May 20 Microdosing of Mindfulness

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

The data on the effectiveness of mindfulness in reducing stress, anxiety, and cravings for controlled substances is strong. Mindfulness is also demonstrated to increase happiness.

In spite of this, many health care professionals and patients have difficulty fully embracing mindfulness as a therapy or practice, long term. Many authors have commented on this, with myriad different explanations and analyses. (For example, this essay contrasts mindfulness with psychotherapy.) Here are some underlying beliefs that may contribute:

  1. Mental illness and experiencing stress are signs of personal weakness to be covered-up or suppressed, instead of understood and addressed.
  2. The mind and body are separate. Those who strongly believe this cannot believe that trying to use their mind to make their body feel better or function better.
  3. Mindfulness takes too much time. Individuals who believe that mindfulness is helpful may conclude that it takes too much time to practice mindfulness regularly. Does one really need to go on a two-week meditation retreat to get into a better state of mind?
  4. Mindfulness equals deep breathing and meditation. Is breathing in through the nose and out through the mouth repeatedly always the best way to re-focus the mind?

The Greater Good Science Center at UC Berkeley embraces a broader conceptualization of mindfulness. Each person is encouraged to try different methods of becoming more mindful (using a broader understanding of mindfulness than its meditative Buddhist roots), finding a method that resonates especially with their personality and beliefs.

The Center performs original research to further the evidence base on different practices, which looks at the concept of micro-dosing mindfulness: spending very short periods of time several times per day to experience a sense of awe about something in your environment, and sharing this with your friends and family. This might be something beautiful, like a flower, a pet, a story or a piece of music. It might be something more intricate and complex, like a well-engineered race car, an innovative food dish, a piece of sculpture, a formal ceremony, or a novel gadget. Whatever it is, you should focus on it for a moment at the exclusion of all else, appreciating some of the intricacies and details, experience a sense of awe, and then perhaps share the details of the experience briefly with someone in your life. For example, take a picture of it with your phone and share it with a brief description of why it affected you!

This last step, the sharing, is critical for making this mindfulness practice not just a method to reduce stress but to increase happiness.  Sharing strengthens interpersonal connection, especially important in this time of physical distancing.  Interpersonal connections are necessary (but not sufficient) for a person to be happy, according to neuroscientist and author Laurie Santos.

Of course, when our friends, family, colleagues or patients share something that gave them a sense of awe, we should pause, give our attention to what is being shared, reflect back what we have heard, and allow ourselves to share some of that awe.

Robert Moore, MD MPH MBA
Chief Medical Officer

May 12 PCP and Public Health COVID Update

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Last Thursday, California released the details of its previously announced “resilience roadmap,” giving requirements and recommendations for safely allowing resumption of activities based on public health risk.  This roadmap starts to give us some longer-term understanding of how the future will unfold in the months ahead. Stages 2 is fairly detailed now; stages 3 and 4 will have additional detail added later.  County health departments have been given important responsibilities in this process, ensuring sufficient community testing to allow opening up to occur, overseeing local implementation of the planning, workplace changes, and citizen communication.  We appreciate the difficult tradeoffs they are balancing in their decision-making; thank you!

The governor’s office is now shifting focus to developing strategies to address the massive budget shortfall being faced next year; their “May Revise” of the budget is due soon.  All programs that rely on state funding (education, health, public safety, transportation) are concerned about what cuts the state will use to prepare a balanced budget.

As of last week, six counties in the PHC service area (Marin, Sonoma, Napa, Yolo, Mendocino and Humboldt) now have mandates for facial coverings/masks when indoors or in crowded outdoor areas where physical distancing cannot be maintained.  Local community groups have stepped up to provide masks/facial coverings to vulnerable populations, including the homeless.  This demonstrates that a community need, combined with community spirit can ensure community-wide adherence to such requirements.

Here are a selection of updates gathered in the last 12 days, which we thought you would find helpful.  Thanks to everyone for sending suggestions and feedback!

  1. Policy updates
    1. Verizon offers FCC grants to promote telehealth deployment.  Since it is a federal grant program, the paperwork and steps are rather complicated.  See the online application to get started.
    2. Congregate living environments have been particularly susceptible to COVID outbreaks across the U.S.  The CDC has posted guidance for owners/managers of these facilities to prevent spread of COVID-19.  Please pass this on to the managers of facilities where your patients live.
  1. Public Health Update:  This pre-print article recalculates the estimated Ro (R-naught) of COVID-19 taking transmission of asymptomatically infected individuals into account.  Their revision increases the Ro to at least 5, with a mean likely Ro of 15.  This higher Ro helps explain the rapid spread in New York City, and the stubborn persistence of new cases and deaths in the California in spite of Public Health mitigation efforts.  The implication:  a higher level of herd immunity will ultimately be needed to eliminate outbreaks.
  1. Efficient use and access to PPE.  In previous communication, we presented some PHC-generated guidelines on re-opening outpatient medical practices.  The AMA released similar guidelines.  In our discussions with local PCPs, insufficient access to sufficient masks and other PPE is a major barrier to re-opening.  Here are some new resources:
    1. CDC guidelines on optimizing efficient use of PPE.  The Centers for Disease Control and Prevention have released optimization strategies for PPE offer options for use when PPE supplies are stressed, running low, or absent.
    2. Free PPE Decontamination for Reuse.  The State of California, in cooperation with federal partners, is offering Battelle Critical Care Decontamination Systems as a solution to the N95 shortages impacting California, which will be available to all practices, free of charge.  There was some early miscommunication indicating that it was only available for hospitals, but we have confirmed that this is not true; outpatient health care offices may also use this service.
  1. COVID Testing Updates
    1. Population Testing: Why is Open Testing a Goal?  The availability to test for SARS-CoV2 RNA is expanding steadily in our region, leading to rapid changes in local recommendations for testing.  While most PCPs are testing based on presence of symptoms or contacts with either cases or vulnerable populations, some external testing sites are encouraging anyone who wishes to be tested to get tested.  While on first blush this looks like an inefficient use of COVID tests, an interesting finding shows that there is some psychology to this policy.  When “asymptomatic” individuals who test positive are questioned, over half actually did have mild symptoms that they discounted at the time, suggesting that subconsciously these individuals were worried enough about these mild symptoms to seek out testing.
    2. Limits of “Rapid” RNA tests.  The first rapid COVID RNA test (Abbott) to come on the market has several important limitations.
      1. Once the specimen is collected, it must be run within 2 hours.
      2. Unlike the standard tests, no viral transport medium can be used; it can lead to false negative results.
      3. The company has not validated this test on asymptomatic individuals, and so recommends only using it for those with symptoms.  This recommendation may change in the future.
    3. Limitations of serology test interpretation.  The California COVID-19 Testing Task Force put together a succinct, easy to understand explanation of what serology tests help with and what they should NOT be used for.  The FDA has updated its policy on SARS-CoV2 antibody testing after a flood of serology tests came to market, some with poor performance and fraudulent labeling.
    4. New method of RNA testing.  Researchers are working to adapt the CRISPR gene editing methodology to identify SARS-CoV2.  Instead of amplifying, the viral sequence to the point of detection (done in PCR tests), the CRISPR method finds the viral sequence and then sends a signal, which is then detected.  The charming name for this testing methodology is SHERLOCK. If this technology is perfected, it will allow large scale rapid testing for RNA.
  1. COVID disparities.  The COVID-19 outbreak initially involved cruise ship customers, international travelers and their direct contacts, and evolved to a pattern of community spread, disproportionately affecting individuals who live in crowded conditions and who continue to work as essential workers.  A steady stream of epidemiological data has showed that community spread in cities has disproportionately affected socioeconomically disadvantaged individuals.  This is reflected in analysis of hospitalizations and deaths in New York City, which showed Manhattan (with a higher median income) with less burden of disease than The Bronx and Queens, which have a much lower median income.  Evaluating race/ethnicity disparities in context is important, as there are many subconscious biases and tropes which humans are prone to attribute as causes of these disparities (thoughtfully summarized in this excellent NEJM article).
  1. COVID Treatment Updates.
    1. Remdesivir:  Gilead asks Federal Government to Distribute for Compassionate Use:  Most Hospitals left out. Remdesivir is less available than previously as Gilead turned over responsibility for distribution of the drug to the Federal Government.  Remdesivir was approved under Emergency Use Authorization on 5/1/2020 for IV administration to hospitalized COVID-19 patients, based on preliminary data from the ACTT-1 study. Per the EUA factsheet, recommended adult dosing is 10 days for critically ill patients (intubated/ECMO) and 5 days for all others, with the ability to extend to 10 days if no clinical improvement. Per the distribution website, hospitals identified by the U.S. government as a recipient for donated remdesivir will be proactively contacted; to find out if your hospital has been designated to receive donated remdesivir, you can email remdesivir@amerisourcebergen.com Certain hospitals were given a supply, others were granted none.  The basis of this allocation has not been clear.
    2. Elevated PTT in serious COVIDAnticoagulate anyway!  This article found that the elevated Partial Thromboplastin Time (PTT) found in critically ill COVID patients is due to the presence of Lupus Anticoagulant, as part of an antiphospholipid syndrome.  As a result, it is an indication of a hypercoagulable state, needing anticoagulation.  Another study (added to several done before with similar findings) showed that critically ill patients with COVID had better outcomes if administered low molecular weight heparin.
    3. Pediatric Multisystem Inflammatory Syndrome (PMIS). A number have reports have been issued in the past two weeks on this topic, affecting 64 pediatric patients in New York and more in other countries with a serious condition that looks somewhat similar to Kawasaki disease:
      1. A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
      2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus.
      3. This literature is evolving quickly; any potential cases would warrant consultation with a pediatric infectious disease specialist for therapeutic advice.
    4. List of all clinical trials for treatment of COVID.  The Medical Letter has shared a comprehensive list of all drug trials being used to test    treatments of COVID.  It is worth a quick look to get a sense of the many strategies being considered.

