CEO Maureen Lewis had a virtual chat with Aceso Global Senior Non-Resident Associate Dr. Robert Janett to discuss how his healthcare organization – the Cambridge Health Alliance (CHA) – adapted to COVID-19. CHA has been a pioneer in implementing new primary healthcare and integrated care models in the US and this proved a major asset in terms of planning and responding to COVID-19. Through flexible management, innovative protocols, smart alliances with private hospitals and an integrated telemedicine program, CHA has been successful in managing COVID-19 while maintaining access for non-COVID patients. Its experience offers lessons for other health systems and countries looking to bolster pandemic preparedness.
The transcript below has been edited for brevity and clarity.
Maureen Lewis: I’m very pleased today to interview Dr. Robert, Janett, who is a Senior Non-Resident Associate here at Aceso Global, and also a practicing primary care physician with the Cambridge Health Alliance in Boston, Massachusetts, which is a very innovative delivery system that has had some very big challenges with the COVID-19 response. In addition to that, he was for 30 years the Medical Director at an [Accountable Care Organization] ACO called MACIPA in Boston, and he’s worked for the World Bank and other organizations, and he teaches at Harvard Medical School. So, we’re very pleased that he has come to talk to us.
I wanted to give a little bit background on the Cambridge Health Alliance. It is a very unique structure, something that we don’t see in very many parts of the world. It is characterized as an “academic community health system”. It is focused on integrated, comprehensive, continuous care. It serves 140,000 patients per year, and it’s largely serving the economically vulnerable population in the region of Cambridge, Massachusetts. It has two hospitals and a whole network of primary care services that are available to different members of the community. And this has been one of its great strengths, and it has been a model for other structures that we see in the United States, most importantly Accountable Care Organizations, which have learned a great deal from Cambridge Health Alliance; and Cambridge Health Alliance itself has ACOs within it.
CHA is financed through [Massachusetts state] public transfers because it does public health for the community, with [additional funding from] private insurance and public insurance, both Medicare and Medicaid. It has a very broad financial base and it’s indicative of the fact that it is unique because although it receives funding from multiple sources, it itself is a quasi-public organization, but with complete independence: in many parts of the world, we would refer to this as a public-private partnership because they have independence on the clinical and the non-clinical side of implementing services, but they are held accountable by the public sector. This model has great application in many parts of the world.
I think that it’s an opportune time to both get a sense of the Cambridge Health Alliance on the one hand, and second, and more timely, get a sense of how it has managed the COVID-19 surge. So, with that, I’d like to turn to Dr. Janett, to get a sense from you of how you see the Cambridge Health Alliance structure and how it has been a positive one for dealing with COVID-19.
Robert Janett: It’s really a pleasure to talk to you about our work here in Cambridge, Massachusetts, and surrounding communities. As the listeners may know, Massachusetts was one of the early epicenters of the COVID epidemic in the United States. I think that our peak hit here around mid-April, and by April 24th we were identifying almost 5,000 new cases per day in a state that has only 6.9 million people. And we peaked at almost 300 deaths per day in late April in the state of Massachusetts. Things have gotten a lot better here. We are now identifying around 100 to 120 new cases per day [as of July 2nd]. We’re seeing 20 deaths per day now compared to the nearly 300 deaths that we were seeing on a daily basis in April. It’s very important for the listeners to understand how we organized ourselves to respond to this surge in demand, which came very quickly.
We are an integrated healthcare delivery network with two acute hospitals, 15 primary care clinics, and a variety of other services. We serve people from newborn through old age and we are a fairly large organization. We have roughly 3,600 non-physician employees, a medical staff of around 700 doctors, we train 200 residents and so there’s a lot of people involved in our care model.
Our care model, as it existed before COVID, was very heavily oriented toward primary care so that of the 140,000 patients that are served by our network, virtually all of them were identified to have a primary care physician. What you had then was among these 15 primary care sites, each site, each physician, had a defined population for which they were linked and they were responsible, and for which they provided full range care from preventive services, through acute services, through chronic disease management, and coordination of care with hospitals and with other specialists. So, it’s this comprehensive community-oriented primary care model that is at the core of the Cambridge Health Alliance. It’s also fair to say that we have a very strong behavioral health component to our care system. We have several inpatient behavioral care units, extensive treatment for substance abuse and outpatient treatment for behavioral disorders; and we integrate that behavioral healthcare into our primary care model as well.
