The Atlanta Long COVID Collaborative: A Multi-Health System Long COVID Coordinated Care Model Serving a Diverse Metropolitan Population

项目摘要 长期COVID是一种高度流行的疾病，可导致生活质量严重受损， 功能护理协调不力已被确定为优化朗肯地区健康结果的关键障碍。 COVID导致医疗成本增加及医疗服务延误。这些挑战具有深远的 对长期难以获得负担得起的服务的得不到充分服务的少数群体的影响， 优质医疗保健。临床医生和社区成员对长期COVID的接受程度有限 导致诊断延误，并影响到适当服务的分诊。焦虑的几率很高， 抑郁症和创伤后应激障碍在这一人群中观察到，行为健康服务往往有限， 脱节的亚特兰大长COVID协作利用城市的协调COVID-19和长 COVID应对，并汇集了亚特兰大都会区的主要学术和医疗机构， 包括Emory Healthcare System、Grady Healthcare System和Morehouse School of Medicine（MSM）。 亚特兰大拥有丰富的多样性，是关键的COVID-19高危人群的家园，包括非洲裔美国人和 西班牙裔人群，服务不足的社区，以及那些有显著的既存合并症。我们 该网站是唯一适合从事临床和社区利益相关者从我们完善的亚特兰大 恢复基础设施，并从我们的格雷迪和埃默里长COVID临床网络。该项目旨在 增加获得护理的机会，改善以人为本的护理协调，扩大多学科网络 行为健康支持。这将通过1.）增加初级长期COVID护理服务 通过扩大面对面和虚拟访问的能力，并通过一个 教育系列，2。增加专门的护理协调、社会服务和语言 口译人员，3.）扩大现有的Long COVID特定专科网络，并建立 多学科病例会议，以改善复杂病例的协作和快速护理，4.） 整合专门的行为健康人员，实施行为健康和康复小组 series，5.）参与社区支持系统，包括患者倡导团体和社区 联盟，以改善获得和保留护理的机会，并确保将长期COVID观点纳入其中 以患者为中心的医疗之家（PCMH）模式。临床评价活动将 对4个关键要素领域进行反复和持续的定量和定性评价，包括 长期COVID护理访问，以人为本的护理，多学科和行为健康网络访问， 和循证医学

Project Summary Long COVID is a highly prevalent disease that can lead to significant impairments in quality of life and function. Poor care coordination has been identified as a key barrier to optimizing health outcomes in Long COVID, resulting in increased healthcare costs and delays in care delivery. These challenges have profound impacts on underserved, minority populations that have a long-standing history of poor access to affordable, quality healthcare. Limited acceptance of Long COVID among clinicians and members of the community contributes to delays in diagnosis and impacts triage to appropriate services. High rates of anxiety, depression, and PTSD are observed in this population and behavioral health services are often limited and disjointed. The Atlanta Long COVID Collaborative leverages the city’s coordinated COVID-19 and Long COVID response, and brings together major academic and healthcare institutions in the Atlanta metro area, including Emory Healthcare System, Grady Healthcare System, and Morehouse School of Medicine (MSM). Atlanta is rich in diversity and is home for key COVID-19 at-risk populations including African American and Hispanic populations, underserved communities, and those with significant preexisting comorbidities. Our site is uniquely suited to engage clinical and community stakeholders from our well-established Atlanta RECOVER infrastructure, and from our Grady and Emory Long COVID clinical network. This project aims to increase access to care, improve person-centered care coordination, and expand multidisciplinary networks and behavioral health support. This will be achieved by 1.) increasing primary Long COVID care access through expanded in-person and virtual visit capacity and increasing provider-based referrals through a coordinated education series, 2.) adding dedicated care coordination, social services, and language interpretive staff, 3.) expanding the existing Long COVID-specific subspecialty network and establishing multidisciplinary case conferences to improve collaboration and expedited care of complex cases, 4.) integrating dedicated behavioral health staff and implementing behavioral health and rehabilitation group series, 5.) engaging community support systems including patient advocacy groups and community alliances to improve access to and retention of care and to ensure Long COVID perspectives are integrated into this comprehensive patient-centered medical home (PCMH) model. Clinic evaluation activities will be iterative and include ongoing quantitative and qualitative evaluation of 4 key element domains, including Long COVID care access, person-centered care, multidisciplinary and behavioral health network access, and evidence-based medicine.