Redesigning Primary Care to Address the COVID-

19 Pandemic in the Midst of the Pandemic

Alex H. Krist, MD, MPH1-3 ABSTRACT
Jennifer E. DeVoe, MD, DPhil4 During a pandemic, primary care is the first line of defense. It is able to rein-
Anthony Cheng, MD4 force public health messages, help patients manage at home, and identify those
in need of hospital care. In response to the COVID-19 pandemic, primary care
Thomas Ehrlich, MD2,3 scrambled to rapidly transform itself and protect clinicians, staff, and patients
Samuel M. Jones2,3 while remaining connected to patients. Using the established public health
framework for addressing a pandemic, we describe the actions primary care
1
Department of Family Medicine and Popu-
needs to take in a pandemic. Recommended actions are based on observed
lation Health, Virginia Commonwealth
University, Richmond, Virginia
experiences of the authors’ primary care practices and networks. Early in the
COVID-19 pandemic, tasks focused on promoting physical distancing and encour-
2
Inova Health System, Fairfax, Virginia aging patients with suspected illness or exposure to self-quarantine. Testing was
Fairfax Family Practice Residency, Fairfax,
3
not available and contract tracing was not possible. As the pandemic spread,
Virginia in-person care was converted to virtual care using telehealth. Practices remained
Department of Family Medicine, Oregon
4 connected to patients using registries to reach out to those at risk for infec-
Health & Science University, Portland, tion, with uncontrolled chronic conditions, or were socially vulnerable. Practices
Oregon managed most patients with suspected COVID-19 at home. As the pandemic
decelerates, practices are now preparing to address the direct and indirect con-
sequences—complications from COVID-19 infections, missed treatment for acute
problems, inadequate prevention, uncontrolled chronic disease, mental illness,
and greater social needs. Throughout, practices bore tremendous financial bur-
den, laying off staff or even closing at a time when most needed. Primary care
must learn from this experience and be ready for the next pandemic. Policymak-
ers and payers cannot fail primary care during their next time of need.

Ann Fam Med 2020;18:349-354. https://doi.org/10.1370/afm.2557.

INTRODUCTION

I
n normal times, 75% of adults report 1 or more illness or injury per
month. Most manage symptoms on their own, but 25% consult a clini-
cian.1 Our health system is right-sized to meet that demand. During
a pandemic, demands and needs completely change. More patients need
infection-related care, but there is also a decreased number of patients
seeking non-infection–related care, potentially with adverse consequences.
Stress rises as do mental health needs and substance misuse, and new
financial burdens cause greater social needs for patients and burdens for
primary care. A pandemic is a time when people need primary care more
than ever and primary care needs to know how to help them.
In 2014, the Centers for Disease Control and Prevention (CDC)
Conflicts of interest: authors report none. Alex
issued a framework to address the influenza pandemic.2-4 They describe
Krist is a member of the United States Preventive
Services Task Force (USPSTF). This article does 6 intervals: (1) investigation of cases of novel influenza, (2) recognition of
not necessarily represent the views and policies of the increased potential for ongoing transmission, (3) initiation of a pandemic
USPSTF. wave, (4) acceleration of a pandemic wave, (5) deceleration of a pandemic
wave, and (6) preparation for future pandemic waves (Table 1 and Figure 1).
The CDC’s framework is a strong public health strategy, but it does
CORRESPONDING AUTHOR
not address the specific needs of primary care nor the patients and com-
Alex H. Krist, MD, MPH
PO Box 980101 munities they serve. As the most common place for first health care
Richmond, VA 23298 contact,5 primary care is the health system’s first line of defense, able to
ahkrist@vcu.edu reinforce critical public health messages, help patients manage infections

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at home, and identify those in need of hospital care. framework. The recommendations are based on the
Done well, this can reduce the spread of infection and experiences of the authors’ community-based primary
protect hospitals from being overwhelmed. care practices during the COVID-19 pandemic. Rec-
This manuscript considers how primary care ommendations are grounded in the core principle of
practices can rapidly and continuously reinvent them- protecting clinicians, staff, and patients while remain-
selves during a pandemic using the CDC’s pandemic ing available and connected to meet patient needs.