We have an adequate supply of specialists, inpatient hospital beds and intensive care beds to meet the usual needs of our population. When patients need high complexity, tertiary level care, we have preexisting contracts, links and alliances with tertiary care systems that provide that high complexity care: the transplants, the heart surgery, the advanced cancer care that we can’t deliver in our community hospitals to our patients. So, we have a network that we operate and own, and then we have these alliances that are very important. Almost all of our physicians are employed by our network and so there’s complete integration between the physician practices and the care model that we deliver. So that’s how things stood prior to this rapid onset of the COVID surge that came in April.
My main thesis here is that Cambridge Health Alliance being organized around the primary care model with this patient medical home approach was very well situated to respond to this surge in demand. But what we knew would happen and that we had to prepare for was [that] traditional face-to-face care models were not going to work in a rapidly evolving epidemic. So the first step that we took, within days, was changed from a system that previously had been 99.9% face-to-face care into a system that was largely oriented to telemedicine.
The other step that we took was develop specialized intermediate care services in a clinic that we called our Respiratory Clinic, where we could direct patients who needed screening for COVID or evaluation of early COVID, and ambulatory management of COVID in a specialized place where there was adequate expertise, adequate physical plant, and protective equipment to be able to deliver that care safely. I think it’s quite telling that with all of this adaptation among our 3,600 employees and our 700 physicians, we only had on the order of 200 cases of COVID among our staff, despite this massive surge in demand, so that these protective measures of trying to eliminate face-to-face care and substitute telemedicine whenever possible, plus redirecting potentially infectious patients to a specialized intermediate center really served both to effectively care for these patients, but also to protect vital medical staff so that we could go on with our day to day functions and provide the patients with the care that they need.
Dr. Lewis: How did having a primary care structure help you in the COVID surge? How were you able to use that network?
Dr. Janett: There are two principal factors here. First of all, it meant that there was a care team that already understood, to a large extent, the care needs of these patients. We understood their co-morbidities; we understood the chronic diseases that they had; we understood their social problems; and we understood their psychological problems. So we knew how to respond to the needs of individual patients. And, you know, when you’re converting care from in-person care to telemedicine, having prior knowledge of your patients is a very important asset.
The other point, and this is a point that I can’t overemphasize, we’ve spent over 10 years investing in electronic health records. We use a very sophisticated system called Epic. It’s probably the most sophisticated electronic record system available in the United States. And because we have this 10 years of development, the ability to then within days switch to telemedicine, and to be able to track patients who were screened for COVID, who developed COVID, understand what their arc of care was, what their symptoms were and what their complications were – this was an essential tool in terms of the success of our care adaptation. I would say that those two factors figure large in preparedness for COVID: What really has been more than a 30 year investment in innovative, advanced primary care coupled with a more than 10 year investment in information systems; doing one without the other is really not possible.
“I would say that those two factors figure large in preparedness for COVID: What really has been more than a 30 year investment in innovative, advanced primary care coupled with a more than 10 year investment in information systems; doing one without the other is really not possible.”
Dr. Lewis: I think that that’s really clear and that knowing your patients becomes such an important component of this, because it has been such a very odd disease and has not played out the way many had expected. I think that that infrastructure is a lesson for basically all health systems, because it’s so central to being able to manage something that is new and pandemic in nature.
I’m also curious – you have two hospitals and that’s pretty modest for the size of your population, and which is also a tribute to the fact that you spend more time and money on primary care and on specialist care than you do on hospitalizations, but with COVID, there was a big surge in the need for hospitals. How did your two hospitals cope with that big of an increase in demand?
Dr. Janett: Well, let me describe that step wise, because hospital preparation was essential to a successful response to this epidemic here in the greater Boston area. The first thing that we did when we saw the surge coming was we converted our management structure into an Incident Command System so that we provided essential functions to essential people, put them in a room together, and the entire decision making authority of the institution for both inpatient and outpatient was put into the hands of this very small elite group of decision makers, where they could make decisions literally within minutes. That was essential.
“The first thing that we did when we saw the surge coming was we converted our management structure into an Incident Command System…[and] the entire decision making authority of the institution for both inpatient and outpatient was put into the hands of this very small elite group of decision makers, where they could make decisions literally within minutes.”
Number two is that we knew that we would quickly exhaust our bed capacity. So the first thing that we did in terms of capacity was to stop all nonessential services. We ceased all elective surgery, for example, immediately to preserve vital resources, to preserve protective equipment and to open up some space for ourselves. So all of the post-anesthesia care areas that would normally be filled with elective surgery patients became auxiliary intensive care units, and we expanded the number of beds on the regular medical floors into every possible space that we could get a bed. We essentially doubled our intensive care capacity and we increased our surge bed capacity by a large percentage, I don’t have the exact number, but the fact is we planned for this this need in terms of physical plant.
