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04/15/2020 08:30 AMWell before the COVID-19 crisis forced medical professionals to convert to “virtual care” by flipping in-person visits to phone or video conferencing, the systems were in place at Veterans Administration CT (VACT) Healthcare System, which serves 50,000 veterans statewide.
The rapid transition is one of the advantages of being part of the country’s largest single-payer healthcare system, says Chris Ruser, MD and chief of primary care for VACT Healthcare System.
“In the V.A., we’d long been leaders in ‘virtual care’ and were thus poised to make this transition more quickly than other healthcare systems, and without the same concerns as a fee-for-service environment,” he says, adding, that, across the U.S., the V.A. has “...about 8 to 10 million patients at any given time. Because we’re not functioning in a fee-for-service environment, we can innovate services without worrying about some of the constraints.”
Chris has led VACT’s primary care program for 10 years. Over the past two months, the Guilford resident’s focus has largely shifted to his involvement in VACT’s COVID Response Team.
One of the team’s first tasks was fully “virtualizing” primary care visits at a critical point in the COVID-19 timeline, he says.
“When it became apparent that health care environments were high-risk places for patients to possibly co-infect each other, even in clinics, and then healthcare workers [would] as well be infected; just like social distancing the in the community, my team here went aggressively forward with a plan to try to attempt to 100 percent virtualize all our care, and only reserve in-person for when it’s absolutely needed,” says Chris. “From [starting out] about the middle of March to as of last week, we were 98.5 percent virtual.”
Converting typical, in-person visits to phone or video visits was especially critical to flatten the curve among VACT’s majority older, higher-risk population. Keeping those patients physically out of medical centers would avoid in-hospital acquisition of coronavirus, Chris says.
Last week, across the state, VACT conducted approximately 2,500 virtual visits in one week.
“About 10 percent were video and the other 90 percent were telephone care,” says Chris, adding the video service requests are increasing.
With the majority of VACT patients over the age of 65, Chris says one might assume video conferencing would be a difficult concept for older patients to grasp, but they are picking it up.
Several years ago, when VACT instituted system-wide email services, “we anticipated it only would be young people that would do it, and we were proven wrong,” he says.
Next Steps
Chris likens the all-hands-on-deck approach to setting up VACT’s virtual services to Phase I of a multi-step COVID-19 approach. Next, the team turned to address other impacts they felt would arise in patient care.
“The second phase was to determine what are the care needs that are emerging because of COVID-19 that didn’t exist before,” he says. “What we saw was a massive spike in call-center demands; lots of people calling with symptoms, whether they were respiratory or not, worried they might be infected. We started getting hundreds of those calls per day.”
VACT already had a baseline call center service for typical requests such as medication refills. In addition, VACT created a COVID-19 virtual triage clinic aligned with doctors and nurse practitioners supporting the call center.
“So now, the call comes into the VACT call center, and if it’s a clinical need, a nurse takes the call and then he or she can send a Skype to a provider who’s in the waiting, and they can do a hand-off of that patient in virtual real-time,” says Chris. “So they can tell them, ‘I’m going to give you to a doctor who can talk to you about your symptoms and whether or not you need to be tested.’”
Another hurdle cleared by VACT in March was developing its own drive-up testing system, which quickly grew to include finding a better way to communicate with hundreds of patients to convey testing results. VACT’s test results usually come back within a day’s time.
“As the prevalence of the disease increased, we realized a big part of our day-to-day is calling back patients who tested positive or negative,” says Chris.
In addition to regular daytime virtual clinics, “we added evening and weekend virtual clinics that are staffed by providers to call back patients with their test results and explain a little bit about the disease,” he says.
Health Care and Public Health
Chris is also associate professor of medicine at Yale University School of Medicine, where he serves as part of the general internal medicine faculty. He’s been on calls for that department’s COVID Response Team, assisting with programmatic challenges and completing connections between Yale and VACT.
“I think the two systems are closely linked,” he says. “The residents from Yale do a lot of their training here at the V.A. So we’ve had a lot of calls about moving the medical residents to the areas where they’re needed the most, and how we cover them when they move.”
