Primary care transformation in a COVID-19 world: Addressing the changing health needs of our most vulnerable patients

This article is a collaboration with our colleagues at Day Health Strategies.

The economic and social impacts of the COVID-19 pandemic will have far-reaching implications on our health system, particularly for primary care. This whitepaper highlights how population health principles and patient-centered access and quality of care standards can be used as a framework to support primary care providers in taking quick action to keep vulnerable patients healthy during (and beyond) the pandemic.


  • Maria Fernanda Levis, MPH, MPA, CFRE, PCMH-CCE
  • Lara Shadwick, MBA
  • Julie H. Levison, MD
  • Sarah Bliss Matousek, PhD 


The economic and social impacts of the COVID-19 pandemic will have far reaching implications on our health system, particularly for primary care.  Social distancing and infectious disease control measures have created significant challenges for primary care providers, however, the impact of COVID-19 on primary care can and should be leveraged to accelerate patient-centered care and the effective use of virtual care in the long-term.

In the United States and its territories, access to comprehensive primary care for those patients that are at highest risk of complications from COVID-19 has always been challenging.  These patients have complex needs which require significant coordination, additional time and/or more resources than those provided with traditional models of care.  There are 46.2 million people aged 65 or older who live in the United States and six out of ten Americans have at least one chronic condition.  Chronic diseases and poverty are often interconnected, making access to proper care even more difficult. Pre-existing conditions, such as diabetes, obesity, cardiovascular disease, and asthma are major causes of morbidity and mortality in US-based Black and Latino populations, placing them at further risk for complications of COVID-19.

The infectious nature of COVID-19 requires that providers completely rethink care models in order to maintain people healthy at home, which is a significant paradigm shift from the current office visit based system. Social distancing policies and the conversion to telehealth and other virtual health platforms, while important for reducing SARS-CoV-2 transmission, threaten the familiar dynamics of routine care if telehealth does not adapt to meet the capacity, needs and abilities of diverse patient populations.

Disruptions in care for patients with complex medical and psychiatric co-morbidities can result in adverse events, particularly when patients experience added emotional stress during this public health crisis.  Primary care providers are under significant pressure to quickly transform how they provide access of care for these vulnerable patients in order to avoid emergency care.  Canceled or delayed primary and preventive health services have also caused massive financial losses for federally qualified health centers which serve the medically indigent, making it more difficult for primary care providers to address the needs of patients.  Federal resources are necessary to support health centers in adapting their current care models to seamlessly incorporate virtual communication and telehealth visits which facilitate the management of chronic conditions and routine care during stay-at-home orders, thus preventing emergency room visits. 

The federal government is making significant investments in telehealth to support a patient’s capacity to stay at home, instituting regulations and payment policies that enable its implementation during the emergency period.  However, many patients remain displaced and unable to access care with this technology. Although current CMS guidelines on management of existing medical conditions recommend evaluations via telehealth, triage to appropriate sites of care and consideration of follow-up through virtual check-ins, many patients and providers are not ready. This crisis presents a great opportunity to galvanize operational improvements in primary care for all patients, however, it can also create greater obstacles in patients’ access to medical resources.  Attention must be paid to the process of understanding both patient and clinic readiness to engage in this type of delivery of care in order to invest appropriately to support its effective implementation. 

This article highlights how Population Health principles and the patient-centered access and continuity of care standards developed by the National Coalition for Quality Assurance’s (NCQA) for their Patient Centered Medical Home (PCMH) Model can be used as a framework for establishing the policies and processes necessary to support primary care providers in taking quick action to keep vulnerable patients healthy, address the underlying health conditions which make these patients high-risk, and protect them from COVID-19.  Specifically, the standards set forth by NCQA for patient-centered access and continuity of care focus on a primary care practice’s competency to “enhance patient access by providing appointments and clinical advice based on patient’s needs” and “support continuity of care through empanelment and systematic access to patient’s medical records”.  By building on lessons learned from the successful implementation of PCMH and telehealth efforts in rural and medically underserved areas, we propose practical measures on how the US primary care system can rapidly transform operations to create safe access for patients. 

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