AMGA CEO and CMO Councils: Fall Planning for COVID-19 and Flu Clinics

AMGA COVID-19 Resources

Discussion Summary
July 31, 2020

This summary is based on discussions via AMGA’s Chief Executive Officer Council listserv as of July 31 and AMGA’s Chief Medical Officer listserv as of July 2. For more information on these Councils, please click here.

CEO Questions:

I am looking for information on what you are planning for the Fall. We have mobile clinics set up outside our facilities, and we have concerns about moving suspect patients back inside. We need to segment our population further as pediatric patients return to school or get sick.

  • What are others doing with facility planning or segmenting patients?
  • If others do not have negative pressure rooms and are seeing patients indoors, can you provide details on infection control?
  • How will you run your flu clinics?

As far as non-COVID testing—RSV/flu/strep—does anyone have a plan they could share about where they will do this? Our initial thought is to have the provider in appropriate PPE (N95, face shield, gown, and gloves) and have dedicated rooms with time between tests for cleaning.

CEO Answers

  • We have invested in respiratory virus testing technology that does PCR testing for a panel of common respiratory viruses including COVID-19.We will be using our drive-up testing facilities to test symptomatic patients with this panel. Currently expecting to have a great demand for this in the fall, and we are firming up the supply chain as much as possible.
  • We are still in the evaluation stages as to whether we want separate ILI (influenza-like illness) clinics, which would be a little challenging with our multi-state footprint. We have drive-through COVID testing now and can easily add flu/Strep/RSV to that. We have developed some "safe lab draw" sites where patients come in by appointment (as the only patient in the waiting area) to have labs drawn and can now get immunizations. We are evaluating drive-through flu shots.

    Shortly after the pandemic hit our areas, we adjusted clinic schedules and screening to allow well patients who needed chronic follow-up care to come in during the morning session and moved all the acute illness appointments to the afternoon. We will likely continue that for those practices who are asking to continue to care for their regular patients, and others will be directed to our acute walk-in ILI clinics.
  • We transitioned three of our urgent care locations into respiratory illness clinics to serve as regional sites for our local community patients and providers. This was a successful way for us to cohort respiratory patients for both our Urgent Care and Primary Care sites, as well provide COVID-19 testing for community providers that didn't have the resources available.

    Our respiratory illness clinics offer in-person and virtual evaluations and screening for COVID-19 symptoms. Our in-person services include PCR COVID-19 send-out testing, as well as point-of-care flu, strep, and UA (urinalysis) as medically indicated. X-ray services are onsite as needed.

    We also offer vehicle-side appointments that are ordered by a patient's provider and scheduled ahead of time to test individuals for COVID-19. Vehicle-side appointments are only for individuals who have already been screened by their primary care provider, meet criteria, and have a written order for a COVID-19 test. As our respiratory volumes fluctuate, we have the ability to quickly transition a current Urgent Care center into a Respiratory Illness Clinic.

    In the fall, we are considering using an underground garage for similar testing to keep people out of the elements. With fewer cars at our locations, this may be more feasible than pre-COVID.
  • We are planning the same, respiratory clinics to handle flu in addition to COVID, as well as drive-through flu shots that are separate from the drive-thru COVID testing. We want to keep the healthy separate from the sick.
  • We will have drive-through flu clinics as well as dedicated flu immunization days, probably on the weekends. Working on a dedicated respiratory clinic for the fall.
  • Given the similarities in viral symptomatology and transmission between COVID-19 and influenza, we too are carefully planning how we guide and direct patients with flu-like symptoms to the appropriate care setting. A few call-outs:
    • We have had designated drive-up COVID testing sites in our markets, but with flu season quickly approaching, we will be adding flu vaccinations at these stations. Importantly, we are moving away from the "temporary nature" of these sites (i.e., tents, etc.) to longer-term structures that provide relief for our care teams in temperature extremes. That said, we believe the drive-up functionality is important, and we will keep that with the longer-term structure solution.
    • We have had designated "Red Clinics" (our terminology for the respiratory clinics whereby any patient with "flu-like symptoms" is directed) in each of our markets. However, we are thinking differently about who will staff these sites (i.e., rather than PCPs redirecting from their own patient panels to care for patients in the Red Clinics, staffing these sites with providers solely focused on assessment and treatment for this defined patient population).
    • As an integrated care delivery system, we are reassessing the location of our designated Red Clinics. We want to ensure we have a Red Clinic in relative proximity to our busier EDs such that when a patient presents, is triaged and determined treatable at a lower acuity level, we have an adjacent site for care/treatment.
    • Finally, a large clinical-operations work plan around the ongoing considerations for care of all patients, including patient messaging and digital navigation to the appropriate care setting, continued use of virtual care when possible, and workflow redesign for in-office care (i.e., touchless registration, bypassing waiting room, visitor restrictions, appropriate PPE, and added cleaning precautions).