When shifting residents out from clinical areas, other professionals, including Chris, are stepping in to take on care that might happen in an out-patient setting.
Working in the realms of two types of U.S. health provision gives Chris an interesting perspective.
“I kind of distinguish health care and public health into two different domains. The U.S. is thought to be a leader in health care, I think, because we can provide lots of innovative technologies and innovative treatments,” he says. “I think, in some ways, we’re lacking behind a lot of other countries in the public health domain, and I think this pandemic has kind of stressed the limitations of our public health system in general.”
As an integrated system around the country, the V.A. has a pre-existing organizational structure that is a much stronger public health system at baseline, he says.
As an example, V.A.’s New England region, which includes Connecticut, has about 250,000 veterans, and “within days of this becoming obvious that this was a pandemic, as far back as February, we were able to send secure messages [via] email to almost 200,000 patients that said ‘phone and stay home,’” he says. “And we were able to send text messages to hundreds of thousands of veterans. In the first week of March, we sent postcards that routine visits were being converted to virtual care. So having that giant, integrated system allowed us to leverage technology much more quickly to get messages out. And I think it’s made a difference in disease prevalence in our population.”
In terms of the public sector’s discussion of “flattening the curve” of COVID-19 cases breaking out, VACT is now seeing its disease curve has flattened. That’s especially encouraging in a system that has a majority of older patients with pre-existing health risks, Chris notes.
“It’s too early to say this definitively, but so far we’ve seen a promising trend of flattening the curve,” he says.
Responding in a Crisis
When the pandemic dust finally settles, many may not recall what it took for those in the medical profession to create plans and pathways to respond to anticipated needs in the face of rising challenges, without much warning. Chris says the earliest point he recalls discussions among his peers with regard to concerns about potential impacts of COVID-19 was mid- to late January.
Asked if there was more that could have been done to prepare, Chris replies, “when anyone’s pointing fingers, I always say this is an unprecedented challenge in modern medical history for the U.S., so I’m a pretty lenient Monday morning quarterback in looking back. I think that there’s more that we could have done, and lessons will be learned, and I think we did make a lot of mis-steps and mistakes, but if you start to build timelines for how quickly we changed practice and responded...I wouldn’t say that we did well, but I would say it was an unprecedented challenge, and it’s hard to look back at that and say obviously how things could have been done differently.”
On a personal note, both Chris and his wife, Dr. Susan Kashaf, are experiencing COVID-19 among the front lines. Susan is a primary care physician at the V.A. and also does some work with Yale Medical School.
“We still get to see each other,” says Chris. “I think there’s an interesting sub-conversation about when there’s two people in healthcare, and when you’re getting into high-risk areas of the hospital, how do you parse out that risk as a family?”
Hospital systems are working to keep partners from being deployed in high-risk rotations at the same time, he says.
Another challenge for medical professionals is simply how to safely go home at the end of the day.
“Even with one spouse who’s in healthcare—do you go home when you’re done with your shift, or do you stay at a hotel or in a dormitory?” Chris asks.
“We have a back-up plan in our house, about how we would isolate if we had a definitive, unprotected exposure,” he says. “In that situation, we have a plan for how we would isolate and take care of the exposed person without exposing our kids.”
Chris and Susan have lived in Guilford since 2001 and are raising their daughters, Sophia, 17 and Leila, 15, here. They girls are going through distance learning and managing well in what is certainly a challenging time for all students, says Chris.
To help give back to their hometown, Chris and Susan were among a March 30 panel of medical professionals in a Zoom conference on the virus organized by First Selectman Matthew Hoey.
Chris says all medical professionals are grateful for the community support that’s reaching them during the COVID-19 crisis. However, as shared by the group on March 30, there’s a single, best, way to help them get through this.
“I think pushing that message of social isolation is important. We’re not out of the woods yet, but we see early evidence that the strategy really does work,” says Chris. “So if people want to know how they can contribute, they can take that really seriously, for as long as health care leaders think that we need to do that. Because it will make a huge difference for how many patients we have to take care of, and how sick the patients are.
“That concept was new to our community as of March, and people are doing such a good job of it,” he says. “I would just emphasize that we’re thankful for them, and hopeful they can keep doing that for a bit longer.”