That’s it for this week!  We at PHC continue to be proud to support and serve you as you support your community in your daily work.

Robert Moore, MD MPH MBA
Chief Medical Officer

 

 

4/29/20 More News and Information on COVID-19

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

See below for this week’s extensive collection of news and information on COVID-19, curated for topics of interest to primary care providers.

These summaries are being posted as blogs on phcprimarycare.org.  We have also posted a draft of our recommendations for re-opening outpatient practices on the blog.

Your team at Partnership HealthPlan is here to help and support you as you adapt to this new medical world we are all now living in!

  1. Optimizing physical exams conducted by video.  Several physicians with extensive experience in providing primary care by telemedicine have posted videos sharing their best practices.  Here are some links to some of the ones that are particularly helpful.
    1. General overviews of best practices:
      1. Bedside” manner by video (10 minutes)
      2. General physical exam (5 minutes)
    2. Provider directed patient self-exam
      1. Overview (16 minutes)
      2. Free CME from Stanford (15 minutes)
      3. Patient assisted virtual palpation (3 minutes)
    3. Best Practice on Observation (4 minutes)
    4. Specific Types of Exam 
      1. Abdominal exam (6 minutes)
      2. Neurologic exam (20 minutes)
      3. Musculoskeletal exam (6 minutes)
    5. Orthopedic exams
      1. Knee
      2. Hip and Groin; Sample exam
      3. Shoulder Exam: flexion, adduction, abduction; preparation for patients before visits
      4. Neck: range of motion, nerve root compression
  1. COVID Testing
    1. Antibody tests covered by PHC and MediCal.  MediCal codes (86318, 86328, 86769) are a benefit with an effective date of April 10, 2020.  The code for the single step method test is 86318, which has a Medi-Cal rate posted.   Rates have not yet been set by the state for the other two tests.  We recommend checking the CLIA status of these tests before ordering them to conduct in your office.

B. Caution:  Antibody tests using Lateral Flow Assay have variable sensitivity.       (From UCSF IDResearchers in the UK (pre-print) evaluated a panel of           antibody-based COVID-19 tests – a novel Enzyme-linked immunosorbent         assay (ELISA) in the lab and 9 commercially-developed Lateral-Flow                 Assays (LFAs) to be used at the point of care. Serum of patients diagnosed       with COVID-19 served as the positive controls and serum of patients in UK       before December 2019 served as negative controls. ELISA identified                 COVID-19 IgM or IgG antibodies in 34/40 cases and 0/50 controls, yielding       a sensitivity and specificity of 85% and 100%. The sensitivity of ELISA IgG       improved to 100% when restricted to patients exhibiting symptoms for ≥10       days. No patients were IgM positive but IgG negative by ELISA. LFA had a       sensitivity of 55-70% with a specificity of 95-100%. IgG titers rose for 3             weeks post symptom onset and began to fall by 8 weeks, but remained             above the detection threshold. This small study was limited by small                 sample sizes and has not yet been peer reviewed. Bottom line: This study       suggests ELISA is best used to identify COVID-19 exposure 10 or more           days following symptoms. Despite being available at point of care,                     currently available LFAs have variable sensitivity. Whether a positive                 antibody test to COVID-19 by one of these tests correlates with immunity is       not known.

C. Persistent virus shedding associated with lower levels of SARS-CoV2 IgG:       persistent infection? A recent report showed that some patients shed viral         RNA in stool for a prolonged period after symptoms resolved and viral RNA       is no longer detectable in nasopharyngeal swabs.  Another analysis from           China of a subset with renewed detection of RNA after several negative             tests found an association with lower levels of viral-specific IgG.  This               suggests that a suboptimal immune response is associated with                         persistent or recurrent infection.  More study is needed, but this                         reinforces caution needed when interpreting positive COVID antibody             tests, especially the LFA tests, as noted above.

D. PCR/RNA tests using sputum contain more viral material than                           Nasopharyngeal swab. This pre-publication summary showcases another         option for appropriate settings, and may be collectable via self-collection.         This may generate more droplets in collection process, but saves swabs           which are often in short supply.

  1. COVID Epidemiology Updates
    1. Using COVID RNA tests of sewage for population monitoring. As noted previously, SARS-CoV2 RNA has been detected in stool of many individuals with symptomatic COVID.  A recent report found that SARS-CoV2 can infect the enterocytes of the human GI tract, suggesting that virus shedding is directly from the GI tract.  Several countries have used RNA detection in sewage to detect COVID-19 infection in a community several days before the first symptomatic cases are confirmed.

    According to an article in Nature, several groups are conducting these              sewage tests in the United States.  One area of development is to look at          the RNA load in sewage to estimate community prevalence of infection.            KQED reported that ten Bay Area Counties and Shasta County are testing        sewage; a separate report indicated that Lake county has conducted tests.        In Lake county the sewage tests converted from negative to positive a few        days before the first cases were identified and confirmed.

    Once a community believes it is COVID-free for a period of time, sewage          testing may be able to confirm this, and act as an early warning of the                return of COVID to a community.  Decades ago, this methodology was used      extensively in tracking polio incidence in communities.

B. Heat and humidity of the environment may decrease transmission COVID        is spreading quickly around the world in countries with a wide variety of            climates.  Urban crowding seems to be one of the larger risk factors.  Other      respiratory viruses have less transmission in the warmer months of the              year.  This may be partly due to the thicker protective mucous in warmer            and moister climates, and partly due to more prolonged indoor exposure          to people in cooler weather.  An elegant analysis of data from multiple                countries suggests that there is some slowing of the COVID doubling                rate in more tropical climates compared to more temperate climates.                  This is a mathematical/epidemiological modelling exercise; it will be                  interesting follow further data analysis from within the United States.                  Somewhat suggestive: COVID spread was more rapid and harder to                  control in the Midwest and Northeastern states which are emerging from          winter, compared to states in the West and Southwest.

C. Pre-symptomatic infections most infectious.  Another complex                            mathematical analysis of available data published in the journal Science            compares the degree and timing of infectiousness in the course of                    different infection scenarios:  pre-symptomatic by droplet/aerosol;                      symptomatic by droplet/aerosol; by environmental contact (fomites); from          asymptomatic individuals.  The graphic below summarizes their                          conclusions:  tau represents the time since infection.  Again, this is a                  model; more data will undoubtedly refine it; it reinforces the rationale for            population wide facial covering to reduce transmission.  I speculate that            the decreased infectiousness of symptomatic individuals may be related            to greater caution taken in this phase.

Blog 1 4-29-20

D. Why are mortality spikes greater than can be accounted by reported                 COVID  deaths, in countries around the world? Last week, an analysis of           reported mortality data from around the world found that, in many                       countries,  the overall mortality rate increased sharply, but much more than       would be accounted for by COVID-reported deaths.  A few days ago, a             similar phenomenon was reported in the United States, for the last two             weeks of March, when COVID deaths accounted for only 53% of excess           deaths.  Here is the graphic:

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     Interestingly, most of these excess deaths were in the Eastern US, the               percentage is notably less in Michigan and absent in Washington state.             There are multiple possible contributory explanations/factors; more                   analysis will shed more light on this.

E. COVID deaths outside the hospital (often at home), not counted in official          estimates; possibly related to the hypoxia without dyspnea described in a          prior update.

F. Strokes in young patients, related to hypercoaguable state induced by              COVID infection, which may be due to the recently documented direct              infection of endothelial cells by SARS-CoV2, with subsequent damage,            promoting thrombogenesis.  New York City found a doubling in the rate of          strokes in the past month, with half the cases in younger patients infected        with COVID.

G. Patients not going to hospital due to fear, dying of heart attacks, strokes,           other emergency medical conditions.

H. Increase in suicides.  Of note for the first possibility:  PHC now covers O2       sat monitors (HCPCS E0445) provided by DME companies.  However,           due to an international shortage, your local DME vendors may encounter           difficulty fulfilling a prescription for an oxygen saturation monitor.  PHC is           working on an alternative consignment and distribution process for O2 Sat       monitors; more to come.

  1. Updates on therapeutics
    1. Tocilizumab for reducing cytokine storm. (From UCSF ID)  Two recent papers seek to uncover the mechanisms behind the development of acute respiratory distress syndrome (ARDS) in a subset of COVID-19 patients often >7 days after onset of symptoms. Blanco-Mello et al compared the transcriptional response of SARS-CoV-2 to other respiratory viruses including Influenza A in a variety of immortalized tissue culture cells, infection of primary airways cells, in vivo samples derived from SARS-CoV-2 infected ferrets, and finally from post-mortem samples collected from the lungs of humans who died with SARS-CoV-2 or normal lung biopsies. These studies, together with serum profiling in the ferret model, revealed a unique and inappropriate inflammatory response characterized by low levels of type I and type III interferons, elevated chemokines, and elevated Interleukin-6 (IL-6) expression.

