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

项目总结 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 2020年以来的成人长期冠状病毒感染患者。该中心是一家专门的转介服务机构，工作人员为 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，以及无缝 在完成对专业长期COVID护理的需求后，过渡回PC。这个节目已经结束了。 到目前为止，有6000名患者。然而，该中心的覆盖范围一直有限。它的两个地点，在曼哈顿下城 对于遭受重创的纽约市社区的大多数居民来说，东区和上西区是遥不可及的 新冠肺炎，包括哈莱姆区和南布朗克斯区的少数族裔和低收入居民。资源 包括人员配备和保护时间在内的限制限制了中心领导人扩展访问权限的能力 关爱患者，减少评估等待时间，引入实践创新并跟上 这一领域的变化。出于这些原因，我们提出了一个项目，将在邮政中心增加第三个地点- 将COVID护理整合到西奈山内科协会(IMA)在东哈莱姆区和 建立持续改进长期COVID护理的资源和流程，并在可持续的 道路。新诊所的工作人员将是在长期COVID护理方面拥有专业知识的PC提供商，一位神经心理学家， 社会工作者和健康导航员。在项目第一阶段，项目团队将创建并定期更新 指导临床医生评估和护理长期冠状病毒感染者和 将它们嵌入电子病历(EMR)。我们将为患者提供全面、高度的 以患者为中心的协调护理，包括认知评估和护理点评估 肺功能测试、护理导航，并方便地访问基于PC的临床服务，如精神科 卫生保健和整个西奈山卫生系统的专科医生。我们将与两个社区合作- 以健康和社会服务提供商为基础，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长期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，提供全方位的护理。我们还将开发一种全面的 为专业的Long CoVID团队和当地PC提供商提供的教育计划，并收集 并对数据进行分析，以进行计划评估和持续质量改进。在项目第二阶段，我们将 培养PC医生在IMA和其他PC实践方面的长期COVID知识和临床技能 (`卫星实践)，培训他们使用嵌入EMR的CDS，并为他们提供访问Long COVID的机会 专家电子会诊和转介，以便他们可以管理复杂性较低的长期冠状病毒感染患者。

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.