A Model for Rapid Transition to Virtual Care, VA Connecticut Primary Care Response to COVID-19.

INTRODUCTION: Traditionally, health care delivery in the USA has been structured around in-person visits. The COVID-19 pandemic has forced a shift to virtual care models in order to reduce patient exposure to high-risk environments and to preserve valuable health care resources. This report describes one large primary care system's model for rapid transition to virtual care (RTVC). SETTING AND PARTICIPANTS: A RTVC model was implemented at the VA Connecticut Health Care System (VACHS), which delivers care to over 58,000 veterans. PROGRAM DESCRIPTION: The RTVC model included immediate virtual care conversion, telework expansion, implementation of virtual respiratory urgent care clinics, and development of standardized note templates. PROGRAM EVALUATION: Outcomes include the rates of primary encounter types, staff teleworking, and utilization of virtual respiratory urgent care clinics. In under 2 weeks, most encounters were transitioned from in-person to virtual care, enabling telework for over half of the medical staff. The majority of virtual visits were telephone encounters, though rates of video visits increased nearly 18-fold. DISCUSSION: The RTVC model demonstrates expeditious and sustained transition to virtual care during the COVID-19 pandemic. Our experiences help inform institutions still reliant on traditional in-person visits, and future pandemic response.

Combined effects of a valgus knee brace and lateral wedge foot orthotic on the external knee adduction moment in patients with varus gonarthrosis.

OBJECTIVE: To test the hypothesis that a custom-fit valgus knee brace and custom-made lateral wedge foot orthotic will have greatest effects on decreasing the external knee adduction moment during gait when used concurrently. DESIGN: Proof-of-concept, single test session, crossover trial. SETTING: Biomechanics laboratory within a tertiary care center. PARTICIPANTS: Patients (n=16) with varus alignment and knee osteoarthritis (OA) primarily affecting the medial compartment of the tibiofemoral joint (varus gonarthrosis). INTERVENTIONS: Custom-fit valgus knee brace and custom-made full-length lateral wedge foot orthotic. Amounts of valgus angulation and wedge height were tailored to each patient to ensure comfort. MAIN OUTCOME MEASURES: The external knee adduction moment (% body weight [BW]*height [Ht]), frontal plane lever arm (cm), and ground reaction force (N/kg), determined from 3-dimensional gait analysis completed under 4 randomized conditions: (1) control (no knee brace, no foot orthotic), (2) knee brace, (3) foot orthotic, and (4) knee brace and foot orthotic. RESULTS: The reduction in knee adduction moment was greatest when concurrently using the knee brace and foot orthotic (effect sizes ranged from 0.3 to 0.4). The mean decrease in first peak knee adduction moment compared with control was .36% BW*Ht (95% confidence interval [CI], -.66 to -.07). This was accompanied by a mean decrease in frontal plane lever arm of .59cm (95% CI, -.94 to -.25). CONCLUSIONS: These findings suggest that using a custom-fit knee brace and custom-made foot orthotic concurrently can produce a greater overall reduction in the knee adduction moment, through combined effects in decreasing the frontal plane lever arm.

Team-Based Hypertension Management to Improve Blood Pressure Control.

OBJECTIVE: Hypertension is the most common condition seen in primary care, occurring in 1 in 3 adults in the United States. The patient-centered medical home provides an opportunity for proactive, team-based care of hypertension. The purpose of this pilot study was to measure the effectiveness of a team-based approach to blood pressure management in a busy, primary care setting. METHODS: Using panel management within 2 primary care clinics, a cohort of patients with blood pressures >160/100 mm Hg, was identified. The patients at 1 clinic were contacted by the primary care team and offered multiple interventions aimed at improving blood pressure control; including discussion of medication compliance, medication titration, home blood pressure monitoring, nutritional counseling, and motivational interviewing. The change in blood pressure for these patients at 4 months was compared to a parallel primary care clinic within the same medical center whose patients were treated with usual primary care. RESULTS: A total of 350 and 315 patients were included in the intervention and usual care cohorts, respectively. At 4 months, the decrease of systolic blood pressure in the intervention group was significantly greater than in the usual care group (15.6 vs 9.9 mm Hg; P < .001). Sixty-two percent of patients in the intervention group had lower systolic blood pressures post intervention, compared with 41% of usual care patients (P < .001). Reduction in diastolic blood pressure occurred in 54% of intervention patients, compared with 37% of usual care patients (P < .001). CONCLUSIONS: Our findings demonstrate the effectiveness of a team-based approach to blood pressure management. This can provide a framework for implementation of team-based care for hypertension in the patient-centered medical home.