{"id":2114,"date":"2020-04-23T15:51:30","date_gmt":"2020-04-23T22:51:30","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=2114"},"modified":"2020-04-23T15:51:30","modified_gmt":"2020-04-23T22:51:30","slug":"41520-primary-care-and-public-health-covid-updates","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=2114","title":{"rendered":"4\/15\/20 Primary Care and Public Health COVID Updates"},"content":{"rendered":"

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.\u00a0 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.\u00a0 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.\u00a0 Yesterday Governor Newsom described<\/a> the outline of how this delicate task might unfold.<\/p>\n

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.\u00a0 To be successful, practices will need to pair careful adherence to rigorous infection control procedures with a positive yet nuanced marketing campaign.<\/p>\n

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

1. Policy Updates:<\/p>\n

A.\u00a0Pending Changes to the 2020 PCP QIP:<\/u> Due to the extenuating\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 circumstances related to COVID-19, PHC\u2019s internal and external\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 committees have made recommendations for changes to the 2020 Primary\u00a0 \u00a0 \u00a0 Care Provider Quality Improvement Program (PCP QIP).\u00a0 The Core\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Measurement Set will be modified to a smaller group of measures, with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 more attainable benchmark goals, as noted below.<\/p>\n

Proposed Point Allocation and Threshold Changes:<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00a0<\/u><\/strong><\/td>\nFamily Practice<\/u><\/strong><\/td>\nInternal Medicine<\/u><\/strong><\/td>\nPediatrics<\/u><\/strong><\/td>\n50th<\/sup> Percentile<\/u><\/strong><\/td>\n<\/tr>\n
Clinical Measures<\/u><\/strong><\/td>\nPoints per measure<\/td>\nFull Points<\/td>\n<\/tr>\n
Well-Child\u00a0 Visit, First 15 months of Life (W15)<\/td>\n15.0<\/td>\n<\/td>\n25.0<\/td>\n65.83%<\/td>\n<\/tr>\n
Controlling High Blood Pressure (CBP)<\/td>\n15.0<\/td>\n20.0<\/td>\n<\/td>\n61.04%<\/td>\n<\/tr>\n
Colorectal Cancer Screening (COL)*<\/td>\n12.5<\/td>\n20.0<\/td>\n<\/td>\n32.24%<\/td>\n<\/tr>\n
Diabetes – HbA1C Good Control <9 (A1c) (CDC)<\/td>\n12.5<\/td>\n20.0<\/td>\n<\/td>\n50.97%<\/td>\n<\/tr>\n
Childhood Immunization Combo 10 (CIS-10)<\/td>\n15.0<\/td>\n<\/td>\n25.0<\/td>\n34.79%<\/td>\n<\/tr>\n
Asthma Medication Ratio (AMR)<\/td>\n15.0<\/td>\n20.0<\/td>\n25.0<\/td>\n63.58%<\/td>\n<\/tr>\n
Non-Clinical Measures<\/u><\/strong><\/td>\n\u00a0<\/u><\/td>\n\u00a0<\/u><\/td>\n\u00a0<\/u><\/td>\n<\/td>\n<\/tr>\n
PCP Office Visits**<\/td>\n15.0<\/u><\/td>\n20.0<\/u><\/td>\n25.0<\/u><\/td>\nTBD<\/td>\n<\/tr>\n
TOTAL POINTS AVAILABLE<\/strong><\/td>\n100.0<\/u><\/strong><\/td>\n100.0<\/u><\/strong><\/td>\n100.0<\/u><\/strong><\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* 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<\/sup> percentile across the entire plan.<\/p>\n

** 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.<\/p>\n

\u00a0 \u00a0 The specifications for measures in the Core Measurement Set are not\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 changing, but some specification modifications are proposed for several\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Unit of Service Measures.\u00a0 Of note, we are lowering the thresholds for\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 submission of attestations for advance care planning conversations and\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Advance Directives\/POLST form updating.\u00a0 This is an excellent time to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 focus attention on this measure, as noted below.<\/p>\n