    Giamarellos-Bourboulis et al compared 28 patients with COVID-19 and            ARDS to 26 patients COVID-19 without ARDS. Control groups included            patients with 2009 H1N1 Influenza A and patients with community acquired      pneumonia-associated sepsis. Some patients with COVID-19 associated-        ARDS had macrophage activation syndrome, and most had immune                  dysregulation characterized by low expression of HLA-DR on a subset of          monocytes (CD14 positive) that is triggered by monocyte hyperactivation,          excessive IL-6 release, and profound lymphopenia. This pattern is distinct        from ARDS-associated bacterial sepsis or 2009 H1N1 influenza. Together,        these studies suggest that COVID-19 associated ARDS may be                        characterized by both a reduced innate immune response coupled with an        exaggerated inflammatory cytokine response.

    A preprint report of a study of 30 patients with severe, deteriorating COVID        pneumonia treated with tocilizumab to block IL-6 eliminated the                          development of cytokine storm, compared to a matched control group.              Larger studies are in process.

B. Alpha-lipoic acid reduces systemic inflammatory response in COVID.  α-          Lipoic acid (ALA), as an antioxidant, has been confirmed to reduce                    systemic inflammatory response in patients with acute coronary syndromes,      liver transplantation patients, and kidney-pancreas combined                            transplantation  patients.  A preprint of a study suggests a benefit in                  reducing cytokine storm in critically ill patients with COVID.  Again, more            study is needed.

C. Remdesivir:  Gilead announced that their trial of Remdesivir has reached           its primary endpoint, which likely means a survival benefit has been found.       More information and detail will be coming soon.

  1. Focus on inpatient care issues with COVID patients.  Given the seroprevalence data from Santa Clara (the COVID hot-spot in Northern California), it is likely that over 97% of residents of PHC counties have not yet been infected with COVID-19.  There is a strong possibility that we will see an increase in COVID hospitalizations in the future, with recruitment of community physicians to assist with their care.  All physicians therefore need to learn the essentials of caring for COVID inpatients.  Here are some highlights to help prepare.

A. Free clinical simulation of caring for patient with COVID on general hospital       floor.  This simulation takes about 15-20 minutes and hits on many                    highlights of caring for COVID inpatients that are not in the ICU.  I highly            recommend it.  The next three items are elaborations of some themes of          this simulation.  The subsequent five items relate more to critically ill                  patients in the ICU.

B. Risk factors for deterioration.  There are many models for estimating the          risk of deterioration.  Here is one called the Early WArning Score (EWAS),        using just 5 factors: age, underlying chronic disease, neutrophil to                      lymphocyte ratio, C-reactive protein, and D-dimer levels.

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    Low risk is a score of 0-2, medium risk is a score of 2.5-3, high risk is a            score of 3.5 to 4.5.  The 14-day cumulative incidence of clinical                          deterioration in the low-risk group was 1.8%, which was significantly lower        than the incidence rates in the medium- (14.4%) and high-risk (40.9%)              groups.  Note the heavy weight given to elevated D-dimer level.

C. Aerosolization of COVID with different types of oxygen therapy.  The                simulation above indicates that less hazardous aerosol is released into the        room with a non-re-breather mask than with other high-flow oxygen delivery      methods.  This study casts some doubt on this popular wisdom, indicating        that the aerosolization of all oxygen delivery methods are about the same.        Bottom line:  wear a tightly-fitting, fit-tested N95 when entering the room of        a COVID patient on oxygen.

D. Heparin reduces hypoxia in hospitalized COVID patients. Since we are             seeing a variety of blood clots in patients with COVID (strokes, pulmonary         emboli, peripheral blood clots), and anti-coagulation is usually beneficial for       most hospitalized patients, it is not surprising that this study found                     improved hypoxia from use of prophylactic heparin in COVID inpatients             without active bleeding.

E. The range of survival for ventilated patients varies greatly by                              hospital/geography:  From a survival rate of 12% in New York City to a              survival rate of 94% in at San Francisco General Hospital.  This is partly            related to the effect of an overwhelmed hospital system, in New York, but          another factor is the organization of health care delivery at different                    hospitals.  SFGH’s CEO Susan Ehrlich has rigourously overseen the                implementation of lean management methods throughout their leadership        structure, which led to strong independent, self-improving teams.  I would          speculate that this is contributing to their amazing outcomes.

F. Outcomes poor for CPR in hospitalized COVID patients with cardiac arrest.      This report notes that if patients with COVID get to the stage of cardiac              arrest, CPR is unlikely to lead to positive outcomes.  Less than 1% of                COVID patients receiving CPR survived without permanent neurologic              sequelae.  This is helpful information for advance care planning                         conversation.

G. ST-segment elevation in COVID: clot vs. myocarditis?  Although the                   COVID virus infects blood vessel endothelial cells, potentially contributing         to blood clots (as noted earlier), this summary found that most patients with       ST-segment elevation on EKG are found to have no obstruction of                     coronary  arteries, suggesting that myocarditis from direct COVID infection       may be the more dominant underlying etiology, as first noted in                         Washington state’s experience.

H. Many critically ill COVID patients found to have aspergillus superinfection.        This pre-print found Aspergillus in 33% of lung specimens of intubated              COVID patients.  This might be colonization or superinfection, the latter            due to impaired immune response.  Evaluating Bronchial secretions of              COVID patients for superinfection with both bacteria and fungus seems            prudent, to not miss a treatable superinfection.

 I. Gut microbiome associated with risk of cytokine storm? Why do some              COVID patients become seriously ill, while others do not?  This analysis            speculates that the proteins produced by the gut microbiome (called                  the fecal metabolome) may affect the probability of developing cytokine            storm.  More analysis is needed to understand how this might be leveraged      for prevention or treatment.

  1. What is “Crazy Paving” and what does it have to do with COVID? Crazy paving refers to the appearance of ground-glass opacity with superimposed interlobular septal thickening and intralobular septal thickening, seen on chest High Resolution CT. It is a non-specific finding that can be seen in a number of conditions. Here are two CT scan views showing this pattern, along with a picture of a mosaic paved pathway that inspired this whimsical radiological description.

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Crazy paving:  not exactly a yellow brick road, but I’ll say goodbye for now.

Robert Moore, MD MPH MBA
Chief Medical Officer

4/23/20 Clinician Office COVID Guideline

(Optional items italicized)

Effective Date:  In place on re-opening or expanding clinical services
Duration: Until public health emergency lifted
Version 1.0 Date:  April 23, 2020

 

Disclaimer:  There are little or no controlled studies underlying these recommendations.  They are based on CDC recommendations, local health department orders, and expert consensus of PHC medical directors.  They should be considered a starting point for evaluation of office systems, and may be modified by the clinical leadership at a practice.  Any directive by a local health officer which is more stringent than these guidelines would take precedence.

Send comments or suggestions for improvements to: rmoore@partnershiphp.org

Patient Care in Office:
  1. Staff and clinicians will wear face masks at all times, as will patients. This should be explained to patients before they arrive at the office.
  2. Patients without their own masks will be given one on entry to the office. The mask should completely cover over the nose to below the chin and fit snugly along the sides.
  3. Staff and clinicians will wear gloves for any patient contact, disposing gloves between patients and washing hands before entering and upon leaving each exam room.
  4. Stethoscopes, blood pressure cuffs and other non-disposable equipment touching patients should be cleansed before and after each use.
  5. When rapid, point of care PCR tests become available for office use, perform a rapid test on asymptomatic individuals prior to performing procedure that will generate significant aerosol (e.g. dental extractions, dental cleanings, office spirometry)
Virtual Visits: (all patients should be contacted by phone before coming to the office)
  1. Patients with contact with a person who tested positive for COVID 19 or who are experiencing fever, chest congestion, flu-like symptoms or symptoms of milder respiratory infection will be asked not to visit the office but rather to consult with the physician via phone or video conferencing.
  2. Patients who are immunosuppressed or are at higher risk for COVID 19 related complications, will be offered phone or video conferencing. If they must be seen, have a plan that minimizes their risk, such as seeing them in the first few hours of the day, or conducting a detailed history over video/phone first, before a brief office visit.
  3. Develop workflows and best practices for visits to be addressed by video/phone as much as possible.  Use these guidelines to limit exposure of patients and staff to potential  infection when in person visits are needed for routine visits ( well child, women’s physicals for example) and as indicated for face to face visits for chronic disease management or other necessary exams. Consider:

a. If a person is coming in for a face to face visit for one reason, ensure all            related reasons for a face to face visit are done at the same time.

b. Methods of optimizing obtaining history and doing a partial physical exam          by virtual visit to make the physical visit short and efficient with minimum          chance of infection transmission.

c. Finding alternatives to more hazardous examinations/procedures, such as       coaching parents on application of fluoride varnish over phone or                       application of silver diamine fluoride to caries instead of tooth extraction or       filling. 

4If patients with symptoms listed below need to be seen in the office, they will be      scheduled at a time and in a manner to prevent potential infection of other                patients. This may include

a. Examining the patient in their car.

b. If the patient may not be examined in their car, they would be scheduled at        a time and location where other patients would not be using the same room      until decontamination is possible.

c. Moving them directly to an examining room with no waiting room time               (potentially through an alternative entrance), followed by thorough                     decontamination/aeration of the exam room.

