COVID-19 Devastates At-Risk Populations
Telemedicine could be new normal
The COVID-19 pandemic appears to have a devastating effect on people with chronic diseases — especially lung conditions — or who are immunosuppressed, are older, or obese. In other words, the people most at risk of serious illness from the disease are the same people case managers help each day.
Case managers should focus more on remote case management, taking the pandemic into account as they contact and monitor patients, says Kathleen Fraser, MSN, MHA, RN-BC, fellow at the American Academy of Nursing and executive director of the Case Management Society of America (CMSA).
A major shift to telemedicine is one of the likely long-term outcomes. These will include remote monitoring that is not synchronous, meaning it is not monitored in real time, says Steve Davis, PhD, associate professor in the department of health policy, management, and leadership at West Virginia University School of Public Health in Morgantown, WV.
Davis is the lead author of a paper on the use of a multifaceted telehealth intervention for a rural population. The study included an adaptive pilot intervention that targeted home- and community-based Medicaid Waiver Program participants. The goal was to prevent reinstitutionalization.1
“During the COVID-19 pandemic, many people [monitored by case managers] are in a high-risk category — diseased, disabled, or have conditions with compromised immune systems,” Davis says. “If they don’t come into the healthcare setting, that’s probably a good thing. That’s one aspect of having telehealth like our program.”
Healthcare institutions are doing their best to catch up with these unprecedented times, Davis notes. “The telehealth model we designed is intended to be sustainable and replicable by other health systems,” he says.
Other healthcare institutions could do the same thing, but it would require investment in equipment that patients can set up at home.
“It might depend on purchasing policies of a healthcare system and their interactions with a particular vendor,” Davis explains. “But once those agreements are in place and everything is ready to go, you can have equipment sent to a person’s home relatively quickly.”
For instance, case managers can assess patients’ mental health and pain via phone, he adds. (See story on telehealth intervention in this issue.)
Other than shifting more patient time to telehealth, case managers will carry on during the pandemic, Fraser says.
“We will have some patients who are on isolation for some type of infection, and the case manager has to coordinate things for that patient,” she adds.
CMSA offers a resource page about COVID-19, containing information case managers can provide to patients. It is available at: https://www.cmsa.org/coronavirus-resources/. The CMSA resource list reviews the evolution of coronaviruses, beginning with SARS-CoV, identified in Asia in 2003.
‘We’re Vulnerable in Our Society’
The COVID-19 pandemic is particularly hard on America’s 4 in 10 adults who have the risk factors of age, diabetes, heart disease, renal disease, other comorbid illnesses, or who do not have health insurance, said Diane E. Meier, MD, FACP, FAAHPM, director of the Center to Advance Palliative Care (CAPC), co-director of Patty and Jay Baker National Palliative Care Center, and professor in the department of geriatrics and palliative medicine, Catherine Gaisman professor and chair, Brookdale department of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai in New York City.
Meier and other palliative care experts spoke about COVID-19 on March 18 at a CAPC webinar focused on the need for greater palliative care capacity in the pandemic era. (See story on palliative care and COVID-19 in this issue.)
Americans are particularly susceptible to serious illness with COVID-19 because the nation is largely unhealthy, according to Greg Poland, MD, professor of medicine and infectious diseases at the Mayo Clinic. Poland also is the director of the Mayo Vaccine Research Group.
“We’re vulnerable in our society in that we tend to be increasingly obese, unfit, smoking, elderly, and an immune-compromised population,” Poland explained. “You put that together and that’s fuel for the fire of severe illness.”
Saying he gained new appreciation for weather forecasters, Poland noted it is difficult to predict how long this pandemic will continue. But, based on available models, it appears that the most important thing the United States could do to end the virus’ rampage is to go into suspend mode.
“What we have seen in other cities that have not done this is devastation,” Poland said. “What we have seen in countries that have gone into suspend mode is it almost right away dampens down cases.”
Flatten the Curve
The key is to reduce the reproductive number of the virus to one or less. This means that at a population level, each person who is infected would spread the virus to one or no other people.
“How many people do you infect when you become infected?” Poland asked. “If it’s one or less, the pandemic will die; if it’s more than one, it will continue on.”