But the other part of planning is a bed does you no good unless it’s staffed. And so we suddenly needed a large influx of nurses, cleaning staff, technicians, nurses assistants, physicians, residents, etc. Through this incident command center, we remobilized our 3,600 employees and trained them up and redeployed them to staff up the hospital. You had people who normally don’t even work in a hospital going through a very rapid training program both in terms of skills and in terms of infection control and self-protection. We put them onto these teams, always teamed up with experienced providers so that people aren’t left on their own, but we did some very creative things.
And then thirdly, and this is where some of my work came in, we understood the importance of palliative care in this environment. I was charged with launching two completely new palliative care units. We didn’t have palliative care units prior to the COVID surge. We set these up in formerly ambulatory spaces and a physical therapy unit, in a cardiovascular testing unit, and we retrained primary care nurses, dental assistants and nurses who worked in information technology to serve as palliative care nurses. This took pressure off the inpatient beds because people who were dying of COVID and were not candidates for ventilators and intensive care because of their stated goals of care or because of their general condition could receive very kind, compassionate end of life care in a bed, but without occupying critical hospital space.
The last thing I’ll mention about hospitals is that the fact that we had these alliances with our partner hospitals in place was absolutely critical to our success. That stems from the main observation, which is that poor people and people of color and immigrants were disproportionately affected by COVID during the surge, and they continue to be disproportionately affected. That meant that our catchment area, our primary patient communities, had very heavy burdens of disease, and our hospitals filled up much more quickly than the private hospitals that you can find two, three, five kilometers from our own hospital centers.
So as we started to fill our capacity, we could take patients from our emergency room and move them right to a private hospital bed in a way that worked – organized, streamlined, efficiently. At the same time when our intensive care units were filled and we had patients in a regular hospital bed who would need intensive care, we could, again, transfer those to an intensive care unit at a partner hospital that wouldn’t be as overburdened as we were. We never, at any point during this epidemic, had to deprive a single patient of needed services. We prepared for that possibility. We worried about that eventuality, but it didn’t happen in greater Boston because of this level of preparedness. That’s not necessarily true in other cities.
Dr. Lewis: I think these kinds of measures are really important and it’s not just in the United States. These are lessons for many of the countries of the world that have had to cope with the pandemic, and the preparedness, the ability to adapt in such a unique way, are the kinds of things that need to happen. But I think also your ability to call on your overflow agreements made a big difference. In other countries, you have basically seen tent cities and they have used that to create their excess capacity. But Cambridge Health Alliance had already set [those agreements] up and it’s indicative also of how much of a primary care focus you have that the hospital part is relatively small, but you have a safety valve. So I think that’s an important lesson too.
Dr. Janett: There are a couple of things to observe here. One is that if a patient called us with a cough or fever or shortness of breath, that call was triaged directly to our Respiratory Center, and we evaluated that patient the same day in a non-hospital setting in a Respiratory Center, unless they were felt to be in extremis. We only had to transfer about 5% of our Respiratory Center patients to an emergency room. We really managed 95% of those patients in an ambulatory setting. And that too took a lot of pressure off our hospitals. So having in place a protocol for ambulatory management of COVID for treating symptoms, treating anxiety, isolating people, preventing the spread and ongoing monitoring either in person or via the telephone was really an essential adaptation.
“If a patient called us with a cough or fever or shortness of breath, that call was triaged directly to our Respiratory Center, and we evaluated that patient the same day in a non-hospital setting.”
Our team actually published their protocol for managing these patients, and it’s available publicly on the Cambridge Health Alliance website and it was also published in the online journal called UpToDate. Anyone with an UpToDate subscription can access our protocol and our data is available. It’s our hope at the Cambridge Health Alliance that other countries would simply copy and adapt what we did so that they don’t have to reinvent the wheel. We’d really like to help them leap over the development barriers to getting effective care systems in place.
The last thing I want to say it is about tent cities, and this was quite interesting. The Commonwealth of Massachusetts in cooperation with the military did set up a field hospital in the largest convention center in Boston, getting ready to handle the anticipated massive overflow from the hospitals, assuming the hospitals would all be full. We really never reached the point in greater Boston where every hospital was full. We always had the opportunity to transfer patients from one hospital to another to balance the needs. That field hospital had very low use. I think they had the capacity to deal with two to three thousand patients, and I think that their maximum census in that hospital at any one time was only one or two hundred people.