 Operational Aspects:
5. Patients will be scheduled in such a manner to maintain six foot spacing in the
            waiting area.  This may require patients to wait in their cars until called in to the
            office, or moving the patient directly to an examination room from the waiting
            room upon arrival.
6. Patients should be seen in the office alone unless they need a caregiver, or they
    are a minor needing an adult.

 

Staffing Aspects: 
1. Temperatures and symptom review (see below) of staff will be done each day.
2. Any staff member with symptoms potentially caused by SARS-CoV2 will be
    referred for testing as a healthcare worker with face-to-face patient contact.
3. Staff members with exposure to a person who tested positive for the virus will be
    asked to remain home under paid sick leave for 14 days, only returning after
    consultation with clinician in charge. In circumstances of significant staff 
    shortage, if rapid PCR testing is widely available, an asymptomatic exposed 
    staff member who tests negative for coronavirus may be considered for return
    to work with continuous mask use for a day or two (they would need to be
    retested every couple days to be sure they do not develop viral shedding).
4. If scribes are used by a practice, consider changes to support infection control.        Examples may include having them support virtual visits or virtual pre-visits              where the history is gathered.

 

Maintenance and Facilities: 
1. Hand sanitizers as well as soap and hot water for hand-washing are readily
    available throughout the office and waiting areas.
2. Cross contamination will be minimized by frequent sanitizing (wiping down) of
    surfaces, doorknobs, light handles, keyboards, phones, etc. with isopropyl
    alcohol or chlorine-based cleansers.
3. Scrubs and lab coats should be laundered daily. Neckties or other loose clothing
    that could contact patients should be avoided.
4. In the setting of an office where patients may walk in for care without a mask or
    where no screening for respiratory infections before visits can be done, adding a
    Plexiglas barrier for reception staff may need to be added.
5. Any break room should be arranged and use scheduled to allow at least 6 feet of
    distance between individuals who are eating and drinking. Discourage
    conversation while eating.
6. Shared restrooms should have surfaces decontaminated with increased
    frequency, depending on how much it is used.
7. Review decontamination procedures done by maintenance staff to ensure they
    are conducting duties in a way that protects them and thoroughly
    decontaminates the office.
8. Develop a procedure for educating staff on these infection transmission
    prevention measures and monitoring their adherence.

 

Symptom Review:
  • Fever
  • Cough
  • Sore throat
  • Shortness of breath
  • Chills
  • Severe fatigue
  • Unusual headache
  • Runny nose in the absence of known allergies
  • Gastro-intestinal symptoms such as diarrhea or stomach cramps
  • Loss of sense of smell (anosmia) or taste or suddenly all food tastes bad (dysgeusia)

Temperature Guidelines:

 Temperature of 100 degrees F or greater or with any symptoms above should be            isolated.

Definition of Higher Risk for Serious COVID infection  (CDC guidelines)

  • Age over 65
  • Residents of congregate living facility (skilled nursing facility, homeless shelter)
  • Chronic Lung Disease, including COPD
  • Chronic Lung Disease, including CHF
  • Kidney failure of advanced kidney disease
  • Cirrhosis or other chronic liver disease
  • Diabetes
  • Other condition impairing immune system
  • Taking medication impairing immune system (includes most on current cancer treatment)
  • Severe obesity (BMI over 40)

Definition of Exposure requiring Quarantine (recommendations vary; CDC guidelines complex)

  • Direct contact with person known to be infected with COVID
  • Less than 6 feet distance for at least 5 minutes with a person known to be infected with COVID who was coughing (regardless of wearing of a mask) or who was not coughing but not wearing a facial covering.
  • Living in same dwelling as a person with COVID, regardless of mask use
  • Recent travel from area more highly impacted by COVID than “home” area, especially if by crowded public transportation.

4/23/20 Safely Increasing Outpatient Health Care

Safely Increasing Outpatient Health Care:  Yesterday, Governor Newsom recommended a resumption of some types of outpatient medical visits, with appropriate precautions to prevent spread of infection.  We know you are working on fine-tuning quality and efficiency of your virtual visits, while working to ensure your offices are safe for visits that need to occur in person.  The CMA released a high level summary on reopening physician practices.  The PHC Medical Director team gathered together a number of best practices for re-opening clinician practices of all types.  Clinician Office COVID Guideline is posted separately in this blog.  It includes operational, staff, patient flow, and facilities recommendations.  We hope it will be a useful check list clinical and operational leaders working to make their offices safe for employees and patients.  Some useful additional advice for optimizing video visits can be found in this NEJM article.

Here is a weekly curation of COVID updates that we thought would be of interest to primary care clinicians, with a special focus on many less-recognized clinical manifestations.  We appreciate leads on topics for future updates, as well as comments and feedback!

  1. PHC Policy Updates Related to COVID
    1. Home Blood Pressure Test Kits:  Virtual care of patients with hypertension includes the ability for the patient to check their blood pressure at home.  Blood Pressure Test Kits are PHC benefit, provided with a prescription by community pharmacies (not DME vendors).  The prescription can specify the size of the cuff that is in the kit (Medium and Large are the two most common), and should include the diagnosis of “hypertension” on the prescription.  You may work with your local pharmacy to see what brands are available and write the prescription for that brand.  Currently, any BP cuff costing under $55 is covered (this limit is likely to increase soon).  Pharmacies that have questions can consult the PHC website for information; please let us know if they refuse to honor a prescription for a BP cuff, and we can reach out to educate them.  More information about coverage of Ambulatory BP monitors and BP monitors that automatically send results to the PCP will be presented in a future update.
    2. Virtual visits by Physical Therapy, Speech Therapy, Occupational TherapyPHC has activated special codes normally used by MediCare for coverage of video visits by PT/ST/OT to provide education and observation of patients who do not need an in-person visit.  We have educated our therapy network of these changes.  Patients needing PT/OT/ST services need a prescription from a referring clinician (no need to use the PHC RAF system).
  1. Role of Serology Testing in Managing COVID. While PCR/RNA/molecular testing is steadily becoming more available, unapproved serology/antibody tests are making their way into the market in a somewhat chaotic fashion.  Jill Taylor of the N.Y. State Department of Health stated in an excellent National Academy of Science presentation yesterday that over 125 new serology/antibody tests (many of questionable accuracy) are now available in the United States, although only 5 had official FDA recognition for emergency use.  She states that many rapid serology tests will detect milder coronaviruses that cause cold-like symptoms (low specificity), causing rapid surveillance studies to suggest higher rates of immunity than actually exists.  Furthermore, we cannot equate presence of an antibody response to true immunity to re-infection.  These factors make antibody testing currently unhelpful for counseling individual patients about immunity or safety to return to work.  This may change in the near future.

  Seroprevalence studies done in early April in Los Angeles and Santa Clara are        good examples.  Both estimate that about 4% of adults have antibodies in their        blood, about 50-fold greater than the number of confirmed positive COVID tests.      While some cross-reactivity with milder coronaviruses may be inflating the                number, the bottom line is that the vast majority of the population is still                    susceptible to SARS-CoV2, even in these two counties with California’s heaviest      COVID-19 toll.  Current estimates are that 60-70% herd immunity would be              needed for COVID infection rates to fall.

  1. How much PCR testing capacity do we need?  The current testing rate in the United States is about 0.4-0.5 PCR tests per 1000 population per day.  Dr. Ashish Jha of the Harvard Global Health Institute estimated that about 1.5 to 2.5 PCR tests per 1000 population per day will be needed to provide the robust testing of all symptomatic individuals, their asymptomatic contacts, and certain asymptomatic essential workers to safely allow significant resumption of economic activity.  For the PHC counties, this would be a total of about 4000-6000 tests per day.  This is possible with the current spectrum of tests available, and far more achievable than the 60-100 PCR tests per 1000 population per day recommended by the Roadmap to Pandemic Resilience report released on April 20.
  1. Additional study on N95 decontamination suggests less repeat decontamination cycles than studies previously reviewed in this newsletter.  This study looked at the ability of N95 masks to filter SARS-CoV2 and evaluated integrity using post-sterilization fit testing.  This suggested that dry heat sterilization can only be done twice before the N95 fails a fit test.  Of note, this study was not yet peer reviewed and comments posted pointed out some important methodological concerns.
  1. Communication aid for having difficult conversations about COVID.  VitalTalks Tips is a free smart phone app that help with difficult conversations with patients, with several sections devoted to COVID-related situations.  I recommend loading it on your smart phone and taking a few minutes to scan through some of the questions/topics that are included.
  1. Therapeutic updates:
    1. A well-publicized Randomized control trial of hydroxychloroquine showed increased mortality.
    2. Trial of remdesivir in macaque monkey model:  (summary from UCSF ID newsletter)  Researchers developed a macaque model of respiratory SARS-CoV-2 infection that recapitulates important aspects of human infections. Investigators from the NIH studiedthe effect of remdesivir treatment starting near the peak of viral replication. Remdesivir was administered with a loading dose 12 hours after respiratory and ocular inoculation, followed by a daily IV dose for 6 days, similar to protocols for humans.  At 12 hours after the initial treatment, the remdesivir-treated monkeys had fewer symptoms and less radiologic evidence of pneumonia compared to the control-treated monkeys, a trend which continued during the 7-day study. The remdesivir-treated monkeys had lower viral loads and titers of infectious virus in the lungs and less damage, but interestingly, drug treatment did not decrease viral shedding in the nose, throat, or rectal swabs. While the Gilead remdesivir clinical trial results are not yet known, this primate model suggests that early treatment of COVID-19 with remdesivir may prevent progression to severe pneumonia and sterilize viral cultures in the upper and lower airways. Upper airway viral shedding was still detectable; however, the significance of PCR detectable virus in the absence of viral growth is not known.
    3. ACEI/ARB not just safe, but also protective:  Early data from China indicating that hypertension was a risk factor for COVID severity, combined with the fact that the ACE2 receptor in the lung led to speculation that use of ACEI or ARB increased risk of COVID complications.  However, a new report from China showed actually that ACE  or ARB use among hospitalized patients with COVID was associated with increased survival.

