With unequaled talent and remarkable courage, the renowned health care system in Massachusetts has run toward the fire during the coronavirus pandemic: Heroic physicians, nurses, and other health care professionals and workers, led by brilliant managers, are working night and day to provide the best possible care while planning for a potentially overwhelming surge of demand. However, given the speed of contagion and the severity of symptoms, especially in older, frail, and unprotected populations, we now face the possibility that the COVID-19 pandemic could overwhelm our hospital and ambulatory care infrastructure sometime in April.
The urgency requires that we rapidly mobilize public and private assets to create a program that will connect every citizen to a care resource that can triage and safely support COVID-19 patients at home or in community-based venues. Additionally, this bulwark could serve as contingency infrastructure; a plan to address the possibility that there may be times when there are not enough care providers, hospital beds, or ventilators to support patients. Focusing initially on highest risk populations — the elderly, people with disabilities, and the chronically ill poor — we must now put in place methods to make certain that those who desperately need these scarce resources will get them. This will ensure that people who can be supported safely at home or in other ad hoc venues don’t have to compete for scarce inpatient resources.
Many COVID-19 patients can be cared for safely in their homes. Many more could be managed with proper remote monitoring and reliable access to a telemedical care center. There is evidence that people with less severe respiratory symptoms may be treated safely with noninvasive ventilators, which are commonly available. Our proposal provides for the appropriate supervision of these devices, both by paramedical personnel deployed to the home, and by continuous remote medical monitoring from a central location. Meanwhile, manufacturers are accelerating the production of ventilators, but those machines are weeks, if not months, away from delivery. We are hopeful our hospitals won’t hit up against current ventilator capacity, but credible alternative systems must be considered immediately.
The technology and talent exist to create an online care center, overseen by the state, which can:
▪ Answer phone calls or text messages from anyone in the state.
▪ Evaluate the caller’s needs for care.
▪ Route acutely ill callers to the best available facility.
▪ Support less acutely ill patients via phone and telemedicine in the home or temporary facilities
▪ Support a subset of these patients in the home using paramedical services and home-based noninvasive ventilation.
▪ Monitor these patients to determine those who need to be transferred to more intensive care environments rapidly.
▪ Create a network of physicians, nurses, and therapists who have been infected and quarantined, but who aren’t sick, or those who are recently retired and able to work, to provide oversight remotely.
▪ Maintain connections for patients with their own care providers so that care can be transferred back to their own doctors and hospitals when capacity returns.
There are three imperatives: The first is to support patients at home and in other venues that are mobilized by the state. This will help blunt the curve. It will allow many people to stay at home, safely monitored and supported, if their infection is not severe. The second is to provide some degree of respiratory and other essential medical support to individuals in the event that a sufficient number of advanced ICU-based ventilators are not available. The third imperative is to decompress the burden placed on doctors and nurses and hospital staff.
To address the first imperative, we propose to scale the current Mobile Integrated Health program regulated by the Massachusetts Department of Public Health. In this model, specially trained paramedics — supported by physician telemedicine consultations, a 24/7 nurse call center, and remote laboratory and biometric monitoring — can provide evaluation, testing, and clinical management and intervention for all aspects of care in the quarantine period for certain individuals with presumptive or confirmed COVID-19 infection. Today, all such individuals will probably seek care in highly stressed health care facilities, increasing the risk of spreading COVID-19 infection. By leveraging a proven national model of Mobile Integrated Health, patients can not only be triaged and treated successfully, but a major source of COVID-19 spread can also be reduced.
To address the second imperative, we propose seizing upon fast-growing initiatives to repurpose ventilation devices used to treat sleep apnea and other conditions to support less ill persons, thereby freeing up ICU beds.
We are confident that with telemedicine and simple monitoring of blood oxygen saturation using widely available and low-cost consumer devices, many patients requiring supplemental oxygen can be safely cared for in their own homes. Other facilities (such as ambulatory surgery centers, etc.) that are now underutilized because of the cancellation of elective procedures, could be used to provide noninvasive ventilation support for patients at higher risk.
We address the third imperative by succeeding, even if only marginally, with the first two.
To be clear, the best possible outcome is that social distancing and ramp-up of the capacity of inpatient medical centers will be adequate to serve the needs of all people in the state. But we must be prepared for the possibility that there may be an inadequate supply of care providers, hospital beds, or ventilators to meet the demand. If this occurs, we must be prepared to step in and provide community-based support.
The entirety of this effort can move forward rapidly under the auspices of the Commonwealth’s Department of Health and Human Services to ensure synergy with current efforts and to avoid a prolonged procurement process or competition among potentially interested parties. A number of committed private sector organizations have already expressed their willingness to step in and support this effort. This effort will also require the volunteer efforts of many health care providers not currently in the workforce and the mobilization of various supplies from the community. It will depend on the unselfish commitment to mission and citizenship that is abundant in Massachusetts.
We need the Commonwealth to provide leadership, coordination, and governance for this and other bottom-up initiatives so that we can be even better prepared for the expected wave of need. Such community-based resources must come online in a matter of days if we are to obviate the tragedy that has unfolded in Northern Italy, where many lives are being lost, and doctors and nurses suffer moral injury because of the necessity to ration high-intensity resources.
Dr. Robert Master is former president and CEO of Commonwealth Care Alliance. Dr. Gary L. Gottlieb is former CEO of Partners HealthCare System and former CEO of Partners In Health. Dr. David Margulies is cofounder and director of Q-State Biosciences and former vice president of Boston Children’s Hospital. Dr. Chris Kryder is a primary care physician and commissioner of Massachusetts Health Policy Commission. Dr. John Loughnane is former chief medical officer of Commonwealth Care Alliance. Dr. David Martin is vice chair of Innovative Care Solutions at Brigham and Women’s Hospital.
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