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Coronavirus: Could delivering toilet paper really save the healthcare system?

How protecting our most vulnerable people helps fight COVID-19

Wuhan has shown the rest of the world that ‘shelter in place’ can #flattenthecurve.  Can it work here in the United States? While no one knows for sure, what we can say, at least statistically, is that a certain percent of people who become infected with COVID-19 will have severe complications, require treatment with mechanical ventilators in intensive care units (ICUs) and possibly die.  To prevent this – and prevent overloading the healthcare system – we need to identify those individuals now and find practical solutions to help them “shelter in place” so they don’t need to leave their homes.  

For those who might claim this is too expensive, it’s worth noting that the cost of a ventilator is approximately $50,000 for the kind of machine used in advanced ICUs.  Even if shelter-in-place supplies cost $50 per day, you can deliver supplies for a long time before you spend that amount of money.  

We already know how to do this.  Care management teams for integrated delivery systems, health plans, and accountable care organizations (ACOs) across the country already know how to do proactive outreach and coordinate services for patient populations, and they have been doing this for years.  They understand the psychology of engagement and how to listen for unmet needs. For COVID-19, care teams can make sure people have what they need to ‘shelter in place’ and have someone to contact if they don’t. Care teams just need to know who they should call.

In fact, care teams are already starting to do this in Chicago which will undoubtedly save lives.  Imagine if we could do this throughout the country – we may just learn that delivering toilet paper not only saves lives, but the healthcare system, too.

The Spread of COVID-19 in the U.S. is a Reality

On March 11, 2020 the World Health Organization (WHO) declared COVID-19 to be a pandemic and the first to ever be caused by a coronavirus.  In their press conference, they were clear that pandemic was not a word they used lightly or carelessly, or to cause unreasonable fear.  They were also clear to stress that they had never seen a pandemic be controlled, but declared that all countries could still act to change its course. 

Today in the United States, the rise in the number of cases and the doubling times are in line with the experience of earlier countries and there is increased concern of asymptomatic transmission.  Public health and healthcare experts agree that rapid and aggressive mitigation is required if we are to slow the spread of COVID-19 and protect our healthcare systems since unmitigated spread risks their collapse.  

A System on the Edge 

On any given day, the United States healthcare system – which has 924,000 hospital beds, 98,000 ICU beds, 62,000 full-featured ventilators and a limited supply of basic units – runs close to capacity.  As health officials prepare for an expected influx of patients, they see a system with a limited amount of ‘surge’ capacity and are alarmed by the lack of ventilators and hospital beds.  

For the sickest patients, we have an inadequate supply of ICU beds, a severely limited number of ventilators, and little the government or local officials can do to increase the ventilator numbers in time.  Capacity models show that, should 10% of infected patients need hospitalized (note that China’s hospitalization rates were 15%; Italy’s were 50%), all our hospital beds would be full by May 10 and we would have run out of ventilators before that.  

But, if we can find a way to stay below a certain threshold, we can keep the healthcare system from going over the edge.  This is why every avoided transmission and prevented case has enormous impact. To do this, we must take aggressive measures. Now.  

Can’t Increase Supply?  Reduce Demand!

In this tension of supply and demand, it is vital we dramatically reduce demand and do it as quickly as possible.  A powerful visual of supply and demand for the UK is shown here. To avoid the worst case scenarios means finding where the surge will come from and intervening so there’s no need for an ICU bed or ventilator.  It means reducing demand and for as many people as possible who, absent any intervention, would otherwise be the ones to need those resources.  

We don’t know who will become infected by COVID-19, but we do know that certain people, if that happens, are vulnerable to serious complications.  People with serious complications from COVID-19 need ICUs and ventilators and die at much higher rates. These are the people we’re talking about. 

We also know from early studies on China’s experience, which had an overall death rate of 1%,  that death rates were 6% for people with cancer, high blood pressure and chronic respiratory disease, 7% for people with diabetes, and 10% for people with heart disease.  They also saw a steep gradient with age; the death rate for people aged 80+ was 15%.

In the U.S., the CDC just released their first preliminary description of outcomes among patients with COVID-19 in the United States.  The statistics and the headlines were quick to point out that millennials should not think they’re immune to COVID-19, since more than 40 percent of patients sick enough to be hospitalized were aged 20 to 54.  This is important, since it supports the message to this group to “stop socializing in groups and to take care to protect themselves and others.”

Less discussed, though, was the fact that the lion’s share of serious complications (i.e. ICU admissions and death) are not millennials.  The more serious complications still lie with older individuals and the curve rises steeply with age. These are the people we want to find and make sure there’s no need for an ICU bed or ventilator in the first place. 

Safeguarding the Vulnerable from COVID-19

While nothing we do can eliminate the possibility of infection, there are several steps that can be highly effective in reducing the risk for individuals vulnerable to severe complications from COVID-19.

A brief environmental scan of community and industry practices revealed that these steps fall into six categories:

  1. Educate people.  Talk with them about COVID-19.  
  1. Create a care plan. Make sure they know what symptoms to look for and can contact providers remotely 
    • Create a contact sheet in case symptoms arise.  
    • Instruct them on what to do if they may have been exposed:  Don’t go directly to a hospital; call or use telehealth to contact a physician. 
    • Make sure they have medications, can use mail order / early refills.   
    • Confirm access to telehealth services
    • Discuss how to monitor their conditions and when to call for medical care
    • Have a backup plan in case their caregiver gets sick
  1. Promote safe practices. Make sure they protect themselves.  
    • Stress that proper hygiene and social practices are their best protection
    • Make sure they screen visitors, wash hands, sneeze / cough / dispose of tissues, wear gloves (if they absolutely must go out) and  know what to do if someone near to them becomes infected
    • Print detailed instructions they can see throughout their home
  1. Ensure they have supplies. Make sure they have key household and hygiene items 
    • Make sure they have medication, food, toilet paper and other essentials in case they remain confined for longer periods of time.
    • Set up delivery services where possible.  Take advantage of local efforts and resources where possible.
  1. Look for Additional Challenges – Pay attention to and look for the other challenges faced by low-income individuals and families 
  1. Be present. You may be their best resource.
    • Check in regularly, ask how they’re feeling
    • Continue to answer (or find answers) to their questions. 
    • Stay connected

Public health experts and healthcare officials all agree that slowing the spread of COVID-19 requires aggressive mitigation.  And because every avoided case has enormous impact, our solutions must include protecting the individuals who are the most vulnerable to severe complications.   

Success depends on having strategies that extend beyond expanding the number of ventilators.  They need to include investing in call centers, care management teams, and meal deliveries. They have to use scalable approaches that identify vulnerable individuals that immediately connect them with practical ways to help them ‘shelter in place’.   

If we’re successful, we’ll flatten the curve by protecting the people who can’t fight off the virus.  And yes, we’ll succeed by delivering toilet paper.

 

About the Author: Carol McCall is an actuary and population health executive whose background spans actuarial work, PBM operations, health services, predictive analytics, health economics and outcomes research, personalized medicine, national health information policy, and public health.

Previous roles include Chief Innovation Officer at Vanguard Health Systems and VP of Innovation, Research and Development at Humana. In policy and advisory roles, Carol has served on the National Committee on Vital and Health Statistics, on Humana’s Health Services Research Center’s governing board, and as advisor to the High-Risk Plaque Scientific Program Board.

Carol is currently Chief Health Analytics Officer at ClosedLoop.ai — Healthcare’s Data Science Platform and is the primary analytics lead for cv19index.com — Open Source Data Science to Fight COVID-19