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Primary care: What changes made in throes of the pandemic are likely to stick?

Primary care: What changes made in throes of the pandemic are likely to stick?

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Refresh cover on primary care Hickey

Dr. Kenyani Davis, a family practice doctor and chief medical officer with the Community Health Center of Buffalo, does a checkup on Trinetta Alston in the Cheektowaga office. The pandemic has changed primary care in a variety of ways, some of which will remain going forward. Masking is among them, at least for a while longer.

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Western New York native Chrystal Doust lived in Ontario when the Covid-19 pandemic tore through North America in spring 2020.

Anxiety that doctors and mental health counselors helped her keep at bay since childhood worsened as the isolation and uncertainty churned toward summer, and beyond.

Doust also needed more support as postpartum depression set in after the birth of her first child. But she was in Canada, where the wait to talk online with a counselor stretched for months.

“I felt like there were no resources for me,” she said.

She turned to Doctor on Demand, a U.S. telemedicine company that addressed her needs as she made plans to move back to the Buffalo Niagara region and reconnect with her family medical practice.

Doust and her Canadian-born husband landed jobs working remotely for American companies, got new health insurance and moved to Hamburg late last year.

They've gotten used to how Covid-19 transformed primary care in the region. Things continue to evolve as the pandemic wanes, but some changes seem destined to remain.

Several doctors – including the physician who treats the Dousts – weighed in on what patients can expect going forward.

Changes in primary care

Dr. Adnaan Sheriff (left) examines Jack Doust, 2, as his mother, Chrystal, looks on earlier this year during an office visit at Amherst Medical Associates. Dr. Adnaan Sheriff, spent part of the visit assuring that Jack was up to date on his vaccination schedule.

Appointments

Health screenings for appointments done by phone changed at the start of the pandemic, when there was no treatment for Covid-19 or readily available rapid test to learn if someone was infected with the virus that causes the respiratory disease. Primary care providers looking to prevent the spread encouraged patients to treat mild symptoms at home and visit a hospital emergency room if labored breathing persisted.

This fall, providers manage Covid-19 and a variety of similar illnesses, including more instances of the flu and an alarming number of cases of Respiratory Syncytial Virus (RSV).

This means nurses who perform the screenings by phone ask more questions about symptoms, particularly when someone looks to schedule a sick visit, said Dr. Fred Archer, interim division chief for general pediatrics with UBMD Physicians’ Group, which runs two child health clinics in Buffalo.

Staff asks if the patient who is sick has had a home Covid-19 test and, if so, the result. Nurses spend more time going through specific symptoms, like an extreme runny nose that might signal RSV, a condition most concerning in children 3 and younger.

Those who test positive for Covid-19 are still discouraged from visiting the office, said Dr. Adnaan Sheriff, of Amherst Medical Associates, who treats Doust and her family.

The last few months have disrupted so much of our community and its health care – for many families, that means visits to the pediatrician have been canceled or delayed. Well-child visits are extremely important. They are a time to assess kids’ growth and development, provide hearing and vision screenings, conduct a thorough physical exam and provide parents with useful information about safety, nutrition and what to expect as your child grows. Don’t delay – call your pediatrician!

The practice also continues to use a more intensive screening process, which helps triage patients, get them the best help more quickly and reduces the number of patients who need to see Sheriff and his colleagues in their North Bailey Avenue office.

"We don't see 30 patients a day in the office anymore," Sheriff said. "We see maybe 15. But our patients are more engaged than they have ever been."

Waiting rooms

Amherst Medical Associates is among primary care practices that added a kiosk in their offices where patients can check in, show an insurance card if necessary, and pay copays or balances. The arrangement gives staff more time to take calls, schedule appointments and streamline patient visits, Sheriff said.

Most primary care waiting rooms also contain fewer chairs, set farther apart.