Dr. Lewis: This is useful as well, because, as I said, there’s been this experience with tent hospitals. There’s also been some experience with primary care and using it as triage, both in the U.S. but also in Vietnam, in particular, and in Costa Rica because they have a network of clinics that they can instruct to talk to their communities and try to provide the kind of triage and backup that CHA provided. It may be simpler, but I think that the basic concept is really a very important one for COVID management from beginning to end.
That brings me to one of my last questions, which is about follow up with those patients. One of the things that we see is that many of the people who have been stricken with COVID-19 have lingering problems. Are you seeing that? And presumably your structure will help you in particular to follow up with those patients because you know your patients and you have that integrated network.
Dr. Janett: Well, it’s no accident that COVID-19 is called the novel coronavirus. It’s a new virus and really, the medical community has very little prior knowledge of what the course and complications of this virus will bring. We’ve made some fascinating and frightening observations about this virus. Number one is the destructive nature of this virus to the lungs. And there are a number of people who survive COVID, but have long-term lung problems. Number two is the impact on the immune system. We know that many of the COVID deaths are due to an over-activation of the immune system, but there are also immunologic injuries to the body that are curious, persistent and still trying to be understood. And then there’s the effect on the blood clotting system, which is probably an immune-mediated process as well, where there’s unexpected blood clots, particularly in younger people, causing strokes or other things.
The long-term consequences of this virus are just being appreciated. We’re not just seeing them in primary care, we’re seeing them in our specialty clinics and we’re sharing the responsibility for some of the more serious complications with our tertiary partners. But the key point here is because of our electronic systems, our electronic records, we can track each and every one of these patients, we can catalog their course, their complications, and we can study that and we can report on it. We’re doing that so that we can contribute to the science of the medical care of COVID.
In terms of treating these patients, the key is that they have very easy access to competent medical services, either through telemedicine – video or audio – or, after appropriate screening and protection, in-person visits at a variety of centers. Right now, we’re in process of reopening all of our services for in-person care, but using new types of care protocols so that infectious people aren’t mixed in with non-infectious people in our buildings. That’s really important, not just to protect people who are coming in to see us, but also to protect the health workers and finally, to give everybody confidence that they can function in a new reality despite the challenges with this pandemic.
Dr. Lewis: Excellent. Well, thank you very much. I would just like to summarize a little bit of what I have taken away from this really interesting discussion. First of all, the Cambridge Health Alliance was prepared and was thinking about it in advance which is very important for something that is as deadly and as intense as the coronavirus was. Secondly, having a command center provides you with the flexibility that you don’t have otherwise, and hospitals and health systems and health networks, and any organization tends to have bureaucratic impediments. So that obviously addresses some of those difficulties. Third, I think the respiratory clinic effort to keep patients away from the emergency room and from going to hospitals, and being able to triage that patient group is really important. And that built on the fact that you had this integration of information and of services to patients, [patients who] trusted the Cambridge Health Alliance [when they said] go to the respiratory clinics. That’s quite important.
Also, this adaptation to telehealth has really taken the world by storm, and clearly you have been part of it, but you’ve also made efforts with the health workers and you also created some competence among your staff so that they can adapt to new circumstances. I think that’s quite critical.
There are two other things that I think are just really fundamental. One is this primary healthcare focus, but it’s a very sophisticated primary healthcare focus. It’s not that you’re waiting for patients to come to you; you go out and find them and you follow them, and when you follow them, when they get really sick, you know what you’re dealing with. That’s partly related to your electronic medical records, which clearly are a keystone of modern healthcare, but [the primary healthcare focus] really makes an enormous difference.
And finally, your general oversight of what’s gone on and the fact that you’ve collected data and you’ve looked at data, you basically made this a research endeavor, and it probably has something to do with your links to academia. But I think from a management point of view, it’s quite central to being able to learn not only what you did well, but what you did poorly and what you’d have to fix in the future. So it places you directly as a learning organization that is going to learn both for your own sake, but also to share more broadly. So with that, I’d very much like to thank you, Rob. This is really excellent. It’s going to help a lot of people understand better what’s going on, has gone on and how you can do it, right, even in an, a pandemic that has caught us all off guard.
Dr. Janett: In terms of, of our listeners, a number of the things we talked about here are quite easy to replicate, even in low resource environments. Implementing an electronic record is a large undertaking, but implementing protocols, triage, intermediate care units, dealing with the surge, managing people pre-hospital and post-hospital – these can be replicated very easily, and I hope that we can help other healthcare organizations and other countries do just that.