Primary care-integrated Long COVID care to improve outcomes for minoritized adults in New York City

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PROJECT SUMMARY The Mount Sinai Center for Post-COVID care has provided specialized evaluation and treatment services for adult Long COVID patients since 2020. The Center operates as a specialty referral service staffed by clinicians, social workers and care navigators. Yet unlike other specialties, it is fully integrated in primary care (PC), which facilitates referrals, access to PC-based services like depression treatment, and seamless transitions back to PC after the need for specialty Long COVID care is complete. The program has served over 6000 patients to date. However, the Center's reach has been limited. Its two locations, in Manhattan's Lower East Side and Upper West Side are out of reach for most residents of New York City communities hard hit by COVID-19, including the minoritized and low income residents of Harlem and the South Bronx. Resource constraints, including staffing and protected time, have limited the ability of Center leaders to extend access to care for patients, reduce waiting times for evaluations, introduce practice innovations and keep up with changes in the field. For these reasons, we propose a project that would add a third site to the Center for Post- COVID care integrated in Mount Sinai's Internal Medicine Associates (IMA) PC practice in East Harlem and build resources and processes that continually improve Long COVID care and extend its reach in a sustainable way. The new practice will be staffed by PC providers with expertise in Long COVID care, a neuropsychologist, social worker and health navigators. In project Phase 1, the project team will create and regularly update clinical decision pathways to guide clinicians through the evaluation and care of Long COVID patients and embed them in the electronic medical record (EMR). We will provide patients with comprehensive, highly patient-centered and coordinated care that involves point-of-care evaluations like cognitive assessment and pulmonary function testing, care navigation, and facilitated access to PC-based clinical services like mental health care and to specialists throughout the Mount Sinai Health System. We will partner with two community- based health and social service providers to develop and implement patient engagement and referral strategies to increase awareness of Long COVID and access to care for it among Harlem and South Bronx residents, and link patients to social services for wrap-around care. We will also develop a comprehensive education program for the benefit of the specialized Long COVID team and the local PC providers, and collect and analyze data for program evaluation and continuous quality improvement. In project Phase 2, we will develop the Long COVID knowledge and clinical skills of PC physicians in IMA and other PC practices (`satellite practices), train them to use the EMR-embedded CDS and provide them access to Long COVID specialist e-consults and referrals so that they can manage Long COVID patients of low complexity.