\u00a0 \u00a0\u00a0<\/strong>This collection of changes is a proposal that is pending final approval\u00a0 \u00a0 \u00a0 \u00a0and final specifications.\u00a0 Final approval will be obtained from our\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Physician Advisory Committee, in early May 2020.\u00a0\u00a0<\/strong>The final details and\u00a0 \u00a0 \u00a0 \u00a0full specifications will be released by Mid-May 2020.\u00a0 We are informing you\u00a0 \u00a0 \u00a0 \u00a0of the highlights of the Core Measure Set Changes so you can align your\u00a0 \u00a0 \u00a0 \u00a0 \u00a0activities to this more focused group of measures.<\/p>\n

B.\u00a0Difficult Conversations in the Time of COVID-19.<\/u> Geriatricians are noting\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0greater receptivity to advance care planning conversations during the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0COVID pandemic.\u00a0 If your PCP practice has extra capacity, you may be\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0considering outreaching to more vulnerable patients to update their\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0advance directives and POLST forms.\u00a0 The Coalition for Compassionate\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Care of California is hosting a free webinar today<\/a> at noon by an expert in\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0palliative care communication, Robert Arnold.\u00a0 A recording of this webinar<\/a>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0will be available afterwards on their website.\u00a0 An excellent prior webinar\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0covering advance care planning in a virtual visit environment and other\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0COVID-specific issues is also available, on the same page.\u00a0 The Coalition\u00a0 \u00a0 \u00a0 \u00a0 \u00a0also has put together an excellent COVID Conversations Toolbox<\/a> with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0other resources.<\/p>\n

C.\u00a0Presumptive Eligibility for Uninsured or Underinsured individuals with<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0COVID.<\/u>\u00a0 The Department of Health Care Services (DHCS) is creating a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 new aid code<\/a> that will allow individuals to seek the necessary diagnostic\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 testing, testing-related services, and treatment services, including all\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 medically necessary care, through the Medi-Cal fee-for-service (FFS)\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 program<\/strong>.\u00a0 This new aid code will be available to California residents with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 no insurance or who currently have private insurance that does not cover\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 diagnostic testing, testing-related services, and treatment service, including\u00a0 \u00a0 \u00a0 all medically necessary care for COVID-19.\u00a0 It will be available, regardless\u00a0 \u00a0 \u00a0 \u00a0 of the person\u2019s immigration status, income, or resources.<\/p>\n

\u00a0 \u00a0 The covered diagnostic test, testing-related services, and treatment\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 services, including all medically necessary care such as the associated\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 office, clinic, or emergency room visit are paid up to the maximum FFS\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Medi-Cal rate.\u00a0\u00a0Individuals in this program will not be enrolled in a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Medi-Cal managed care plan, so services must be billed through FFS.\u00a0 <\/strong><\/p>\n

D.\u00a0<\/strong>DHCS requested flexibility on timing of Initial Health Assessments (IHA) for<\/u>\u00a0 \u00a0 \u00a0 \u00a0new Medi-Cal beneficiaries.<\/u>\u00a0 CMS requires DHCS to require the health\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0plans to ensure that all new Medi-Cal beneficiaries have an initial health\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0assessment (a first visit, including a health screening with the DHCS\u2019s\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Staying Healthy Assessment questionnaire.\u00a0 Normally this assessment\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0includes an examination and must occur within 120 days of enrollment into\u00a0 \u00a0 \u00a0 \u00a0Medi-Cal Managed care.\u00a0 Since a new Medi-Cal member has 1 month to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0select a PCP, the assigned PCP has about 90 days to complete this\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0assessment.<\/p>\n

\u00a0 \u00a0 \u00a0Four days ago, DHCS requested the flexibility<\/a><\/span> to have up to 180 days to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0complete this initial assessment.\u00a0 We will monitor this and inform you when\u00a0 \u00a0 \u00a0 \u00a0CMS responds.\u00a0 In the meantime, as mentioned in the last email (related to\u00a0 \u00a0 \u00a0 \u00a0state prisoner release), we hope you will develop a process for conducting\u00a0 \u00a0 \u00a0 \u00a0new patient intake appointments through virtual visits.<\/p>\n

2.\u00a0Coronavirus PCR Testing<\/u><\/p>\n

A. Quest issued an updated specimen collection guide (attached).<\/u> This\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0includes the methodology for collecting nasal swab specimens (which can\u00a0 \u00a0 \u00a0 \u00a0 \u00a0be self-collected), as well as a number of permitted substitutions for scarce\u00a0 \u00a0 \u00a0 \u00a0collection gathering supplies.<\/p>\n