Table 1. Primary Care Preparedness and Response to a Pandemic

CDC-Defined Primary Care Actions to Care for

Intervals CDC Indicators2 Primary Care Experience Patients and Communities
Investigation Investigation of Business as usual for primary Continue usual acute, chronic, wellness, mental health, and
(Interval 1) infection care; be ready for a potential social care
pandemic Participate in public health surveillance programs
Maintain readiness to address local or global spreads of
infections
Recognition Recognition of Patients in sentinel communi- Rigorous hand washing
(Interval 2) increased poten- ties begin to get infected; cli- Separate patients with infectious symptoms and those who
tial for ongoing nicians hear about pandemic are well
transmission possibility
Implement physical distancing measures for all
Minimize patients in waiting room
Have patients and staff wear masks
Disinfect rooms after every patient encounter
Switch to virtual visits and telephone-based care
Testing and contact tracing
Initiation Confirmation of human Infections rapidly spread in and Convert to complete virtual care for first contact
(Interval 3) cases globally with across communities; patients Only see patients in person after triaged as necessary
human-to-human worry about their risk of
transmission infection Implement proactive population care to identify and reach out
to at-risk patients for infection and worsening chronic condi-
tions, mental health, or social needs
Implement policies to protect patients, staff, and clinicians
Keep patients away from emergency departments and hospitals
unless necessary
Acceleration Consistently increasing Infections spread; patients Continue virtual care and proactive population care
(Interval 4) rate of infection, get infection complications Limit patient contact with emergency and hospital care to nec-
indicating estab- and require hospitalization; essary care
lished transmission patients defer care of non-
infectious conditions Systematically implement testing protocols
Define criteria for hospitalization
Create care teams to check in daily/weekly with patients in need
Reinforce and support hospital care teams
Create home hospital care for sick patients not hospitalized
Expand home palliative care for patients who want less aggres-
sive care
Deceleration Consistently decreasing Patients get infected—but Support convalescing patients
(Interval 5) rate of infection fewer patients; hospitalized Support home rehabilitation care services
patients improve and need
rehabilitation; resume care Consider overflow recovery centers or new home care services
for non-infectious conditions Develop a strategy to resume “normal” in person care
Monitor reopening strategies to ensure patients, clinicians, and
staff remain safe
Preparation Low infection activ- Patients suffer from uncon- Attend to pent-up demand as a result of delayed care
(Interval 6) ity but continued trolled and missed conditions Address adverse consequences of delayed or deferred care
outbreaks possible in and risks; there is a high
some areas burden of mental and social Expand the provision of evidence-based care for unhealthy
needs; practices recover from behaviors, mental health, and social needs
financial and staffing burdens Expand the role of social workers and community health workers
Leverage the clinician-patient longitudinal relationship to
address needs
Advocate for essential social and economic policies
Rebuild practice

CDC = Centers for Disease Control and Prevention.

Note: many tasks started in early intervals continue throughout subsequent pandemic intervals.

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Figure 1. The Centers for Disease Control and Prevention interval framework for influenza pandemic—
hypothetical cases as a function of pandemic interval.
Hypothetical number
of influenza cases
intervals
CDC

Investigation Recognition Initiation Acceleration Deacceleration Preparation

Prepandemic intervals Pandemic intervals

CDC = Centers for Disease Control and Prevention.

Note: This is a hypothetical depiction of the number of infectious cases as a function of the Centers for Disease Control and Prevention’s pandemic intervals. Reprinted
from Qualls et al.4

CDC PANDEMIC INTERVALS FRAMEWORK distancing by separating healthy patients from those
Interval 1 with symptoms, minimizing the number of patients in
Investigation common areas like waiting rooms, and spreading chairs
During the first interval, the CDC defines the main out 6 feet apart to enforce distancing.6
public health activity as investigation of infection.2 For For any pandemic, hand washing is essential before
primary care this is business as usual—continued provi- and after every encounter for all parties. Rooms must be
sion of acute, chronic, wellness, mental, and social care. thoroughly disinfected after visits. For respiratory illness
pandemics, patients and staff can wear masks while in
Actions the office. To prepare for a higher prevalence of infected
To be prepared for a possible pandemic, primary care individuals in the community and to minimize spread,
can participate in public surveillance programs, notify practices can increase virtual visits and telephone-based
the health department of reportable cases, monitor care and delay nonurgent appointments. Testing is
for outbreaks, and even supply real time electronic essential. Ideally, testing is widely available and accurate.
health record (EHR) data for monitoring. Ideally, Through testing and contact tracing, primary care can
primary care can maintain readiness for an outbreak, identify those who need to quarantine—a critical ele-
including adequate supplies for testing, protective ment to dampen the spread of an epidemic.7
gear for clinicians and patients, and treatments for
those who could get sick. Interval 3
Initiation
Interval 2 This interval is marked by confirmation of human
Recognition cases and global spread.2 For primary care, this interval
The CDC defines this interval as the recognition of really begins with spread in the practice’s community.
increased potential for transmission.2 For primary care, Patients show signs of illness. Fear and anxiety spread.
cases begin to appear in sentinel communities, but for Patients, primary care clinicians, and hospital staff and
many practices, life may feel normal. Offices are open leaders need to act urgently.
and functioning in the status quo, but patients are
beginning to worry, some may develop symptoms, and Actions
clinicians hear about a pandemic possibility. To “flatten the curve” (ie, slow the spread and protect
the hospitals from being overwhelmed) primary care
Actions must be a leader in promoting physical distancing,
Now is the time primary care must act. During the hand washing, and limiting contact.8 This includes
COVID-19 pandemic, practices promoted physical both teaching and promoting these principles to