7. Clinical Updates: As time passes, more reports are showing the wide spectrum        of signs and symptoms associated with COVID.  Some of these are contrary to        the early information we had about the disease, so they are important to                  incorporate into our clinical decision making, so we don’t reassure patients              infected with SARS-CoV2 that they have something else, leading to spread of          infection (something we are concerned is occurring, due to the shortage of              tests).

A. Co-infection rate with other respiratory pathogens. A study in Northern              California published in JAMA found that 20% of those diagnosed with                COVID were co-infected with another respiratory pathogen.  Based on this,      individuals with symptoms potentially due to COVID should be tested for          COVID, even if another test, such as rapid influenza or RSV tests, are              positive.                                                                                                    BSmell and taste disturbance in COVID. A physician in Italy noted (in                  the setting of the epidemic) that sudden anosmia or dysgeusia with                    nausea –even without other respiratory symptoms—was universally                  found to be associated with a positive PCR test for COVID.   A recent                JAMA study of patients with these abnormalities found that most                        (97%) eventually develop other symptoms of COVID (including even                  nasal congestion in 35%), but that 12% noted anosmia or dysgeusia as            their first symptom.  A case report of one such patient found mucous                  obstruction just below the olfactory nerve, but no imaging abnormality of the      olfactory nerve itself, suggesting the etiology may be  obstructive, but not          ruling out direct infection of the olfactory nerve.                                                 C. Why are COVID patients dying at home? The report yesterday that                   two individuals in Santa Clara who died in early February were found                 to be infected with COVID is not only interesting for the historical                        epidemiologic implications, but also as an indicator of an important                   scary clinical scenario: hypoxia without dyspnea.  NY times                         article (highly recommended reading) noted that these individuals                     have pneumonia with decreased oxygen levels but with a normal CO2.             They compensate with a more rapid respiratory rate but don’t feel the               dyspnea until the pneumonia worsens with elevated CO2, at which                   time they decompensate quickly, potentially dying at home or requiring             intubation by EMS.  The article gives anecdotes of the use of oxygen                 saturation monitors by patients sent home with pneumonia to monitor               for detecting hypoxia earlier.  PHC is looking into options for making                 oxygen saturation monitors available to our members.  There is a                       world-wide shortage of these devices currently.                                       D. CT scans identify asymptomatic COVID in New                                                   York.  Another report from an Emergency Room Physician in New                     York found that a number of asymptomatic individuals or minimally                     symptomatic individuals who came to the ED for other reasons were                 found on CT to have COVID pneumonia.  This included a patient with               abdominal pain, nausea and vomiting and another with symptoms of                 acute coronary syndrome.                                                                                  E. Are there cutaneous manifestations of COVID-19?:  (summary                          from UCSF ID newsletter)                                                                                    Cutaneous findings were rarely reported (<1%) inlarge studies from                  China.  A recent study from Italy found that 18 of 88 (20%)                                  hospitalized patients had skin findings: erythematous rash (78%),                      diffuse urticaria (17%), and vesicles resembling varicella (5%)                            Another report from Italy described 22 patients with                                            papulovesicular eruption resembling varicella. In both reports, the                      trunk was most commonly involved, and itching was uncommon.                        Individual case reports of patients with COVID-19 and a diffuse                          erythematous rashdiffuse urticariapetechial rash,                                            and violaceous lesions in the toes have been described as well                          (sometimes called “COVID toes”), as shown below.                                            Photo: Northwestern University

Northwestern University

       The American Academy of Dermatology has launched a COVID-19                   dermatology registry to better understand the cutaneous manifestations             of COVID-19.                                                                                                    F. Neurologic manifestations of COVID: (summary from UCSF ID                           newsletter)  What neurological manifestations are seen in patients with              COVID-19? Several reports were published this week on neurological                findings in patients with COVID-19. A Chinese study described 214                    patients and found that 36.4% had neurologic manifestations which                  included dizziness (16.8%), headache (13.1%), myopathy (10.7%),                    impaired consciousness (7.5%), taste impairment (5.6%), smell                          impairment (5.1%), acute stroke (2.8%), and seizure (0.5%). A second              French study of 58 ICU patients found agitation (69%), corticospinal                  tract signs such as clonus (67%), and confusion (65%). 13 patients                    had MRIs which revealed leptomeningeal enhancement in 62% and                  acute stroke in 15%. 7 patients had an LP – all were normal and                        negative for COVID-19 by PCR. Conclusion: Neurologic finding are                    common in patients with severe COVID-19. Possible mechanisms                    include hypercoagulability, inflammation, exacerbation of underlying                  vascular comorbidities, or direct CNS infection. However, only a single              case of meningoencephalitis with a positive CSF PCR has been                        published to date.                                                                                            G. Ocular manifestations of COVID-19: (summary from UCSF ID                            newsletter)  The main ocular manifestation of COVID-19 is                                conjunctivitis. A recent report described the ocular findings in a cohort                of 38 patients from China: 12 patients (38%) had chemosis,                                conjunctival hyperemia, and epiphora (watery eyes). All 12 patients                    had moderate, severe, or critical illness, suggesting that ocular                          findings may be found in more severe disease. Notably, one patient                  had epiphora (“watery eyes”) as the first symptom of COVID-19. Two                out of the 12 patients had a positive conjunctival swab for COVID-19,                suggesting the possibility of transmission directly from the eye. Prior to              this report, there were also a few case reports where conjunctivitis                    was described as part of the clinical syndrome of COVID-19.                        H. Is COVID death sometimes due to multiple blood clots to lungs?                         (summary from UCSF ID newsletter)  Are patients with COVID-19                     hypercoagulable and would they benefit from intensified                                     anticoagulation interventions? A report indicates that some patients                   who die of COVID have many blood clots found in the lungs.  A                         hypercoagulable state is well described in patients with pneumonia and             sepsis.  Elevated D-dimer and elevated IL-6 (mediator of cytokine                     induced coagulation) are correlated with poor outcomes in COVID-19.               Among 21/183 non-survivors hospitalized with COVID-19 pneumonia,               71% met criteria for disseminated intravascular coagulation. In a                       retrospective study of severe COVID-19 cases with coagulopathy,                     heparin was not associated with a benefit in reduction of 28-day                         mortality except in a subset of patients with very high d-dimers levels.               Bottom line: More data are needed to inform these clinical decisions. In             the meantime, in light of patient isolation and limited mobility, we agree             with The American Society of Hematology (ASH) recommendation that             “all hospitalized patients with COVID19 should receive pharmacologic               thromboprophylaxis with low molecular weight heparin (LMWH ) or                   fondaparinux (suggested over unfractionated heparin to reduce                         contact) unless the patient is judged to be at increased bleeding risk.”

That’s it for this week!  We hope this is helpful; again we welcome feedback.  We appreciate all that you and your team are doing to support your patients, your community and your families in this challenging time,

Robert Moore, MD MPH MBA
Chief Medical Officer

4/15/20 Primary Care and Public Health COVID Updates

It has been 25-28 days since local and State-wide Orders to Stay at Home was issued, and there are early signs that this (combined with related activities: many essential staff working from home, physical distancing, wearing facial coverings in public) have slowed the rate of new case identification, deaths, hospitalizations, and ICU bed utilization.  It is too soon to ease up on vigorous public health measures, but this trend, combined with analysis of current bed capacity suggests that the peak number of cases for this first wave of COVID-19 in our region may not stress our health care delivery system as severely as we were concerned about earlier.  The price of this apparent success is a large non-immune (and therefore susceptible to COVID) population which can lead to rapid focal outbreaks as public health measures are eased.  Yesterday Governor Newsom described the outline of how this delicate task might unfold.

A major task for outpatient providers will be to establish trust in the population that they can safely come in to the office for important medical, dental, vision, lab, radiology and physical therapy visits (that cannot adequately be done via video visits), even while many public health restrictions remain in place.  To be successful, practices will need to pair careful adherence to rigorous infection control procedures with a positive yet nuanced marketing campaign.

Here is a summary of major updates from PHC, the state and the medical word related to COVID-19, from the last 5 days.

1. Policy Updates:

A. Pending Changes to the 2020 PCP QIP: Due to the extenuating                        circumstances related to COVID-19, PHC’s internal and external                        committees have made recommendations for changes to the 2020 Primary      Care Provider Quality Improvement Program (PCP QIP).  The Core                  Measurement Set will be modified to a smaller group of measures, with            more attainable benchmark goals, as noted below.