B.\u00a0Scarce testing materials being spread out.<\/u>\u00a0 Quest informed us that due to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0regulatory reasons related to responding to a shortage of supplies, testing\u00a0 \u00a0 \u00a0 \u00a0 \u00a0materials that are sent out must be mostly used up before replacement\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0testing materials are replenished.\u00a0 This means that most large volume\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0testers will be frequently feeling like they are on the verge of running out of\u00a0 \u00a0 \u00a0 \u00a0supplies.\u00a0 Close communication as any particular component of testing\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0runs low is important.<\/p>\n

C.\u00a0Adapting testing recommendations in office setting as tests become more<\/u>\u00a0 \u00a0 \u00a0 \u00a0 available.<\/u>\u00a0 The CDC recommends that individuals with mild illness consult<\/a>\u00a0 \u00a0 \u00a0 \u00a0 their medical provider to decide if they should be tested or not.\u00a0 Office-\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 based testing criteria may be looser than County Health Department\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 criteria for testing.\u00a0 If patient is staying at home anyway, there is little\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 urgency in identifying milder cases of COVID.<\/p>\n

\u00a0 \u00a0 As testing becomes more available, and as Stay at Home Orders are lifted,\u00a0 \u00a0 \u00a0 we must think differently about testing milder illness to identify clusters of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 infection earlier.\u00a0 County Health Departments will be involved in making\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 recommendations to their local PCPs about testing criteria.\u00a0 If a PCP has\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 plenty of testing capacity, be sure to let your local health department know,\u00a0 \u00a0 \u00a0 \u00a0 so they can guide you on what criteria to use to expand testing.<\/p>\n

\u00a0 \u00a0 \u00a0Examples of expanded testing strategies:<\/u>\u00a0 The county health department\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0may ask PCPs to assist with testing known contacts of confirmed COVID\u00a0 \u00a0 \u00a0 \u00a0 \u00a0cases or doing follow up testing on patients with suspicious symptoms with\u00a0 \u00a0 \u00a0 \u00a0a negative initial test, for example.\u00a0 They may ask a subset of providers to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0test all patients with mild respiratory symptoms as part of community\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0surveillance or recommend testing anyone with any level of suspicious\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0symptoms (something being done in Michigan<\/a>).\u00a0 With sufficient capacity,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0some testing of asymptomatic essential workers (e.g. grocery store clerks,\u00a0 \u00a0 \u00a0 \u00a0bus drivers, EMTs, hardware store workers) who are regularly exposed to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0the public may be helpful to prevent asymptomatic transmission.\u00a0 A\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0hospital in New York<\/a> tested all pregnant women arriving in labor, and found\u00a0 \u00a0 \u00a0 \u00a014% of asymptomatic women tested positive, prompting precautions to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0prevent spread in the hospital.<\/p>\n

\u00a0 \u00a0 \u00a0These are but a few options.\u00a0 Developing a local strategy for scaling up\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0testing as it becomes more available is worth a joint discussion between\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0local clinicians and public health leaders.<\/p>\n

D.\u00a0PCR tests vs. Imaging for confirming COVID.<\/u>\u00a0 The sensitivity of COVID\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0PCR tests is fair (around 70%), and the results take a while to come back.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0An emergency room in New York<\/a> found that half of all patients with COVID\u00a0 \u00a0 \u00a0 \u00a0had an abnormal chest X-ray (usually bilateral, peripheral or basilar\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0pattern,\u00a0 sometimes described as ground glass interstitial pneumonitis).\u00a0 A\u00a0 \u00a0 \u00a0 \u00a0 \u00a0study in China<\/a>, among patients admitted with COVID, found that 95% had\u00a0 \u00a0 \u00a0 \u00a0 \u00a0an abnormal CT scan of a particular pattern.\u00a0 Some radiologists in the US<\/a>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0have been hesitant to recommend using CT for diagnosis, citing concerns\u00a0 \u00a0 \u00a0 \u00a0 \u00a0about the need to sterilize the CT scanner after scanning a patient with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0suspicious symptoms.\u00a0 As their primary justification, they state that there\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0are methodological problems with the studies published so for on CT\u2019s\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0specificity for COVID.<\/p>\n

