Advancing Long COVID Care in our Community through Access, Equity, and Collaboration

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PROJECT SUMMARY/ABSTRACT Long COVID manifests differently for each person and can contribute to disabling, life-changing symptoms such as extreme fatigue, cognitive dysfunction, breathing difficulty, and autonomic dysfunction in people across the age spectrum, including in people who were previously healthy and in people who had minimal or no symptoms associated with acute COVID-19 infection. Multidisciplinary Long COVID clinics were a mainstay of patient support during the initial phases of the COVID-19 pandemic, but as the pandemic is shifting to a new phase, care models must also evolve in order to meet the complex medical, rehabilitative, and social needs of the continually growing number of people who are affected by Long COVID. The purpose of this project is to transform an existing, university-based Long COVID clinic into a broader Long COVID community network in order to expand equitable access to care, improve the patient care experience, and support primary care practitioners. This project will invest in two particularly underserved populations: 1) the Black community in St. Louis, Missouri, which is a historically mistreated population who continues to be marginalized by previously sanctioned segregation practices; and 2) rural communities across Missouri. Aim 1 is to expand equitable access to Long COVID care by: 1) building clinical capacity, and 2) removing structural barriers to care. This will be accomplished by: 1) hiring additional clinicians for the Long COVID Clinic in order to reduce wait times; and 2) removing patient requirements for clinic evaluation that disproportionately affect underserved populations. Aim 2 is to improve the Long COVID care experience by: 1) streamlining care that crosses multiple disciplines and physical care sites, and 2) supporting patients’ social needs. This will be accomplished by: 1) supporting a clinical case manager to directly assist patients with coordinating medical care and connecting with community resources, and 2) iteratively assessing and addressing referral challenges between clinics. Aim 3 is to support primary care teams as they care for patients with Long COVID by co-creating: 1) educational resources for PCPs, and 2) streamlined communication and referral pathways between PCPs and specialty clinicians. This will be accomplished by engaging multiple key stakeholders to: 1) develop multi- modality educational materials related to Long COVID patient assessment and management; 2) disseminate materials via culturally and logistically preferred approaches (including via established, trusted community intermediaries and via an established ECHO (Enhanced for Community Healthcare Outcomes) virtual educational infrastructure); and 3) refine existing handoff processes to minimize the administrative workload on PCP teams and facilitate their ability to meet patients’ needs. Continuous stakeholder input, comprehensive data tracking, and iterative needs assessments using mixed methods approaches will facilitate ongoing project evaluation and adaptation in order to respond to the community’s evolving needs.