Proposed Point Allocation and Threshold Changes:

  Family Practice Internal Medicine Pediatrics 50th Percentile
Clinical Measures Points per measure Full Points
Well-Child  Visit, First 15 months of Life (W15) 15.0 25.0 65.83%
Controlling High Blood Pressure (CBP) 15.0 20.0 61.04%
Colorectal Cancer Screening (COL)* 12.5 20.0 32.24%
Diabetes – HbA1C Good Control <9 (A1c) (CDC) 12.5 20.0 50.97%
Childhood Immunization Combo 10 (CIS-10) 15.0 25.0 34.79%
Asthma Medication Ratio (AMR) 15.0 20.0 25.0 63.58%
Non-Clinical Measures      
PCP Office Visits** 15.0 20.0 25.0 TBD
TOTAL POINTS AVAILABLE 100.0 100.0 100.0

* Colorectal Cancer Screening is the only measure in the PCP QIP that does not have an NCQA Threshold equivalent for PHC. The threshold here is the 25th percentile across the entire plan.

** The threshold for PCP Office Visits will be established after PHC has more data on the impact of the COVID-19 Pandemic and orders to shelter in place.

    The specifications for measures in the Core Measurement Set are not              changing, but some specification modifications are proposed for several            Unit of Service Measures.  Of note, we are lowering the thresholds for              submission of attestations for advance care planning conversations and            Advance Directives/POLST form updating.  This is an excellent time to              focus attention on this measure, as noted below.

    This collection of changes is a proposal that is pending final approval       and final specifications.  Final approval will be obtained from our               Physician Advisory Committee, in early May 2020.  The final details and       full specifications will be released by Mid-May 2020.  We are informing you       of the highlights of the Core Measure Set Changes so you can align your         activities to this more focused group of measures.

B. Difficult Conversations in the Time of COVID-19. Geriatricians are noting           greater receptivity to advance care planning conversations during the               COVID pandemic.  If your PCP practice has extra capacity, you may be             considering outreaching to more vulnerable patients to update their                   advance directives and POLST forms.  The Coalition for Compassionate           Care of California is hosting a free webinar today at noon by an expert in           palliative care communication, Robert Arnold.  A recording of this webinar         will be available afterwards on their website.  An excellent prior webinar             covering advance care planning in a virtual visit environment and other             COVID-specific issues is also available, on the same page.  The Coalition         also has put together an excellent COVID Conversations Toolbox with               other resources.

C. Presumptive Eligibility for Uninsured or Underinsured individuals with                COVID.  The Department of Health Care Services (DHCS) is creating a            new aid code that will allow individuals to seek the necessary diagnostic            testing, testing-related services, and treatment services, including all                medically necessary care, through the Medi-Cal fee-for-service (FFS)            program.  This new aid code will be available to California residents with          no insurance or who currently have private insurance that does not cover          diagnostic testing, testing-related services, and treatment service, including      all medically necessary care for COVID-19.  It will be available, regardless        of the person’s immigration status, income, or resources.

    The covered diagnostic test, testing-related services, and treatment                  services, including all medically necessary care such as the associated            office, clinic, or emergency room visit are paid up to the maximum FFS              Medi-Cal rate.  Individuals in this program will not be enrolled in a              Medi-Cal managed care plan, so services must be billed through FFS. 

D. DHCS requested flexibility on timing of Initial Health Assessments (IHA) for       new Medi-Cal beneficiaries.  CMS requires DHCS to require the health             plans to ensure that all new Medi-Cal beneficiaries have an initial health           assessment (a first visit, including a health screening with the DHCS’s               Staying Healthy Assessment questionnaire.  Normally this assessment             includes an examination and must occur within 120 days of enrollment into       Medi-Cal Managed care.  Since a new Medi-Cal member has 1 month to           select a PCP, the assigned PCP has about 90 days to complete this                   assessment.

     Four days ago, DHCS requested the flexibility to have up to 180 days to           complete this initial assessment.  We will monitor this and inform you when       CMS responds.  In the meantime, as mentioned in the last email (related to       state prisoner release), we hope you will develop a process for conducting       new patient intake appointments through virtual visits.

2. Coronavirus PCR Testing

A. Quest issued an updated specimen collection guide (attached). This                   includes the methodology for collecting nasal swab specimens (which can         be self-collected), as well as a number of permitted substitutions for scarce       collection gathering supplies.

B. Scarce testing materials being spread out.  Quest informed us that due to         regulatory reasons related to responding to a shortage of supplies, testing         materials that are sent out must be mostly used up before replacement             testing materials are replenished.  This means that most large volume               testers will be frequently feeling like they are on the verge of running out of       supplies.  Close communication as any particular component of testing             runs low is important.

C. Adapting testing recommendations in office setting as tests become more        available.  The CDC recommends that individuals with mild illness consult        their medical provider to decide if they should be tested or not.  Office-              based testing criteria may be looser than County Health Department                  criteria for testing.  If patient is staying at home anyway, there is little                  urgency in identifying milder cases of COVID.

    As testing becomes more available, and as Stay at Home Orders are lifted,      we must think differently about testing milder illness to identify clusters of          infection earlier.  County Health Departments will be involved in making            recommendations to their local PCPs about testing criteria.  If a PCP has          plenty of testing capacity, be sure to let your local health department know,        so they can guide you on what criteria to use to expand testing.

     Examples of expanded testing strategies:  The county health department           may ask PCPs to assist with testing known contacts of confirmed COVID         cases or doing follow up testing on patients with suspicious symptoms with       a negative initial test, for example.  They may ask a subset of providers to         test all patients with mild respiratory symptoms as part of community                 surveillance or recommend testing anyone with any level of suspicious             symptoms (something being done in Michigan).  With sufficient capacity,           some testing of asymptomatic essential workers (e.g. grocery store clerks,       bus drivers, EMTs, hardware store workers) who are regularly exposed to         the public may be helpful to prevent asymptomatic transmission.  A                   hospital in New York tested all pregnant women arriving in labor, and found       14% of asymptomatic women tested positive, prompting precautions to             prevent spread in the hospital.

     These are but a few options.  Developing a local strategy for scaling up             testing as it becomes more available is worth a joint discussion between           local clinicians and public health leaders.

D. PCR tests vs. Imaging for confirming COVID.  The sensitivity of COVID             PCR tests is fair (around 70%), and the results take a while to come back.         An emergency room in New York found that half of all patients with COVID       had an abnormal chest X-ray (usually bilateral, peripheral or basilar                   pattern,  sometimes described as ground glass interstitial pneumonitis).  A         study in China, among patients admitted with COVID, found that 95% had         an abnormal CT scan of a particular pattern.  Some radiologists in the US         have been hesitant to recommend using CT for diagnosis, citing concerns         about the need to sterilize the CT scanner after scanning a patient with             suspicious symptoms.  As their primary justification, they state that there           are methodological problems with the studies published so for on CT’s               specificity for COVID.

     Decisions to test a patient should not be dominated by concern over                 cleaning the equipment.  If patient with hypoxia and a normal Chest X-ray         is admitted to the hospital, given the differential diagnosis, a CT scan                 would often be helpful in ruling out non-COVID pathology, as well as                 helping with in-hospital disposition if the patient does have a pattern                 consistent with COVID, while awaiting PCR test results which have only a         70% sensitivity.

3. Coronavirus Antibody Tests  (Thanks to Dr. Marshall Kubota for gathering these studies) 

A. Pattern of Development of Neutralizing Antibodies.  A Chinese study of 175       patients with COVID found that SARS-CoV2 specific neutralizing                       antibodies developed starting 10-15 days after “onset of disease.”  Patients       with milder disease had lower plasma titers of these antibodies than those         with more severe disease.  Ten patients with confirmed COVID had                   undetectable antibodies, suggesting either a poor response or perhaps that       the PCR test/clinical diagnosis had a specificity of 94% to match its                   sensitivity of 70%.

B. Similar pattern of antibodies was found in a Norwegian Study of H1N1,            which found that 2/46 patients diagnosed with mild H1N1 had no                        detectable antibodies to H1N1.  Again, this may reflect either a poor                  generation of an immune response or a specificity of 96% in the initial                diagnostic test for H1N1.

C. Other Coronaviruses Exhibit waning Immunity over Time.  Interviews of             experts by NPR noted that the more benign coronaviruses that cause the         common cold can cause repeat sickness, even if a person has a                       documented prior antibody response.  Speculations on potential reasons           include genetic variation of the virus over time or some other factor that             impacts the effectiveness of antibodies from prior infection.  Since classic         SARS was found to have a more robust and long-term immune response,         and they were all symptomatic with serious infection, this supports the               hypothesis that surviving more serious illness generates a longer-lasting           and stronger response.

4. Bio-aerosols and masks

A. The study that prompted CDC to recommend wearing face coverings in             public showed that surgical masks reduced coronavirus detection and viral       copies in large respiratory droplets and aerosols from exhaled breathing           (versus coughing, in which some spread occurs with any facial covering).

B. Another study pointing toward potential aerosol spread was done at the US      biohazard containment center in Nebraska.  Presented at a National                  Academy of Science Webinar, Dr. John-Martin Lowe showed that viral RNA      was detected at distances greater than 6 feet from 82% of COVID positive        outpatients in a quarantine facility and was also detectable in air samples in      the hallways outside the patient rooms.  It is not known yet if this viral DNA        was part of infectious viral particles.  In the Q&A, Dr. Lowe quoted a                  Singaporean study that showed that viral RNA was found on particles 1-4          microns in size (bio-aerosol size).  He said it was better to think of Droplet        and Aerosol as being part of a continuum of infectiousness and infectivity in      COVID.  This means that perhaps the aerosol infectivity is less than                  measles, it can still be transmitted via aerosols, particularly in closed                spaces where the infectious aerosols can build up in concentration to a            dose sufficient to infect those who spend time in that space.