\u00a0 \u00a0 \u00a0Decisions to test a patient should not be dominated by concern over\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0cleaning the equipment.\u00a0 If patient with hypoxia and a normal Chest X-ray\u00a0 \u00a0 \u00a0 \u00a0 \u00a0is admitted to the hospital, given the differential diagnosis, a CT scan\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0would often be helpful in ruling out non-COVID pathology, as well as\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0helping with in-hospital disposition if the patient does have a pattern\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0consistent with COVID, while awaiting PCR test results which have only a\u00a0 \u00a0 \u00a0 \u00a0 \u00a070% sensitivity.<\/p>\n

3.\u00a0Coronavirus Antibody Tests<\/u>\u00a0\u00a0(Thanks to Dr. Marshall Kubota for gathering these studies)\u00a0 <\/em><\/p>\n

A.\u00a0<\/em>Pattern of Development of Neutralizing Antibodies.<\/u>\u00a0 A Chinese study<\/a> of 175\u00a0 \u00a0 \u00a0 \u00a0patients with COVID found that SARS-CoV2 specific neutralizing\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0antibodies developed starting 10-15 days after \u201conset of disease.\u201d\u00a0 Patients\u00a0 \u00a0 \u00a0 \u00a0with milder disease had lower plasma titers of these antibodies than those\u00a0 \u00a0 \u00a0 \u00a0 \u00a0with more severe disease.\u00a0 Ten patients with confirmed COVID had\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0undetectable antibodies, suggesting either a poor response or perhaps that\u00a0 \u00a0 \u00a0 \u00a0the PCR test\/clinical diagnosis had a specificity of 94% to match its\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0sensitivity of 70%.<\/p>\n

B.\u00a0Similar pattern of antibodies was found in a Norwegian Study of H1N1<\/a>,<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 which found that 2\/46 patients diagnosed with mild H1N1 had no\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 detectable antibodies to H1N1.\u00a0 Again, this may reflect either a poor\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 generation of an immune response or a specificity of 96% in the initial\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 diagnostic test for H1N1.<\/p>\n

C.\u00a0Other Coronaviruses Exhibit waning Immunity over Time.<\/u> \u00a0Interviews of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0experts by NPR<\/a> noted that the more benign coronaviruses that cause the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0common cold can cause repeat sickness, even if a person has a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0documented prior antibody response.\u00a0 Speculations on potential reasons\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0include genetic variation of the virus over time or some other factor that\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0impacts the effectiveness of antibodies from prior infection.\u00a0 Since classic\u00a0 \u00a0 \u00a0 \u00a0 \u00a0SARS was found to have a more robust and long-term immune response,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0and they were all symptomatic with serious infection, this supports the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0hypothesis that surviving more serious illness generates a longer-lasting\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0and stronger response.<\/p>\n

4.\u00a0Bio-aerosols and masks<\/u><\/p>\n

A.\u00a0The study that prompted CDC to recommend wearing face coverings<\/a> in<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0public<\/u> showed that surgical masks reduced coronavirus detection and viral\u00a0 \u00a0 \u00a0 \u00a0copies in large respiratory droplets and<\/em> aerosols from exhaled breathing\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0(versus coughing, in which some spread occurs with any facial covering<\/a>).<\/p>\n

B.\u00a0Another study pointing toward potential aerosol spread was done at the US<\/u>\u00a0 \u00a0 \u00a0 biohazard containment center in Nebraska.<\/u>\u00a0 Presented at a National\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Academy of Science Webinar<\/a>, Dr. John-Martin Lowe showed that viral RNA\u00a0 \u00a0 \u00a0 was detected at distances greater than 6 feet from 82% of COVID positive\u00a0 \u00a0 \u00a0 \u00a0 outpatients in a quarantine facility and was also detectable in air samples in\u00a0 \u00a0 \u00a0 the hallways outside<\/em> the patient rooms.\u00a0 It is not known yet if this viral DNA\u00a0 \u00a0 \u00a0 \u00a0 was part of infectious viral particles.\u00a0 In the Q&A, Dr. Lowe quoted a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Singaporean study that showed that viral RNA was found on particles 1-4\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 microns in size (bio-aerosol size).\u00a0 He said it was better to think of Droplet\u00a0 \u00a0 \u00a0 \u00a0 and Aerosol as being part of a continuum of infectiousness and infectivity in\u00a0 \u00a0 \u00a0 COVID.\u00a0 This means that perhaps the aerosol infectivity is less than\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 measles, it can still be transmitted via aerosols, particularly in closed\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 spaces where the infectious aerosols can build up in concentration to a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 dose sufficient to infect those who spend time in that space.<\/p>\n