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patients and leading by example. An essential element perplexing to see rates of usual hospital admissions
is to convert to nearly complete virtual care.9,10 This dramatically decrease.12 Hospitals reacted by rede-
means that every initial patient encounter needs to be ploying nearly all hospital beds to treat COVID-19
a video visit or telephone call. A skeleton crew of clini- infected patients, and asked outpatient clinicians to
cians can see the few patients that must be seen (eg, support inpatient hospital teams.
someone with an abscess to drain), but only after triag- Managing some patients at home that would nor-
ing through virtual care. mally be hospitalized could minimize hospital burden,
To remain in touch with patients, practices can protect patients from spreading or contracting infec-
implement proactive population care. Population tions, and even improve health outcomes.13 Primary
care is different during a pandemic. In normal times, care is well positioned to lead this “home hospital” care.
many practices utilize registries of patients driven by While there have been some studies on home hospital
traditional quality measures to reach out to patients care,14 it has not been widely deployed. The home hos-
overdue for care, who need specific services, or who pital services during a pandemic could range from (1)
have uncontrolled conditions.11 During a pandemic, managing less-severely ill patients with the infection,
practices should shift registry functions to identify (2) managing patients with noninfectious conditions
vulnerable patients. This includes patients at risk to reduce their exposure risk, and (3) home hospice
for infection, with uncontrolled chronic disease, or care for those who are sick but not eligible for or not
experiencing social needs. These patients must be interested in receiving intensive care. The infrastruc-
prioritized and proactively contacted to periodically ture used for virtual visits could bring clinicians into
check-in. Further, as clinicians see patients virtually the home; multi-disciplinary teams could be assembled
who need more active follow-up, they can be added as needed; check-ins could be more intensive; basic
to the contact list. Staff should call these patients essential remote monitoring equipment (eg, oxygen
frequently, and if the patient worsens, elevate care to saturation or blood pressure monitors) and treatment
repeat virtual visits, in-person office visits, or even equipment (eg, oxygen, antibiotics, pain medications)
hospitalization. could be supplied through retailers, pharmacies, and
home health agencies; mobile monitoring could be
Interval 4 deployed in communities (eg, mobile telemetry unit);
Acceleration and non–health care workers like family and friends
During this interval there is a consistently increasing could aid in physical care (eg, cleaning, feeding).
rate of infection.2 For primary care, more patients are
infected, more patients become acutely ill or experi- Interval 5
ence complications and need hospitalization, and Deceleration
patients avoid care for noninfectious conditions. This During this interval, there is a consistently decreas-
simultaneously creates increased demands related to ing rate of infection.2 Hospitalized patients recovering
the pandemic and decreased need for routine in-person from life-threatening illness enter the recovery phase
primary care. and are discharged from the hospital. However, they
are still in need of rehabilitation and support. At some
Actions point in this interval, primary care practices transition
Throughout this phase there is a need for primary from the virtual care systems they developed during
care to maintain virtual care, population care, and the the pandemic to “normal” in-person care.
protective functions described above. A key goal is
to limit patient contact with hospitals. This will both Actions
protect patients from unnecessary exposure and allow Primary care practices need to engage with nursing
the hospital to focus on patients needing their services. homes, rehabilitation centers, and home health agen-
Primary care and health systems will need to coordi- cies to help care for their convalescing patients. While
nate on criteria for emergency assessments, criteria practices commonly participate in post-acute rehabili-
for hospitalization, and overflow care when hospital tation care of their patients, practices should be pre-
capacity is exceeded. Practices that routinely provide pared for a greater than normal volume of rehabilita-
hospital care for their patients will need to prepare for tion care. Additionally, rehabilitation centers and home
a surge of infection-related admissions and a reduction health agencies may be overwhelmed and/or may be
in noninfectious admissions. Clinicians who typically reluctant to accept patients who are post-infectious.
provide outpatient care may be called on to provide Similarly, patients who are recovering from other con-
inpatient care, depending on their community’s needs. ditions may be unwilling to go to rehabilitation cen-
During the COVID-19 pandemic, for example, it was ters. Without a place for care, patients could linger in