CMO Questions

  • Are your ambulatory clinics doing point of care (POC) influenza antigen testing now and in the fall?
  • If you are removing POC testing (POCT) from ambulatory clinics, are you collecting samples for influenza to send to a central lab testing site?
  • Is your plan to do at least influenza and COVID 19 testing this fall on all respiratory samples?
  • How are you managing upcoming respiratory illness season with increased volume overwhelming respiratory clinics and testing capacity being strained to offer at limited sites?

CMO Answers

  • We offer POCT for influenza in our urgent care locations and may expand to pediatrics. We will continue to offer this but will likely not add POCT for COVID - rather send the same swab to our central lab.

    At this time, we offer COVID testing primarily for symptomatic patients at our urgent care locations and by appointment at a drive-thru site that also manages our pre-operative testing. Most primary care patients with symptoms are assessed first via video or telephone visit and I anticipate we would continue to do this initial evaluation and send stable patients through the drive-thruough for testing. With flu season coming, our plan would be to test for both.

    Any patient that needs in-person evaluation at this time is generally sent to our urgent care respiratory locations (though our pediatric offices are seeing patients on the respiratory side). However, we are planning now for how we might expand evaluation opportunities to include respiratory locations in adult primary care. We also are looking at how we could expand testing locations in anticipation of increased demand across our geography.

    Finally, we are planning for flu clinics by appointment (as opposed to walk-in as we have done in the past) with screening for symptoms prior to appointment. We are planning to establish "hubs" in our various geographies. This would be in addition to offering flu vaccines for patients who do come for face-to-face visits.
  • We have created a "Virtual Respiratory Clinic" staffed by our primary care and urgent care providers where all patients with respiratory symptoms are seen via telemedicine visit initially. If testing is indicated by this visit, the patient is getting tested through a designated drive-through testing site. If in person evaluation is deemed necessary, then we have a designated "Upper Respiratory Clinic" for these patients. With increasing demand, we are moving towards opening more testing sites and, as demand dictates, open additional "Upper Respiratory Clinic" sites. We are also investigating having physically separated "warm" and "cool" sites at each of our primary care locations. We plan to continue this model into the fall and winter, permitting ongoing payment for telemedicine visits by insurance. We are ramping up testing by adding rapid COVID antigen testing with our current Sofia platform and will be adding Abbott rapid molecular testing in September, both of which will be kept at all our primary care locations.
  • We are still using our Acute Respiratory Clinics to manage the sick population, and it serves as our test collection sites with outdoor tests or covered areas to decrease exposure risks. This includes direct scheduling availability for our community members, and we plan to continue this model into the influenza season.

    We are looking at a platform that has the potential to combine COVID and Influenza. We also know respiratory pathogen panels and strep testing are additional tests that providers and patients are also looking for, and these options are available. We also stopped influenza and respiratory panels as part of our standing orders and will be looking to restart them in the fall/winter once the seasons overlap.

    Some of our smaller and rural sites will have a similar sick/well split, but it will likely involve different entrances and waiting areas, as opposed to a separate site or building.
  • Our 60+ sites continue to offer COVID testing at our ambulatory sites and at separate locations (ideally outside). We plan to continue this process for the foreseeable future.

    The "best practice" of separating sick patients from well patients by caring for them outdoors or off-site at respiratory clinics that operate outdoors may become the mainstay even in the fall and winter seasons.

    We hope to offer Abbott POC testing in early September at most of our ambulatory clinics. We will resume combined influenza screening when signs of "flu season" begins again. We will expand respiratory testing as needed using innovations that were needed in April, such as tents, RVs, etc. Also, transitioning centralized care coordination nurses to help screen patients over the phone to minimize unnecessary office visits will be used again if needed.