C.\u00a0Dry heat better than autoclave for sterilizing N95 masks for re-use.<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0(Thanks\u00a0 to Dr. Mills Matheson for finding this reference.)<\/em>\u00a0 In an earlier\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 email a couple of weeks ago, I reviewed an article showing that autoclaving\u00a0 \u00a0 \u00a0 preserved filtration better than alcohol, ultraviolet light and gas sterilization.\u00a0 \u00a0 \u00a0 A better study looking<\/a> at various conditions shows that heating masks to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0170-200 degrees Farenheit for 30 minutes resulted in a trivial loss of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 filtration, even when repeated 20-50 times<\/em>.\u00a0 Filtration started to drop off\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 steeply at temperatures over 212 degrees.\u00a0 Steam resulted in greater loss\u00a0 \u00a0 \u00a0 \u00a0 of filtration integrity (about 2% per steam cycle), explaining why\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 autoclaved N95 masks should probably be discarded after just a few\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 autoclaved cycles, and why the rice cooker sterilization method mentioned\u00a0 \u00a0 \u00a0 \u00a0 in a prior email is done without adding water to the rice cooker.\u00a0 A CDC\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 summary<\/a> of methods of re-using N95 is not very helpful, listing many\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 options but not distinguishing between them very well.<\/p>\n

5.\u00a0Other Scientific Updates\u00a0 <\/u><\/p>\n

A.\u00a0Case report of Guillain Barre syndrome<\/a><\/u> associated with onset<\/em> of COVID\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 (\u201cparainfectious profile\u201d) instead of \u201cpostinfectious profile\u201d seen with Zika\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 and other viruses.<\/p>\n

B.\u00a0Studies of Compassionate Use of Convalescent Plasma.<\/u>\u00a0 The same NAS\u00a0 \u00a0 \u00a0 \u00a0 webinar<\/a> as noted above described the state of knowledge of studies of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 using plasma from patients who have recovered from COVID to treat\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 critically ill patients with COVID.\u00a0 Earlier studies in classic SARS found a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 tripled survival rate associated with this treatment.\u00a0 Starting March 24, the\u00a0 \u00a0 \u00a0 \u00a0 FDA has allowed compassionate use of convalescent plasma to treat\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID.\u00a0 A clinical trial was started on April 3 at Johns Hopkins.\u00a0 On April 8,\u00a0 \u00a0 \u00a0 the FDA published recommendations on its use<\/a>.\u00a0 Blood banks can collect\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 plasma from patients recovered from COVID.\u00a0 See the American Red Cross\u00a0 \u00a0 \u00a0 website for screening criteria<\/a>.\u00a0 For a moving account of one New York City\u00a0 \u00a0 \u00a0 \u00a0 Oncologist\u2019s effort to find matching plasma for her critically ill brother-in-\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 law\u2019s father, see this article<\/a> in the Atlantic.\u00a0 One recovered patient\u2019s plasma\u00a0 \u00a0 \u00a0 can be used to treat 3 critically ill patients.<\/p>\n

C.\u00a0Compassionate Use Experience of Remdesivir.<\/u>\u00a0 This summary of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0experience with the use of Remdesivir<\/a> based on compassionate use in\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0hospitalized patients suggested better outcomes compared to historical\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0experience.\u00a0 Controlled trials are in progress.<\/p>\n

6.\u00a0On a lighter note:<\/u> Personalizing care while wearing full PPE<\/u>:\u00a0 put your\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0portrait onto your gown.<\/p>\n