C. Dry heat better than autoclave for sterilizing N95 masks for re-use.                    (Thanks  to Dr. Mills Matheson for finding this reference.)  In an earlier              email a couple of weeks ago, I reviewed an article showing that autoclaving      preserved filtration better than alcohol, ultraviolet light and gas sterilization.      A better study looking at various conditions shows that heating masks to           170-200 degrees Farenheit for 30 minutes resulted in a trivial loss of                  filtration, even when repeated 20-50 times.  Filtration started to drop off            steeply at temperatures over 212 degrees.  Steam resulted in greater loss        of filtration integrity (about 2% per steam cycle), explaining why                          autoclaved N95 masks should probably be discarded after just a few                autoclaved cycles, and why the rice cooker sterilization method mentioned        in a prior email is done without adding water to the rice cooker.  A CDC              summary of methods of re-using N95 is not very helpful, listing many                options but not distinguishing between them very well.

5. Other Scientific Updates 

A. Case report of Guillain Barre syndrome associated with onset of COVID            (“parainfectious profile”) instead of “postinfectious profile” seen with Zika          and other viruses.

B. Studies of Compassionate Use of Convalescent Plasma.  The same NAS        webinar as noted above described the state of knowledge of studies of              using plasma from patients who have recovered from COVID to treat                critically ill patients with COVID.  Earlier studies in classic SARS found a          tripled survival rate associated with this treatment.  Starting March 24, the        FDA has allowed compassionate use of convalescent plasma to treat                COVID.  A clinical trial was started on April 3 at Johns Hopkins.  On April 8,      the FDA published recommendations on its use.  Blood banks can collect          plasma from patients recovered from COVID.  See the American Red Cross      website for screening criteria.  For a moving account of one New York City        Oncologist’s effort to find matching plasma for her critically ill brother-in-            law’s father, see this article in the Atlantic.  One recovered patient’s plasma      can be used to treat 3 critically ill patients.

C. Compassionate Use Experience of Remdesivir.  This summary of                       experience with the use of Remdesivir based on compassionate use in             hospitalized patients suggested better outcomes compared to historical             experience.  Controlled trials are in progress.

6. On a lighter note: Personalizing care while wearing full PPE:  put your                       portrait onto your gown.

PPE Portraits

PPE Portraits

See this document for details, credits and a how-to guide.  “PPE Portraits are simply disposable portrait picture stickers (4×5) put on PPE – personal protective equipment.  Anecdotal pilot data captured during treatment of Ebola showed the PPE Portrait Project helped patients feel connected to their caregivers, and helped healthcare workers feel more like a team and less dehumanized, though this has yet to be formally studied.  From a placebo standpoint, we know that provider warmth and competence are positively associated with physiological health biomarkers.  From our standpoint, PPE signals competence; portraits could be one of the only signals of warmth for COVID19 and potentially-COVID19 patients.”

Thanks for your hard work and innovative spirit in this challenging time!

Robert Moore, MD MPH MBA,
Chief Medical Officer

The Critical Importance of the Two Month Well Child Visit: The Key is Rotavirus

PHC expects to achieve accreditation this year from the National Council of Quality Assurance (NCQA).  NCQA requires accredited health plans to report on an expanded set of HEDIS measures, beyond those required by the DHCS in California.  We will start collecting data on these measures this year, and they are likely to become part of the PCP QIP in coming years.

One of these new measures is the childhood immunization “Combo 10” vaccine.  The current vaccine measure includes 7 different vaccines given by the 2nd birthday.  The Combo 10 adds the Influenza, Hepatitis A and Rotavirus vaccines to the 7 vaccines currently measured.

Of these 3 new immunizations, the Rotavirus vaccine will be most likely to affect the vaccination rate.  Why is this the case?

First, there is no partial credit for the Combo-10 vaccine measure.  If even one vaccine in a series is missing, it will not count as a vaccinated child.

Secondly, the vaccine window for Rotavirus is unique; if the child misses early vaccine visits, they can never complete the Combo-10 series.  To understand this better, here is some more detail on Rotavirus and the vaccine:

History of the Rotavirus Vaccine:  In 1973 Dr. Ruth Bishop, an Australian scientist, discovered a new virus and named it rotavirus, due to its wheel-like appearance (rota = wheel in Latin) under electron microscopy.

Rotavirus is found almost everywhere in the environment and can survive for months outside of a human host. It is only found in mammals and is typically transmitted via fecal-oral route. Incubation period is 48 hours or less and symptoms usually last 5-7 days. One of the hallmarks of rotavirus infection is extreme watery diarrhea.

Prior to the introduction of vaccines rotavirus illness was responsible for 400,000 doctor visits, 200,000 ED visits, 55-70,000 hospitalizations and 20-60 deaths every year in the U.S. Worldwide it accounts for almost 500,000 under 5 pediatric deaths every year predominantly in developing countries.

The first rotavirus vaccine, Rotashield, was introduced in 1998 but was pulled from the market 1 year later after it was found to be associated with cases of intussusception. (1 case per 10,000 vaccine recipients) Not until 2006 was a second vaccine, RotaTeq, introduced followed by Rotarix in 2008. Both are oral vaccines and have similar efficacy with the only difference the number of doses. (RotaTeq = 3, Rotarix = 2)

The Challenge: Narrow window for catching up. The most unique thing about the rotavirus vaccine(s) is the administration schedule. Like most of the primary series it is given at a set interval – 2, 4, and 6 months. (or 2,4 for Rotarix) However while most vaccines, if missed or delayed, can be given as part of a “catch-up” schedule, rotavirus vaccines cannot be initiated in children if they are older than 15 weeks. And if the infant has not completed the full schedule by 8 months, no further vaccines are given.

This means if the child misses their two month well-child visits and shows up for a 4 month visit (typically at 16 weeks), they are too late to even start the rotavirus series!

As PHC migrates to a new immunization measure, CIS-10, which includes the rotavirus series this may have an impact on a clinic’s QIP scores. Given this small window of possible vaccine administration it is vital to make timely appointments and not delay any vaccines for the youngest of our members.

Of course, prioritizing infant appointments and keeping them on schedule for Well Child Checks will be vital, not just for rotavirus, but all the preventable illnesses they are vaccinated against.

(Thanks to Dr. Jeff Ribordy, PHC’s Whole Child Model Medical Director, for contributing to this article.)

Alcohol and Drug Use and Health Care Expenses

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

In 2017, Partnership HealthPlan (PHC) spent $178 million to provide inpatient medical care for members with a primary or secondary diagnosis of a substance use disorder (SUD).  This represents about 24% of all PHC-covered hospital costs (including costs for maternity and pediatric inpatient care).

Studies done at Kaiser South Sacramento found that an integrated approach to treatment of Substance Use Disorder (mainly Alcohol and Opioid Use Disorders) reduced inpatient hospital and ER visits, saving about $1.44 for every $1.00 spent on integrated treatment (combining SUD treatment, mental health treatment and physical health treatment).  In terms of scale, the potential impact is impressive and inspiring.

PHC is pursuing 3 strategies to improve the quality of life for our members with SUD:

  1. A regional model for health plan administration of traditional SUD services
  2. Support for housing high cost members affected by homelessness
  3. Bolstering the treatment of SUD within primary care and acute care hospital settings.

Regional Model:  First, Partnership HealthPlan is in the midst of negotiations with the California Department of Health Care Services to develop a regional model for providing Substance Use Services to the Medi-Cal population.  These services would include outpatient and residential treatment, as well as Opioid Treatment Centers or “Methadone clinics.”  The provider network for these services is very thin in our service area, so PHC is working to increase capacity.  No other Medi-Cal Managed Care plan in California is seeking to integrate SUD services, although many other states in the United States have done so.

Homelessness:  Second, the combination of homelessness with substance use is associated with high costs.  23% of inpatient expenses for 2017 were incurred by members who were homeless. Studies show that previous policies that required treatment of substance use before offering housing have mostly not helped.  The current trend is “housing first” where housing plus intensive social support is provided, resulting in lower utilization of health care resources and more success in reducing substance use.

In 2017, the PHC invested $25 million to complement local funding to address homelessness, with particular emphasis on those with the highest use of resources.

Leveraging our Current Providers:  Services addressing SUD on different levels can be provided in our current PHC network, including primary care and acute care hospital settings.

Primary care can include medication-assisted therapy for opioid use disorder and home or community based alcohol withdrawal management.  When provided with behavioral health counselling (in many of our Health Centers), this integrated environment has proved successful.  Substance use services provided by primary care clinicians is paid by PHC when provided by PHC primary care or mental health clinicians who are addressing mental health conditions such as depression and anxiety.