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the hospital, occupying needed resources, or patients help patients improve health behaviors, address mental
may be sent home with insufficient support and treat- health needs, and improve social risks. Even when not
ment. Some communities may need to establish over- trying to recover from a pandemic, these are tremen-
flow recovery centers to handle demand or expand dously difficult issues, requiring intensive support over
home health support. Primary care could play a key prolonged periods of time from community-based
role in caring for patients in such overflow settings. and social service programs. These programs may be
To decide when to re-open, primary care should struggling themselves with increased demand and lack
follow the advice of public health authorities. Reopen- of adequate infrastructure. Robust clinical-community
ing will involve a gradual transition from virtual to partnerships will be needed to address these basic
in-person care. Initially, care that is equally effective patient needs.18 For mental health, primary care may
virtually and care for more at-risk individuals should consider developing or extending integrated mental
remain virtual. Throughout the process, primary care health into the primary care practice.19
will need to monitor the health of their clinicians, staff,
patients, and community. If increases in infection rates
are observed in any of these populations, the reopen- DISCUSSION
ing process may need to be modified. During a pandemic, the quicker that public health and
primary care can identify each interval, the quicker
Interval 6 they can transform care to protect patients and com-
Preparation munities. A key challenge is that infections are com-
For public health, this interval is a return to normal. mon, but only rarely is there a pandemic with the mor-
The CDC defines the interval as having low infec- bidity and mortality of COVID-19. Monitoring, early
tion activity, but possibly outbreaks in some areas. identification, and preparation for rapid, early action
The preparation interval loops back to the investi- are essential to prevent exponential spread.
gation interval as public health and others monitor We have described a roadmap for how primary care
for the next outbreak.2 This period of “picking up can transform itself during a pandemic (Table 1). As the
the pieces and putting them back together” remains pandemic progresses, primary care will need to sustain
highly demanding for primary care. Before consider- activities in prior intervals and add in the new activities
ing preparing for the future, primary care will need to for the next interval. Different communities will experi-
address the consequences of the pandemic. The direct ence intervals at different times and with varying sever-
consequences include premature deaths, prolonged ity. Some intervals happen simultaneously, and some
recovery periods for those infected, the death of loved repeat. This means local tailoring is needed based on
ones due to COVID-19, and sequela of infections. local events and needs. To address the pandemic, it will
The indirect consequences may be even greater, and take a partnership in every community between public
include missed treatment for acute problems; inad- health, primary care, specialty care, hospital systems,
equate preventive care; uncontrolled chronic disease; palliative care, mental health, informatics, rehabilitation
new onset or worsening depression, anxiety, alcohol centers, home health agencies, community service pro-
and substance misuse, and domestic violence; and viders, insurers, and policymakers.
greater social needs such as financial troubles, hous- There are many barriers to an effective pandemic
ing instability, and food insecurity. Adding to these response. Entering the COVID-19 Pandemic, much
demands, health disparities will worsen.15 During the of the needed infrastructure was poorly developed—
COVID-19 pandemic, we saw greater infection rates informatics infrastructure was inadequate for virtual
and complications among underserved populations,16 care, clinician communication, and home hospital
who had to work and could not physically distance.17 care. Groups that needed to partner, operated in silos.
The underserved also suffered greater financial loss Primary care, mental health, community-based orga-
and social hardship. It is already predicted that the nizations, and social services were underfunded and
financial strain (and ruin) from COVID-19 will be felt understaffed. It remains to be seen whether the innova-
by many communities for decades. tions to address these barriers during the COVID-19
pandemic will remain.
Actions With any new pandemic, we should expect uncer-
Primary care will need to address pent-up demand tainties. We will not know the infection’s natural his-
and adverse consequences from delayed or deferred tory and we will not know how to diagnose and treat
care. This involves ensuring access to care, expanding the infection. As a result, we will not have needed
hours and staffing, and identifying those in need of supplies. During COVID-19, we lacked tests (swabs,
overdue care. Additionally, primary care will need to medium, reagents), personal protective gear, hospital

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beds, and ventilators. The unknowns and limited 3. Centers for Disease Control and Prevention. Pandemic influenza
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