\"PPE<\/a>

PPE Portraits<\/p><\/div>\n

See this document for details, credits and a how-to guide<\/a>.\u00a0 \u201cPPE Portraits are simply disposable portrait picture stickers (4×5) put on PPE \u2013 personal protective equipment.\u00a0 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. \u00a0From a placebo standpoint, we know that provider warmth and competence are positively associated with physiological health biomarkers.\u00a0 From our standpoint, PPE signals competence; portraits could be one of the only signals of warmth for COVID19 and potentially-COVID19 patients.\u201d<\/p>\n

Thanks for your hard work and innovative spirit in this challenging time!<\/p>\n

Robert Moore, MD MPH MBA,<\/h5>\n
Chief Medical Officer<\/h5>\n","protected":false},"excerpt":{"rendered":"

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) … Continue reading →<\/span><\/a><\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-2114","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\n4\/15\/20 Primary Care and Public Health COVID Updates - PHC Primary Care Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/phcprimarycare.org\/?p=2114\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"4\/15\/20 Primary Care and Public Health COVID Updates - PHC Primary Care Blog\" \/>\n<meta property=\"og:description\" content=\"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) … Continue reading →\" \/>\n<meta property=\"og:url\" content=\"https:\/\/phcprimarycare.org\/?p=2114\" \/>\n<meta property=\"og:site_name\" content=\"PHC Primary Care Blog\" \/>\n<meta property=\"article:published_time\" content=\"2020-04-23T22:51:30+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/ml3zltbr0lxh.i.optimole.com\/w:auto\/h:auto\/q:mauto\/ig:avif\/https:\/\/phcprimarycare.org\/wp-content\/uploads\/2020\/04\/PPE-with-photo.jpg\" \/>\n<meta name=\"author\" content=\"RMoore\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"RMoore\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"13 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114\"},\"author\":{\"name\":\"RMoore\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/#\\\/schema\\\/person\\\/e2261897cb15c2610b283200b210f79c\"},\"headline\":\"4\\\/15\\\/20 Primary Care and Public Health COVID Updates\",\"datePublished\":\"2020-04-23T22:51:30+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114\"},\"wordCount\":2568,\"commentCount\":0,\"image\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#primaryimage\"},\"thumbnailUrl\":\"https:\\/\\/phcprimarycare.org\\/wp-content\\/uploads\\/2020\\/04\\/PPE-with-photo.jpg\",\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114\",\"url\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114\",\"name\":\"4\\\/15\\\/20 Primary Care and Public Health COVID Updates - PHC Primary Care Blog\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#primaryimage\"},\"thumbnailUrl\":\"https:\\/\\/phcprimarycare.org\\/wp-content\\/uploads\\/2020\\/04\\/PPE-with-photo.jpg\",\"datePublished\":\"2020-04-23T22:51:30+00:00\",\"author\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/#\\\/schema\\\/person\\\/e2261897cb15c2610b283200b210f79c\"},\"breadcrumb\":{\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114\"]}]},{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#primaryimage\",\"url\":\"https:\\/\\/phcprimarycare.org\\/wp-content\\/uploads\\/2020\\/04\\/PPE-with-photo.jpg\",\"contentUrl\":\"https:\\/\\/phcprimarycare.org\\/wp-content\\/uploads\\/2020\\/04\\/PPE-with-photo.jpg\",\"width\":172,\"height\":261,\"caption\":\"PPE Portraits\"},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/?p=2114#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/phcprimarycare.org\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"4\\\/15\\\/20 Primary Care and Public Health COVID Updates\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/#website\",\"url\":\"https:\\\/\\\/phcprimarycare.org\\\/\",\"name\":\"PHC Primary Care Blog\",\"description\":\"Partnership HealthPlan of California\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/phcprimarycare.org\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\\\/\\\/phcprimarycare.org\\\/#\\\/schema\\\/person\\\/e2261897cb15c2610b283200b210f79c\",\"name\":\"RMoore\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g\",\"url\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g\",\"contentUrl\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g\",\"caption\":\"RMoore\"},\"url\":\"https:\\\/\\\/phcprimarycare.org\\\/?author=2\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"4\/15\/20 