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

项目摘要 西奈山新冠肺炎后护理中心为以下患者提供了专门的评估和治疗服务： 自2020年以来的成年长期COVID患者。该中心作为一个专业的转介服务工作人员， 临床医生、社会工作者和护理导航员。然而，与其他专科不同的是，它完全融入了初级保健 (PC)，这有助于转诊，获得基于PC的服务，如抑郁症治疗， 在完成对长期COVID专科护理的需求后，将过渡回PC。该计划已服务于 6000名患者至今然而，该中心的影响力有限。它的两个地点，在曼哈顿的下 东区和上西区对于遭受严重打击的纽约市社区的大多数居民来说是遥不可及的。 COVID-19，包括哈莱姆和南布朗克斯的少数民族和低收入居民。资源 限制，包括人员配备和保护时间，限制了中心领导人扩大访问的能力， 护理病人，减少等待评估的时间，引入实践创新，并跟上 外地的变化。出于这些原因，我们提出了一个项目，将增加第三个网站的中心后， 新冠肺炎护理整合在西奈山的内科协会（IMA）PC实践在东哈莱姆和 建立资源和流程，不断改善长期COVID护理，并以可持续的方式扩大其覆盖范围。 路上了新的做法将配备个人电脑提供商的专业知识，在长期的COVID护理，神经心理学家， 社会工作者和健康导航员。在项目阶段1，项目团队将创建并定期更新 临床决策路径，以指导临床医生通过评估和护理长期COVID患者， 将其嵌入电子病历（EMR）中。我们将为患者提供全面、高度 以患者为中心的协调护理，包括即时评估，如认知评估， 肺功能测试、护理导航，以及方便访问基于PC的临床服务，如心理健康、 医疗保健和整个西奈山卫生系统的专家。我们将与两个社区合作- 基于健康和社会服务提供者，开发和实施患者参与和转诊 在哈莱姆和南布朗克斯提高对Long COVID的认识和获得护理的战略 居民，并将患者与社会服务联系起来，进行全面护理。我们亦会制订一套全面的 教育计划，为专门的长期COVID团队和当地PC供应商的利益，并收集 并分析数据以进行项目评估和持续质量改进。在项目第二阶段，我们将 在IMA和其他PC实践中培养PC医生的长期COVID知识和临床技能 （“卫星实践”），培训他们使用嵌入EMR的CDS，并为他们提供长期COVID访问 专家电子咨询和转诊，以便他们能够管理低复杂性的长期COVID患者。

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.