now seeing really huge rates of increase in Covid transmission,” said Schroeder. Santa Clara, which previously maintained low growth rates, is projected to have 13,500 new cases by December 27, representing an increase of about one-third in just three weeks. “Because Santa Clara contains so many people in the tech industry and other professions who have been able to work from home effectively, they have not seen these growth rates before. But apparently this is now changing quickly,” said Schroeder.
Direct Relief will continue to monitor the projected spread of Covid-19 and provide updated predictions as data becomes available.