Community Action Response Plan Objective Rapidly launch and

Community Action Response Plan • Objective: Rapidly launch and operate a COVID-19 testing-telemonitoringvoluntary isolation initiative in Buffalo • About 1 in 5 US residents live in a multigenerational family – a household with children, adults and grandparents • Target Population: (1) high-risk, low-income individuals and (2) positive / presumptive-positive with mild and moderate illness • Tomorrow, Erie County will add a zip code feature to its COVID-19 map. So far, the largest cluster of cases includes people in 14215, which is the City of Buffalo’s East Side • Outcomes: (1) improve treatment, (2) reduce mortality, (3) reduce burden on hospitals

Informatics Resource Support Treatment Community Response Plan Population Health Testing Teletriage

G-Health Leadership INFORMATICS • Donald Stroka, Program Analyst • Roan Reynolds, CIO • Louis Garcia, Director of IT RESOURCE SUPPORT • Ivan Agosto, COO • Gabrielle Diaz, Director – Outreach and Engagement • Yaritza De. Jesus, Director – Transportation POPULATION HEALTH • Nicole Pearcy, Director – VBP • Chelsea Adamski, Asst. Director – VBP • Adrianne Lawal, Office Manager – UFP TELETRIAGE • Chelsea Adamski, Asst. Director – VBP • Levenia Baker, Pharmacist • Nicole Pearcy, Director – VBP TESTING • Dr. Chet Fox, CMO • Levenia Baker, Pharmacist • Terrance Gaiter, Office Manager – UFP TREATMENT • Dr. Raul Vazquez, CEO • Dr. Chet Fox, CMO • Levenia Baker, Pharmacist

GBUACO Network Committees DATA ANALYTICS • • • Create chase lists for distribution to outreach staff Develop risk analysis based on urgency; diagnoses, age, and social determinants of health Develop and monitor metrics for ongoing evaluation and tracking • • • Outreach Testing Treatment OUTREACH TEAMS • Outreach to patients to screen for symptoms, social support and basic needs • Connect people in need of social support to church volunteers, care coordination and CBOs CLINICAL GUIDANCE • Develop clinical guidelines • Create work flows for testing and treatment • Monitor patients in isolation • Conduct telehealth visits

Informatics – holon • • Setup data transfer between MCC, GBUACO and Holon Develop data parameters 1. Demographics 2. PCP 3. Contact Information 4. Diagnoses* (clinical staff only) 5. Other (? ) DATA USE GUIDELINES USER MANAGEMENT DATA MANAGEMENT • Administrative staff • • Teletriage nurses • • Church staff (paid v. volunteers) • Community Health Outreach • Population health teams • CBOs Actions Needed: • What are the timelines for data management, user setup? • Who is involved in efforts; what users from practices need access to systems? • Data use agreements for participating groups • What is the IT capacity from other participating groups for system setup? Store patient data for outreach and social support Utilize referral management system for: 1. CBOs 2. Waitlist for testing 3. Hotel isolation units 4. Patients without PCP

INSIGHTS: • Access patient contact information • Identify patient risk level • Identify if patient is in a health home (? ) • Identify patient’s primary care provider REFERRALS: • Instant Message system for sharing encrypted information between referral sights • Customizable questionnaires based on what patient information is needed • Ability to attach and securely send documents • Capacity to organize referrals by level of urgency; assign referrals to specific staff members or groups

Set the status based on whether or not it has been picked up yet, scheduled, declined, canceled, etc. This is like an inbox of activity between all the referrals Instant messages and the sending back and forth of documents would appear here Track and assign referrals using filters You can follow the activity timeline to ensure timeliness of follow up

This is where you would fill in the difference. You can create customized questionnaires based on where the referral is going. You can also attach documents within the referral when you send it.

Skype Free Conference Calls 1. You will get a link sent to you 2. You can sign in as a guest or create a login where access to the conversation/chat 3. You have to use Microsoft Edge or Google Chrome as a browser *Easy for continuous IM communication between external staff

Resource Support CHURCH • Make outreach calls to members • Use Holon referral management system to connect with Triage, Primary Care Providers and CBOs • Connect members needing mental health support with Endeavor, telepsychiatry if needed CBOs Coordination • • • Patient Health Navigators do regular check ins, help set up appointments with doctors • Food pantries • Childcare organizations Enroll in wellness for social support, virtual activities, healthy recipes • Peer support • Housing organizations Assist patients with transportation to testing if needed Actions Needed: • Who are all the participating CBOs and community resources? • What kind of transportation services will be available for patients?

Outreach

Teletriage Actions Needed: • What Medent systems have cross scheduling privileges for nurses? • How will nurses schedule in external EMR systems? • What nurses are available from other practices to help teletriage? • What systems in other groups are already in place? • Need specific protocols and provider guidance

Testing Actions Needed: • What kinds of testing units? • Where are the testing venues?

Treatment Actions Needed: • Develop clinical criteria on symptoms and treatment levels • How to work with patients who need assistance with home isolation and resources

Treatment tracker and Therapeutic Learning System - Covid 19. oracle. com

Community Action Response Plan • Week 1: Staging • Data, staffing, locations (hospitals, healthcare facilities, hotel), systems setup, resources for basic needs, determination of funding • Week 2: Outreach Efforts • Call patients on chase lists, route to triage line or PCP, set up testing sites and testing for patients with symptoms, connecting patients with social services and essential living needs • Week 3: Patient Management • Outreach, testing, monitoring patients, treatment • Week 4+: Continued Patient Management

Requires Attention 1. Staffing needs (i. e. Physicians reviewing tests, monitoring patients in isolation, nurse triage line) 2. Equipment needs (i. e. PPE, Tytocare units, rapid testing machines, thermometers) 3. Definitive clinical guidelines for screening and treatment; CDC guidelines changing daily 4. Development of appropriate metrics and tracking 5. Availability of tests and wait times for results 6. Funding