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

项目摘要 慢性冠状病毒病是一种高度流行的疾病，可导致严重的生活质量和 功能。长期以来，护理协调不力被认为是优化健康结果的关键障碍 COVID，导致医疗成本增加和护理提供延迟。这些挑战具有深远的意义 对服务不足的少数族裔人口的影响，这些人口长期以来难以获得负担得起的 高质量的医疗保健。临床医生和社区成员对长期冠状病毒感染的接受度有限 造成诊断延误，并影响对适当服务的分诊。焦虑的比率很高， 抑郁症和创伤后应激障碍在这一人群中被观察到，行为健康服务通常是有限的 脱节的。亚特兰大Long CoVID协作区利用该市协调的新冠肺炎和Long COVID响应，并将亚特兰大大都市区的主要学术和医疗机构聚集在一起， 包括埃默里医疗保健系统、格雷迪医疗保健系统和莫尔豪斯医学院(MSM)。 亚特兰大具有丰富的多样性，是包括非裔美国人和 西班牙裔人口，服务不足的社区，以及那些先前存在重大共生关系的社区。我们的 Site非常适合与我们亚特兰大久负盛名的临床和社区利益相关者接触 恢复基础设施，并从Grady和Emory Long COVID临床网络中恢复。该项目旨在 扩大护理可及性，加强以人为本的护理协调，拓展多学科网络 和行为健康支持。这将在1之前实现。)增加初级长期COVID护理机会 通过扩展面对面访问和虚拟访问能力，以及通过 协调教育系列，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COVID专科专科网络，建立 多学科案例会议，以改善协作和加快复杂病例的护理，4.) 整合专职行为卫生人员，实施行为健康康复小组 系列，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，并确保综合长期COVID观点 进入这种以患者为中心的综合医疗之家(PCMH)模式。临床评估活动将是 迭代，包括对4个关键要素领域进行持续的定量和定性评估，包括 长期COVID护理访问、以人为中心的护理、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.