Primary Care and Public Health COVID Updates - PHC Primary Care Blog","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/phcprimarycare.org\/?p=2114","og_locale":"en_US","og_type":"article","og_title":"4\/15\/20 Primary Care and Public Health COVID Updates - PHC Primary Care Blog","og_description":"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) … Continue reading →","og_url":"https:\/\/phcprimarycare.org\/?p=2114","og_site_name":"PHC Primary Care Blog","article_published_time":"2020-04-23T22:51:30+00:00","og_image":[{"url":"https:\/\/ml3zltbr0lxh.i.optimole.com\/w:auto\/h:auto\/q:mauto\/ig:avif\/https:\/\/phcprimarycare.org\/wp-content\/uploads\/2020\/04\/PPE-with-photo.jpg","type":"","width":"","height":""}],"author":"RMoore","twitter_misc":{"Written by":"RMoore","Est. reading time":"13 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/phcprimarycare.org\/?p=2114#article","isPartOf":{"@id":"https:\/\/phcprimarycare.org\/?p=2114"},"author":{"name":"RMoore","@id":"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c"},"headline":"4\/15\/20 Primary Care and Public Health COVID Updates","datePublished":"2020-04-23T22:51:30+00:00","mainEntityOfPage":{"@id":"https:\/\/phcprimarycare.org\/?p=2114"},"wordCount":2568,"commentCount":0,"image":{"@id":"https:\/\/phcprimarycare.org\/?p=2114#primaryimage"},"thumbnailUrl":"https:\/\/ml3zltbr0lxh.i.optimole.com\/w:auto\/h:auto\/q:mauto\/ig:avif\/https:\/\/phcprimarycare.org\/wp-content\/uploads\/2020\/04\/PPE-with-photo.jpg","inLanguage":"en-US"},{"@type":"WebPage","@id":"https:\/\/phcprimarycare.org\/?p=2114","url":"https:\/\/phcprimarycare.org\/?p=2114","name":"4\/15\/20 Primary Care and Public Health COVID Updates - PHC Primary Care Blog","isPartOf":{"@id":"https:\/\/phcprimarycare.org\/#website"},"primaryImageOfPage":{"@id":"https:\/\/phcprimarycare.org\/?p=2114#primaryimage"},"image":{"@id":"https:\/\/phcprimarycare.org\/?p=2114#primaryimage"},"thumbnailUrl":"https:\/\/ml3zltbr0lxh.i.optimole.com\/w:auto\/h:auto\/q:mauto\/ig:avif\/https:\/\/phcprimarycare.org\/wp-content\/uploads\/2020\/04\/PPE-with-photo.jpg","datePublished":"2020-04-23T22:51:30+00:00","author":{"@id":"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c"},"breadcrumb":{"@id":"https:\/\/phcprimarycare.org\/?p=2114#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/phcprimarycare.org\/?p=2114"]}]},{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/phcprimarycare.org\/?p=2114#primaryimage","url":"https:\/\/ml3zltbr0lxh.i.optimole.com\/w:auto\/h:auto\/q:mauto\/ig:avif\/https:\/\/phcprimarycare.org\/wp-content\/uploads\/2020\/04\/PPE-with-photo.jpg","contentUrl":"https:\/\/ml3zltbr0lxh.i.optimole.com\/w:auto\/h:auto\/q:mauto\/ig:avif\/https:\/\/phcprimarycare.org\/wp-content\/uploads\/2020\/04\/PPE-with-photo.jpg","width":172,"height":261,"caption":"PPE Portraits"},{"@type":"BreadcrumbList","@id":"https:\/\/phcprimarycare.org\/?p=2114#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/phcprimarycare.org\/"},{"@type":"ListItem","position":2,"name":"4\/15\/20 Primary Care and Public Health COVID Updates"}]},{"@type":"WebSite","@id":"https:\/\/phcprimarycare.org\/#website","url":"https:\/\/phcprimarycare.org\/","name":"PHC Primary Care Blog","description":"Partnership HealthPlan of California","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/phcprimarycare.org\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Person","@id":"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c","name":"RMoore","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g","url":"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g","caption":"RMoore"},"url":"https:\/\/phcprimarycare.org\/?author=2"}]}},"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p293xY-y6","_links":{"self":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/2114","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2114"}],"version-history":[{"count":24,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/2114\/revisions"}],"predecessor-version":[{"id":2198,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/2114\/revisions\/2198"}],"wp:attachment":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2114"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2114"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2114"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}