Long COVID Care Resources and Education to Advance Community Health (REACH)

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Long COVID affects millions of people in the U.S. and has disproportionately impacted vulnerable populations including low-income persons and communities of color who often face barriers to healthcare access. As trusted, accessible providers, federally-qualified healthcare centers (FQHCs) are well-positioned to help mitigate inequities by providing access to Long COVID care in their medically underserved communities. We propose that a care model, Long COVID Care Resources and Education to Advance Community Health (REACH) where a centrally-coordinated, multidisciplinary Long COVID hub program that supports and partners with networks of safety-net FQHCs in the community will help expand and improve the care of vulnerable patient populations suffering from Long COVID. The Stanford Long COVID hub program is a team-based multidisciplinary clinical and research program rooted in a primary care-specialty care partnership and, together with key community partners including Community Health Center Network and San Mateo Medical Center and others, our goal is to extend the reach of this program and expand access for vulnerable patients with Long COVID through the following specific aims: AIM 1: Improve community awareness and education on Long COVID for patients and clinicians. AIM 2: Support primary care providers in partner safety-net FQHCs by creating a collaborative learning community with peer-to-peer asynchronous and real-time consultation. AIM 3: Improve Long COVID care referral coordination and access at the Stanford hub clinic. Our approach is to build upon the evidence-based and well-established Chronic Care Model (CCM) with innovative components that are adaptive and responsive to the rapidly changing landscape of Long COVID care. We will implement the tiered educational outreach and peer-to-peer primary care support strategies across partnering FQHCs with synergistic expertise from our colleagues at the Evaluation Sciences Unit, Office of Community Engagement, and Center for Continuing Medical Education. We will utilize a stepped wedge design and evaluate the model with a formative and summative mixed-methods approach guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to assess overall project reach and impact and adapt strategies throughout the REACH project duration. As part of the cooperative, we will collaborate with AHRQ and other recipients in the Learning Community to share, incorporate, and disseminate learnings in a collective effort to support the primary care community in Long COVID education and management. Overall the goals are to expand access to comprehensive, coordinated, and person-centered care for vulnerable patients with Long COVID.