Current PHC initiatives support our goal to reduce the burden of SUD in our community:

  • PHC’s successful Intensive Out-Patient Care Management program (IOPCM) provides intensive outpatient care management though agreements with community organizations (mostly Health Centers). About 40% of individuals in this program have some type of SUD.
  • PHC seeks to decrease the number of individuals newly addicted to opioids through limits on initial opioid prescriptions that follow CDC guidelines, part of our Managing Pain Safely
  • PHC is supporting two innovative community-based programs for high risk individuals: the Petaluma Sober Circle and La Clinica Vallejo’s Transition Clinic.
  • PHC is hosting a series of educational events promoting improved care for pregnant women and newborns who are exposed to opioids. The next will be on October 1, with support from the California Healthcare Foundation.  Follow this link to register:  https://opioidexposureinpregnancy.eventbrite.com

For acute care hospitals, voluntary inpatient detox (VID) is covered by state Medi-Cal, but is under-used.  Prior to implementation of the Affordable Care Act in 2014, VID was not covered in acute care hospitals.  State guidance on Treatment Authorization Request criteria was vague, but was clarified this year (as summarized in the Spring PHC Provider Newsletter). When the state finally did announce coverage, it was not widely publicized and unclear billing requirements led to lack of success with reimbursement.  For any acute care hospitals reading this newsletter, here they are:

  • Claims must include a specific phrase in Box 80 {“Remarks” field) on the claim form when billing DHCS for VID for Medi-Cal managed care beneficiaries. The phrase that must be included in Box 80 is “Voluntary Inpatient Detoxification” or “Voluntary Inpatient Detox.”
  • VID TARs should also be submitted with the VID special handling (SH) code, which is “VID”.

Our Hospital Quality Symposium in August featured speakers describing the benefits of initiation of Medication Assisted Therapy for opioid use disorder in the inpatient and emergency department settings.

Summary:  PHC has 3 strategies for addressing the high costs associated with SUD: integration of SUD services at the health plan level, support of “housing first” for homeless individuals with SUD, and support of SUD services provided by physical health providers.

To be successful, we will need to have sustained and meaningful communication with many of our community partners, persuading them to make programmatic changes and work together in new ways.

We at PHC are committed to doing the hard work necessary to make this happen, for the good of our members, our community, and the taxpayers of California.

Benzodiazepine Tapering

By James J. Cotter, MD, MPH, Regional Medical Director

Benzodiazepine Tapering

Benzodiazepines are one of the most used psychotropic medications in the US. Although the indications for short term use include anxiety or sleep disturbances, many adults are prescribed benzodiazepines for years to decades despite warnings against long term use. Side effects of benzodiazepines include sedation and lethargy, impaired cognition and memory, dependency and abuse and increased risk of falls in older adults.  Alcohol increases the risks of side effects as does co-prescription with opioid medications.

Long term use of benzodiazepines is problematic and the significant risks of long term use outweigh any potential (and poorly proven) benefits.  If benzodiazepines are to be used long term, it is preferable to avoid short acting agents and to use the lowest effective dose.  Some benzodiazepines, such as alprazolam, appear more associated with misuse and should be avoided.  Patients using short acting benzodiazepines may increase the dose and frequency due to anxiety or restlessness between doses or difficulty sleeping at night. Warning signs for abuse or diversion include escalating dose or frequency, deteriorating function, “lost” pills, or other evidence suggesting misuse of the drug.  The risk of dependency and abuse is particularly worrisome on opioids and those individuals with a history of substance use disorders.

In some cases, the patient may notice decreased cognitive function or begin having falls and then ask for help in tapering off the benzodiazepine.  One should definitely consider tapering benzodiazepines for your patients who are over 65 years of age, are taking multiple benzodiazepines, or those who have cognitive difficulties and patients with substance or alcohol use disorder.

Outpatient Tapering

Once the decision to taper has been made, what methods work best to safely and effectively taper?  Assuming this is an outpatient setting and there is no evidence of drug abuse or diversion, there are many algorithms for the safe tapering of benzodiazepines. For patients under 65 years of age, most algorithms recommend switching to a long acting benzodiazepine, such as diazepam.  When switching to diazepam, choose a dose equivalent to the short acting agent’s dose.  However, the starting dose of diazepam should not exceed 40 mg daily.  In older patients, the safest options are lorazepam or temazepam since they do not have active metabolites.

Drug

Half Life (hours)

Active Metabolites

Dose equivalent to 5 mg diazepam
Oxazepam 5-15 none 15 mg
Temazepam 8-15 none 10 mg
Lorazepam 10-20 none 1 mg
Alprazolam 6-26 none 0.5 mg
Clonazepam 18-50 none 0.5 mg
Diazepam 20-80 several 5 mg

If the patient is on a high dose of benzodiazepines (over 40 mg of diazepam or equivalent), it may be possible to initially reduce the dose by as much as 25% and then continue decreasing the dose by 10% per week.  Usual therapeutic doses may begin tapering at 10% per week.  Side effects of tapering include anxiety and restlessness, agitation, tremors and panic attacks.  Long term withdrawal symptoms may include anxiety, confusion, depression and cognition/memory symptoms.  Anxiety-related withdrawal symptoms may be mitigated by beginning cognitive behavioral therapy, SSRIs, TCAs or buspirone prior to tapering the benzodiazepine.  Insomnia can be “pre-treated” by cognitive behavioral therapy, TCAs and sleep hygiene education.

For patients with a history of seizures or current active drug use, assistance from an addiction specialist may be necessary.  Patients with severe mood disorders or suicidality may require psychiatric consultation.

A standardized office based approach to dose reduction of benzodiazepines can be very successful. Studies have shown success achieving complete withdrawal in about half of patients on benzodiazepines and a significant dose reduction in another quarter of benzodiazepine patients. The factors indicating the highest likelihood of success are:  a caring clinician, current use of benzodiazepines at a diazepam dose equivalent to 10 mg or less and patients without underlying depression.

Summary:

  • Taper benzodiazepines in patients who are 65 or older, those on multiple benzodiazepines, those with cognitive issues and patients with alcohol or substance use disorder
  • Consider non-benzodiazepine treatment for anxiety or sleep disorders prior to tapering benzodiazepines.
  • Convert patients under 65 to the long acting diazepam at an equivalent dose, but do not exceed 40 mg of diazepam daily.
  • Taper by 10% per week for most patients.
  • Get assistance in tapering for patients with substance use disorder, a history of seizures and patients with significant mental health disorders.

References:

Management of benzodiazepine misuse and dependence. Aust Prescr 2015;38:152-5

Benzodiazepine: Use and Taper.  Canadian Guideline http://nationalpaincentre.mcmaster.ca/opioid/

Helping Patients Taper from Benzodiazepines. National Center for PTSD 2017

Regional variation in referral to Palliative Care: What does it mean?

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Partnership HealthPlan’s new Intensive Palliative Care Benefit has been in place since last winter, but we are seeing wide variation in its use.

In Mendocino, Humboldt and Del Norte Counties, we are seeing strong use of the program, with over 80 patients currently enrolled.  In all the remaining counties, enrollment rates have been very low.

Several studies of intensive outpatient palliative care have shown:

  1. Excellent patient experience/better quality of life
  2. Patients live longer (not shorter)
  3. Health care costs are significantly lower, mostly due to decreased hospital use in the month before death.

What is the explanation for under-use of palliative care in 11 out of 14 counties?

It is not due to an inadequate network.  Partnership has worked diligently to provide a network of intensive palliative care providers that can cover all parts of our service area, including remote frontier areas.

It is also not due to having few patients who qualify.  The eligibility criteria includes:

  1. Stage 3-4 Cancer
  2. Advanced cirrhosis/liver disease
  3. Severe COPD
  4. Severe CHF

Other patients with advanced disease but without these 4 conditions may not be eligible for the full benefit, but may still be referred to palliative care for a comprehensive evaluation with development of a treatment plan.

If you aren’t sure if a patient qualifies:  make the referral!  The palliative care team will assess the patient and get them on the right track.

Low rates of use of intensive outpatient palliative care are primarily related to low rates of referrals of appropriate patients.  Specialists, hospitalists, and primary care physicians are not identifying patients who are good candidates and referring them to their palliative care colleagues for evaluation and management.  Many physicians interpret the term “palliative care” as being the same as hospice.   While hospice care is part of the spectrum of palliative care, the rules for enrollment into hospice are rather rigid:  no curative care; patient expected to live 6 months or less.     In intensive outpatient palliative care, the patient has an expected life expectancy of less than 1 year, and may be receiving concurrent care whose goal is to cure the disease or otherwise ameliorate symptoms.

Which organizations are providing Intensive Outpatient Palliative Care in your region?  See the chart below.

 

Counties Served Organization Referrals
Del Norte Resolution Care Phone: 707-442-5683
Humboldt Resolution Care Phone: 707-442-5683
Lake Hospice Services of Lake County Phone: 707-263-6270 ext 140
Lassen Resolution Care Phone: 707-442-5683
Marin Hospice by the Bay Phone: 415-444-9510
Mendocino Resolution Care Phone: 707-442-5683
Modoc Resolution Care Phone: 707-442-5683
Napa Collabria Care Phone: 707-258-9080
Shasta (Redding vicinity)Shasta Medical Home Care Professionals Phone: 530.226.5577
Resolution Care Phone: 707-442-5683
Siskiyou (Yreka vicinity) Madrone Hospice Phone: 530-842-3160
Resolution Care Phone: 707-442-5683
SolanoSolano (Vallejo) Continuum Hospice Phone: 707-540-9838
Collabria Care Phone: 707-258-9080
Sonoma Collabria Care Phone: 707-258-9080
Hospice By the Bay Phone: 415-444-9510
Trinity Resolution Care Phone: 707-442-5683
Yolo Dignity Health – WoodlandYolo Hospice Phone: 916-281-2370Phone: 530-758-5566

Get help for your patients who are nearing the end of their lives, but may not be ready for hospice.  Refer them to your local palliative care team!

Robert Moore, MD MPH

Chief Medical Officer