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Caring for Primary Care Patients

Caring for Primary Care Patients

The Harriet Lane Clinic reaches out to the community to improve access for children through both in-person and telemedicine visits.

Undoubtedly, telemedicine has been a godsend for Johns Hopkins Children’s Center patients since early March when positive cases of the pandemic coronavirus were first identified in Maryland. While there has been a significant effort by Children’s Center pediatricians to steer as many children as possible to telemedicine visits in compliance with state stay-at-home orders, there are still many patients who should be seen in clinic. Some, however, delay care due to financial and transportation issues made worse by the pandemic, fears of exposure to the coronavirus in a health care environment, and confusion about whether Johns Hopkins clinics are even open and seeing patients.

First off, stresses Mark Marcantano, Johns Hopkins Children’s Center’s chief administrative officer, “We are very much open for business for the patients who need us and want to see us. We can see them in person in a healthy and safe way, as well as through telehealth.”

Adds pediatrician and Harriet Lane Clinic Medical Director Megan Tschudy, “In clinic, we’re seeing healthy babies, children and young adults who need to have vaccines that are vital to keep them healthy. We are treating children and young adults who do not have symptoms related to the coronavirus but have other acute and chronic medical issues that need to be treated now. We are here in person and via telemedicine to serve children, their families, and the community."

To cut through any confusion in the community and address socio-economic factors that are often barriers to care, pediatricians in the Harriet Lane Clinic have been reaching out in resourceful ways, following its tradition of treating the whole patient, the whole family and the whole community. Their first steps included reviewing patients’ schedules weeks in advance, notes Tschudy, and then identifying those among their 8,000 patients who need to be seen in clinic, as well as those medically complex patients in the community who require special attention at home. “We’re not waiting for families to call us but systematically calling all of our medically and socially complex patients, checking in with them and making sure they have the medicines and supplies they need,” says Tschudy. “Do they need refills of their medications, physical therapy and occupational therapy, and could we push some of that through telemedicine? How can we help them navigate all of the medical and social services they need?”

Another issue needing navigation is immunizations for newborns and babies up to two years of age. Some families have found reduced access to private practices and local clinics, as well as to Baltimore City Health Department vaccination services. Harriet Lane pediatricians have been connecting with their community counterparts and the Maryland chapter of the American Academy of Pediatrics (AAP) to support their immunization efforts.

“This was another aspect of our outreach, leveraging both our physician-patient relationships and our electronic health records to reach out to children due for immunizations,” says pediatrician Julia Kim. “This was a big concern because the last thing we wanted is a measles outbreak on top of COVID-19.”

Johns Hopkins pediatricians are also working with the Maryland Chapter of the American Academy of Pediatrics in an effort to survey community pediatric practices in the region to get a sense of how well they are faring during this crisis.

“The aim is to give voice to the struggles that practices are facing in maintaining operations, to make sure the essential medical needs of children in the community are being met,” says pediatrician Rachel Thornton, who helped develop the survey. “We want to really understand how the pandemic itself and the mitigation measures required to battle the pandemic are affecting their bottom line and their ability to be available.”

Patients dependent on technological support for their medical condition, like ventriculoperitoneal shunts for hydrocephalus or gastrostomy tubes for feeding issues, is another concern. Serendipity played a role in preparations for these patients, explains Kim, as she and her colleagues were developing a quality- improvement project before the coronavirus arrived.

“Our goal is to improve the care coordination notes in the patient’s chart so that the information would be readily available to the multiple specialties who care for these complex patients,” says Kim. “We’re also working with Johns Hopkins Pediatrics at Home to provide their services to patients who now may need them due to the coronavirus.”

Another priority? Patients with mental health concerns. In addition to any existing psychiatric conditions, some are experiencing pandemic-related anxieties and fears not only about themselves but also their parents — especially if they work as first responders or health professionals — and grandparents. Families are asked if these children need to be seen in clinic, or via a video visit, with social worker LaToya Mobley or mental health consultant Jami Margolis for counseling.

Why all the outreach?

The impact of the pandemic, notes Barry Solomon, director of the Division of General Pediatrics, has also triggered a financial crisis, which children in resource-poor neighborhoods tend to bear the most.

“As we know, a lot of our families are facing more financial insecurity, whether they’re furloughed or losing their jobs, which certainly creates stress in the family,” says Solomon.

Among the consequences are more disparities in children’s access not only to medical care but also social services in the community, says Kim: “The families we serve are experiencing the impact of this pandemic in ways that affect all aspects of their life, including food insecurity, job security and child care. That really emphasizes the importance of reaching out, to make sure all of the needs are being met.”

Hopkins Community Connection, an advocacy group that works with over 800 patient families through both the Harriet Lane Clinic and the Children’s Medical Practice at Johns Hopkins Bayview Medical Center, has been a robust resource in meeting those needs. Those concerns include transportation and financial barriers, but access to food appears to be the most urgent need.

“It’s a little bit of everything, of course, but when food is challenging to obtain, everything else becomes secondary,” says Kristin Topel, who oversees the program comprised of Johns Hopkins University students and other volunteers. “Our families tend to obtain food from local corner stores that now are out of so much food. Going down the road a few miles to another store is not feasible for many neighborhood families.”

To support that need, Hopkins Community Connection provides bags of groceries to families as needed. Before the coronavirus, the group was planning to serve 20 families a month. Now it has served 150.

“I do feel so grateful to have an incredible team constantly working to be up to speed on the resources that are working for families and cultivating those relationships,” says Topel. “It really feels special when families are calling our clinic for help with food or navigating utility bills. It’s such a nice testament to the work our undergrads and community health workers are doing.”

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