In the first days after the COVID-19 pandemic took off back in March, pediatrician Jonathan Miller, M.D., knew he and his team had to shut all non-urgent visits down.
All the well visits for kids. All the vaccine visits. All of it needed to be put on hold while their practices joined others across the country in figuring out their next moves.
"I'm a general pediatrician. Telling a family not to come in for vaccines or for an infant's well visit goes against everything that I've ever learned and that I believe in," said Miller, who is the medical director of value-based care and chief of primary care in the Delaware Valley for Nemours Children's Health System.
"But it was a trade-off," he told Fierce Healthcare. "It was two weeks of missing some well visits and immunizations versus having all of our families potentially expose themselves to a virus we did not yet completely understand as a society."
While plenty of adult primary care as well as pediatric practices continue to report sluggish returns in visits among their patients, Miller said Nemours has been able to return to somewhat normal visit volumes. What's more, they've actually increased immunizations among kids year-to-date compared to the same time period of 2019.
"Our data shows we were really able to catch everyone up and keep everybody safe," Miller said.
How they did it
Nemours is a large children's health network with several hospitals and 38 primary care practices in Florida, Delaware and Pennsylvania and about 180,000 patients.
With locations in different states that were impacted differently, officials were forced to create an infrastructure that would be nimble and flexible depending on local conditions, Miller said.
The tactics they used included:
Separating patients into cohorts. They separated sick visits and well visits either by the time of day (for instance, scheduling well visits in the morning and sick visits in the afternoon) or separating them by the location of the visit by designating some offices as "clean practices" which were only going to see newborns or kids who were not sick.
Some locations were specifically designated for vaccines. Other practices had tents devoted to triaging kids who might have a fever or cough, making them a suspected COVID-19 case and who needed to be seen in person instead of through telemedicine. "We quickly changed into one large patient-centered medical home," Miller said, instead of 38 separate ones.
Offering on-demand and scheduled telehealth visits. Nemours also ramped up the use of its telemedicine infrastructure, which it already had in place but rarely used. "We were seeing sick patients on demand, where they would enter a virtual waiting room and be seen on demand almost like walk-in patients," Miller said.
They also started offering combined in-person exams with telehealth visits. They held the in-person visits in tents where "we could lay hands on, get a quick exam, get height and weight and immunizations done, but in a safe outdoor way. And the rest of that well visit was all done on telemedicine," Miller said. "It really helped us make our patients feel safe to come in."
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Proactive outreach. Finally, Nemours reallocated some of its talent to the phone lines. With lower overall visits, the practices had staffers move from other jobs including administrative and nursing roles to begin calling families to let them know what visits they were due for as well as, explain the safety protocols and encourage them to get an appointment on the books.
They also took the time to automatically screen families for new social determinants of health issues and connecting them with resources when necessary. "It really allowed us to assess some of our patients for what we knew was going on like food insecurity, and poverty and job insecurity for the parent."
The mix of strategies ultimately worked, Miller said.
Across Nemours' entire network, the health system saw a 28.5% decrease in the total number of immunizations among pediatric patients between March and May compared to the same period in 2019. But to date, Nemours now has done 4.6% more immunizations in 2020 compared to 2019. "We're actually ahead on this curve despite how far we fell behind this spring," Miller said.
When it came to primary care visits, Nemours saw 48% fewer total visits between March and May compared to the same time period in 2019. In all, 20,0000 visits were canceled in the spring. A large chunk of the decline was due to drops in sick visits as children were isolated from each other and were less likely to spread infections among each other than usual, but many visits were well visits where families didn't feel comfortable coming in. "We're nearly caught up for the hole we were in during this spring," Miller said. They've been able to see about 85% of those canceled visits since then.
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"We were really worried families were going to be hesitant to bring their kids in when they might have serious things going on," Miller said. "We were worried patients were going to have cancers or surgical issues that would go untreated. What we found was a number of these instances in the spring where with our safety net of telemedicine and brief exams in the tent, we ended up catching several kids with cancers, we caught a child with physical abuse, and we didn't really hear too many stories over time of cases that got missed. We're proud in retrospect that our systems really seemed to have provided the type of care our population needed during this really traumatic time."
Finally, a quarter of Nemours visits in 2020 have been via telemedicine, Miller said. That's compared to about 0% in 2019, he said. "It was a huge change in how we've operated," he said. They've completed about 10,000 telemedicine well visits this year in the Delaware Valley now that insurance companies are willing to pay for that, Miller said.
Lessons learned
It was difficult to have to shut down, especially as primary care practices outside the Nemours network proceeded differently, Miller said. But the group learned a lot by taking the chance to pause and thoughtfully determine the strategies it would follow.
"I think we did the right thing," he said. "We shut down for a couple of weeks. We all learned about masking and temperature checking and physical distancing and closed our waiting rooms and put ourselves into a really safe position to then open up again," he said. "We told them, 'we're going to start by prioritizing infants and toddlers and complex cases who really needed their well visits and immunizations first—and then everyone else,'" Miller said.
Some of the innovations won't be long-lasting, Miller said. For instance, Nemours found having outdoor visits in tents didn't work anymore in the intensity of the summer heat. They were also pricey.
"Tents were extremely expensive. In retrospect, I wish we'd bought the tents and actually owned them because we're going to be up against these same issues again in the spring and next fall."
Some state regulations were also big obstacles early on, such as physicians being unable to practice telemedicine across state lines. He worries regulations that have been relaxed to allow telemedicine to work as well as it has will come back and stymie its use again.
But he hopes that many of the gains in telemedicine will be long-lasting changes, as well as the "cohorting" of patients. Social determinants of health screening also was a crucial change, he said.
"They are all things that are just becoming part of what we do now as we're sort of creating a 'new normal' compared to what we did in the past," Miller said.