Depending on how many people are infected by each person with the disease, the pandemic could continue to spread like wildfire. “The best thing you can do is suppress that viral reproductive number down to one or less, and the only way to do it is through social distancing and handwashing,” Poland said. “If you do not breathe in the virus and do not touch a contaminated surface, it is impossible to get the infection.”
As of April 3, there is an almost 4% mortality rate in the United States, based on people who tested positive for COVID-19, Poland noted.
“That’s an overestimate because we don’t know the denominator,” he explained. “It’s a devastating number, while people are still going on in their lives like nothing is happening.”
Social distancing and suppression measures are designed to spread out demand for critical care services in hospitals and prevent a peak outbreak that sends many more people to the ED than the hospital can handle at one time.
“It’s widely reported that a peak demand in the outbreak, potentially, we would need 900,000 ventilators in the United States,” said Paul Biddinger, MD, MGH, endowed chair in emergency preparedness, director of the Center for Disaster Medicine, and vice chairman for emergency preparedness in the department of emergency medicine at Massachusetts General Hospital in Boston. Biddinger spoke to journalists and others at an Accumen/WIRB-Copernicus Group web conference on March 13. “The most optimistic estimate is we have 100,000 ventilators, which is a nine-fold lack of resources. We look at severe supply and demand mismatches.”
When a city’s hospitals, as was seen in New York City in late March, experience a greater demand than availability for ventilators, personal protective equipment (PPE), and other necessary supplies, the community moves into crisis mode, he explained. “We need protocols that are fair, transparent, evidence-based, and shared across healthcare systems so no one system will do something different than another system,” Biddinger said.
Once in a Generation
COVID-19 is a once-in-a-generation pathogen, noted Scott Gottlieb, MD, former Food and Drug Administration commissioner and current member of the boards of Pfizer and Illumina. Gottlieb also spoke at the March 13 web conference.
“All emerging evidence is this is a dangerous virus that straddles that terrifying area of being contagious enough to spread quickly and widely, and virulent enough to kill people,” Gottlieb said.
Estimates are that the death rate is 1% globally, and the viral transmission rate is between two and three people per infected person. “A lot of discussion is about how this is affecting older Americans,” Gottlieb said. “But, a lot of people in their 30s, 40s, and 50s still are getting very sick from this virus. The case mortality rate for the 40 to 50 age group is about 0.25 to 0.4%, meaning one in 500 people who get it are going to die from it. That’s an enormous figure for a virus of this kind.”
The death rate is dramatically higher from COVID-19 than it is for the flu, which has a death rate of 0.02%, overall, but kills as many as 14% of people over age 80, he explained.
Case managers and other healthcare professionals also should keep in mind that younger people who become seriously ill from COVID-19 might develop acute respiratory distress syndrome (ARDS), which can be deadly. Damaged lungs can cause ARDS survivors to develop a long-term comorbidity. (For more information, visit: https://health.clevelandclinic.org/heres-the-damage-coronavirus-covid-19-can-do-to-your-lungs/.)
When case managers monitor their elderly patients with diabetes and other chronic illnesses, they should bear in mind that the most commonly reported COVID-19 symptoms — cough, fever, shortness of breath — could look different in this older cohort. For example, geriatric patients might not have as high of a fever than younger adults and children with the illness, said XinQi Dong, MD, a researcher in epidemiology at Rutgers University in New Brunswick, NJ. Dong spoke at a March 12 video conference. (A recording is available at: https://www.newswise.com/articles/covid-19-exploring-the-unanswered-questions-with-newswise-live-expert-panel?sc=sphn.)
If a patient reports a mild fever, cough, and shortness of breath, case managers should consider the possibility that the person is infected with COVID-19 and make appropriate referrals.
Dong also suggested case managers follow the recommended social distancing measures to ensure their own safety. “Wash your hands, and we recommend staying one-and-one-half arm’s lengths away from people,” he said.
When visiting an elderly person’s home, case managers should wash their hands, with gloves, he added.
- Davis SM, Jones A, Jaynes ME, et al. Designing a multifaceted telehealth intervention for a rural population using a model for developing complex interventions in nursing. BMC Nurs 2020;19:9.
The COVID-19 pandemic appears to have a devastating effect on people with chronic diseases or who are immunosuppressed, are older, or obese. In other words, the people most at risk of serious illness from the disease are the same people case managers help each day. Case managers should focus more on remote case management, taking the pandemic into account as they contact and monitor patients.
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