Changes in primary care

Dr. Adnaan Sheriff uses an interactive touch screen in one of the waiting rooms at Amherst Medical Associates in Amherst. It helps him explain health conditions and treatments when meeting with patients.

The screening process became more important in deciding how best to treat patients before they arrive.

“If a kid is here for sick visit, we want to get them triaged appropriately so they're not sitting in the waiting room too long,” Archer said.

UBMD Pediatrics was among practices that set aside isolation rooms in 2020 for patients who scheduled office visits and might have Covid-19.

“We don't call them isolation rooms anymore,” he said of the dedicated rooms, “but we do have what we call our ‘sick rooms’ for kids who have more acute respiratory-type illnesses.”

Those and other rooms where patients have symptoms of a respiratory condition undergo a deeper cleaning between patients, he and Sheriff said.

Dr. Kenyani Davis, telehealth

Telehealth has its advantages and should be here to stay, but there are questions going forward over reimbursement, says Dr. Kenyani Davis, a family practice doctor and chief medical officer with Community Health Center of Buffalo.

Telehealth

Doust, 29, who grew up in Niagara County, and her husband, Brian, work remotely from home. Their son, Jack, turns 3 in December.

All three see Sheriff, whose office is about 25 miles north of their home.

Throughout the pandemic, most of the contact has taken place online or by phone.

Doust worked online with Sheriff to come up with a mental health treatment plan and assure she was on track. She also dealt that way with a rash on her son.

“I honestly don't even know how we went to the doctor before there was telemedicine,” she said. “I have to drop my son off at day care at 8:30, and then I’ve got to work at 9. It's nice to have a 30-minute pocket of time from my desk to be able to prioritize myself and my health.”

The appointments save her a long drive and allow her to address urgent matters with a primary care staff that has treated her for 15 years. The tradeoff of driving to and from Amherst for occasional wellness visits is worth the comfort she feels.

To be sure, telehealth today isn’t what it was during pandemic surges.

Last year, 37% of adults, including four in 10 patients in the Northeast, used it at least once, the Centers for Disease Control and prevention reported last month

Telemedicine use in 2021

Amherst Medical had two telehealth appointments in 2020 before March 1.

It had 617 from May 1 to June 30 of that year.

The numbers also came down before and after the Delta and Omicron surges last winter. There were 38 phone and video appointments in the last two months of 2021, Sheriff said, and 155 in the first 10 months of this year.

Dr. Kenyani Davis, chief medical officer with Community Health Center of Buffalo, said telehealth appointments ebbed and flowed in the practice in much the same way, but continue to play an important role, especially with mental health visits.

The federally qualified health center serves more than 20,000 patients at offices in Buffalo, Cheektowaga, Lockport and Niagara Falls.

During the pandemic, all kinds of appointments were conducted online, Davis said. They even included urgent appointments that allowed dentists to diagnose abscesses online and prescribe antibiotics until patients could get into the office.

“It reduced our no-show rate, which was somewhere between 20% and 22%, down to 10% to 13%,” Davis said.

It also underlined two challenges that limit the ability to complete scheduled primary care office visits, the lack of reliable transportation and child care, she said.

“One of the great things about telehealth is that you get a chance to see the patient in their own environment,” Davis added. She recounted seeing a patient online in her late 70s walk to the bathroom to get her medication – and throw rugs, a tangle of electrical cords and sharp-edged furniture along the way. The look-in prompted her to ask a community nurse to visit the patient at home and conduct a risk assessment for falls.

PROSPECTUS ADNAAN SHERIFF GEE

"We don't see 30 patients a day in the office anymore. We see maybe 15. But our patients are more engaged than they have ever been," says Dr. Adnaan Sheriff of Amherst Medical Associates. 

Patient portals

More patients of all ages have learned during the pandemic that leaving primary care providers a message by email or through a confidential patient portal is a good way to get questions answered without visiting the office or even making a phone call. Messages are returned within 24 hours, and often much sooner.

