Covid-19 Impact on U.S. Primary Care Practices with Diverse and Underserved Patient Populations: Survey Results from a Quality Improvement Network

Thirty-seven primary care practices with diverse and underserved patient populations in the Eastern and Midwestern region of the United States, who participate in a quality improvement network, responded to a survey on the impact of the COVID-19 pandemic. Falling revenue and staff reductions were most often mentioned concerns, along with responding to patient questions and fears and staff anxiety. Practice changes including telehealth implementation, mobile or outdoor provision of services, and sequestering at risk patients were reported along with reductions in cancer screenings and ongoing management of cardio metabolic disease. Respondents requested support in educating their patients, practice-based strategies to improve patient and staff safety, and ongoing information about COVID-19 prevention and treatment.


Introduction
Preliminary data spotlight challenges posed by  to primary care, with falling revenue and changing care delivery models [1][2][3]. Underserved and diverse communities confront this challenge against a backdrop of too few health care providers, race-based health disparities, and a disproportionate impact of the COVID-19 pandemic [4][5][6]. The National Minority Quality Forum launched the Center for Sustainable Health Care Quality and Equity (SHC) to support primary care teams in underserved regions through provider and patient education and quality improvement. In order to better support such practices, we surveyed their experiences and needs during the COVID-19 pandemic.

Methods
SHC Quality Improvement Network (QIE) employs the rapid cycle QI model along with health care team-and community engagement strategies [7], currently 52 primary care practices in 10 states participate in the program. The focus of activities includes influenza vaccination, cancer screening, and management of cardio metabolic disease. In the third week of May 2020, practice contacts were emailed a survey concerning the impact of COVID-19 on their practice and potential training or support needs. Thirty-seven responses were received.

Results
Responding practices varied in location, specialty, and organization, including general internal medicine (8), family practice (12), OB-Gyn (7), and pediatrics (10). Practices ranged in size from 1 physician to more than 10, and included federally qualified health centers, independent and system-owned practices, and resident training programs. Blacks represented 25 percent or more of the patient population in most practices (26). Practices were located in urban, rural, and suburban centers on the U.S. East coast and Midwest. Twenty practices reported that 25 percent or more of their patients had Medicaid.
When asked to rate practice changes experienced during the COVID-19 pandemic, the highest number of respondents indicated changes in: cancer screenings; cardio metabolic disease monitoring; use of telemedicine (via computer/smart phone or telephonically); implementation of drive-through, mobile, or outdoor care; dedicated COVID-19 practice space; and pro-active outreach to patients with chronic or serious conditions (Figure 1).

Figure 1: Changes implemented during COVID-19 pandemic.
At least 25 percent of respondents identified the following top concerns: business threatening practice revenue decrease (14); staff lay-offs due to reduced revenue (19); making sure that patients with significant medical care needs due to chronic illness or a serious health event were getting treatment (11); managing patient questions and fears (10), and staff anxiety (10). At least 25 percent identified the following practice needs: education for patients on testing,treatment,and prevention (18); updates on COVID-19 research and screening/treatment recommendations (17); and, education on practice-based strategies for protecting patients/staff from COVID-19 risk (15). The need for PPE (14) and testing supplies (10) also was raised.

Discussion
Concerns expressed about the financial viability and reduced staffing conform with previous reports, highlighting the potent risk to underserved and diverse communities as do reductions in cancer screenings and cardio metabolic disease monitoring.
Patient education was the most frequently sited need by the practices, aligning with expressed concerns about answering patients' questions and fears. We believe patient education is a heretofore unrecognized, unmet need of clinicians in the COVID-19 crisis, highlighting the importance of assisting practices with health literate, culturally-relevant, and effective strategies for educating their patients.
Many respondents expressed the desire for further training on how to minimize patient and staff COVID-19 risk. Meeting this training need may help increase patient trust while allaying patient and staff anxiety [8,9].
The benefits of the education and training are moot if practices have ongoing challenges securing PPE and testing supplies, or if they are forced out of business. Expeditiously meeting the financial, supply and training needs for primary care in underserved communities is critical to reducing health disparities and successfully addressing the COVID-19 pandemic.