It is common to see lab results and other paperwork – including vaccine records – as well as manage mild illnesses.

Doust gets appointment and payment reminders on the Amherst Medical Associates patient portal. She also gets a synopsis from Sheriff of their appointments, as well as references to resources that can buttress her health and wellness.

“It's been a huge help,” she said. “I’m very comfortable with it. Honestly, I think my grandmother could use it.”

More mental health

Most adult practices have lost patients to Covid-19. Most patients have lost at least one friend or family member. This, coupled with the isolation and uncertainty Covid-19 wrought, increased post-traumatic stress, anxiety and depression.

It kept social workers and mental health counselors at Buffalo Community Health Center among the busiest on the 130-member staff.

In 2021, they completed 2,071 virtual visits for behavioral health, Davis said.

Mental health concerns doubled among patients with Amherst Medical Associates, Sheriff said.

“Mental health awareness has gone up,” he said, “and you hear the topic of burnout where maybe it wasn't as prevalent before.”

vaccine hesitancy

Dr. Kenyani Davis, chief medical officer of Community Health Center of Buffalo, draws a Johnson & Johnson Covid-19 vaccine in May 2021 during a pop-up vaccination clinic in a joint effort with Upper Room Church of God in Christ and the Canisius College New Buffalo Institute.

Vaccine recommendations

Expect primary care providers to add their voices to federal recommendations that adults, as well as children 6 and older, get vaccinated to lower the risk for infection and a bad case of Covid-19.

“Vaccinations were always part of our workflow,” Sheriff said. “Pneumonia vaccine, flu vaccine, shingles vaccine, you name them.”

They are all contagious illnesses for which a vaccine is available.

Refresh cover; Pediatricians and back to school

Dr. Fred Archer (left), visits with patient Ava Rutherford, 6, and her father, Rodney Sr., during a wellness visit at Niagara Street Pediatrics.

Masking

Some medical specialty clinics have lightened up on mask-wearing protocols. It remains mandatory for patients and staff in most primary care offices.

“It is needed so primary care staff doesn’t get sick and can’t work, as well as to protect patients most vulnerable to severe respiratory diseases,” Archer said.

Federal standards have long called for hospital staff to wear masks when treating patients with the flu and other contagious viruses, Sheriff said, and even more personal protective equipment when treating those with more deadly infections, including Methicillin-resistant Staphylococcus aureus (MERSA).

Sheriff believes masking policies will change, but it could take years.

“Prior to the pandemic, there were times where someone came in and they were coughing or looked really ill,” the family doctor said. “We would have them wear a mask, just to limit contagiousness or spread during that time. It wasn't every patient.

“I think, as time goes on, the higher the vaccination rates go, hopefully the milder the variants, the comfort level will increase. And I think we'll learn how to live with Covid, just like we've learned how to live with flu and other respiratory illnesses.”

Dr. Kenyani Davis

Primary care practices have changed because of the pandemic, including strengthening patient-provider relationships, says Dr. Kenyani Davis, chief medical officer at Community Health Center of Buffalo.

What you won’t see

The pandemic also accelerated a greater move away from the fee-for-service model toward value-based primary care, in which providers are paid more by health insurance companies for keeping patients healthy and out of the hospital.

“Instead of focusing on the number of visits per day, it allows you to deliver care that may be most directed to the patient,” Sheriff said, and therefore more helpful.

Telehealth services and patient portals work well within this model, but can create challenges for practices that have lots of patients with more than one chronic health condition. That means longer hours for physicians, physician assistants and nurse practitioners.

Primary care providers worry that insurers will start to pay less for non-office care. Some already have, those interviewed for this story said.

“The greatest challenge that remains is reimbursement,” Davis said. “We have all of this new technology, and all of these new ways of doing things, but it has required us to pivot very quickly. You need the resources to do that. 

“Now that we've have telehealth, you can't put it back in the bag,” she said. “People are used to it.”

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