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Michael Carrese: We're all understandably focused these days on the Corona virus, but that vigilance shouldn't come at the expense of paying attention to preventing other diseases, managing health conditions you may already have and getting the care you need. Health providers are particularly concerned that people are not seeking care due to fear of contracting COVID-19 and healthcare facilities, or that they're straying from the routines.

They should follow to manage their health. And there's also concerned about those at risk for social isolation and communities that were already facing challenges. With regard to housing and food insecurity, substance use, and other barriers to health. So today we're going to talk through these issues with Dr.

Rob DeMuro he's medical director of primary care at the university of Vermont health network, Elizabeth town, community hospital, and Lindsey Morris, director of care coordination for the UVM health network. Welcome to you both.

Lindsay: Thank you.

Michael Carrese: So Dr. DeMuro let’s start with you. So there has been this widespread concern throughout the pandemic about people delaying care. There's been some statistics to indicate that. Can you talk about what's happening on the ground there in Elizabeth town, your region, and what your guidance is to patients about that?

Dr. DeMuro: Yeah. So early on in the pandemic, I would say it was more the health care institutions that shut down care and said to people, Hey, let's, you know, let's have it. Stayed home. Wait this out. Let's see what happens over the next few months. And that was really the spring of this year. and, at that time we will, we got into a zoom visits.

We weren't doing any, telehealth video visits for primary care. So that was tremendously helpful at that time. and also where we're doing phone visits, which I think we achieved quite a bit, with, so, so that was a little different from, then we had kind of a return to normal in the summertime, and then we would get some spikes, here and there of cases, which then kind of shifted things and made the patients, more self-select of whether they want to go out and seek care.

And, the, we, we, a five did some of those spikes were in very localized, well contained areas, but it was interesting from a primary care point to see that, patients often would group things together in a region, they would say all of that town is riskier or that County is riskier. And. And so they look at it a little differently.

So no, I would say was it, it's a few days of, of a reduced census when you pick up on the fact there's that, that heightened fear, a lot of people didn't talk about it, but, then when you would bring it up, you'd get that sense that they were avoiding certain areas. And even in Elizabeth town, it's interesting that, people would be very comfortable going to one building on one side of the street.

but a building on the other side of the street, they would be a little more cautious. So I think we learned a lot about sort of human nature, human dynamics in, in those scenarios. Um,

Michael Carrese: what guidance do you have for patients? What can they expect when they come to the hospital or to your office, other clinics in terms of precautions being taken and what they should be doing?

Dr. DeMuro: Yeah. So, I remind them that we have been a vigilant really from the start. you can't come in any of these facilities without wearing a mask, hand sanitizer everywhere. you're getting your temperature checked, whether you come into the health center, whether you go into the hospital. so, I think we're following the guidelines that all facilities are and it's really worked out well.

You know, we've had very few, outpatient positives in the community. And I try to reassure people that there is not this greater risk of, going to the hospital to have a lab drawn compared to going into Stuart's and getting their coffee. and they just need to think of all those places as being some level of risk and taking the appropriate precautions.

and then I think they'll do well.

Michael Carrese: Yeah, that's a good message. So, Lindsay, you know, there, there is this other, group of folks who may not be getting care, not because of concern about going to facilities, but because there's other obstacles in the way. So can you talk a little bit about those folks that you have in mind and how the UVM health network is trying to support them in these times?

Lindsay: Well, we did see you earlier on during this pandemic that obviously transportation, was a part of the issue. It was a barrier even before the pandemic and has. Then since and even more so for our rural populations, I think this was a caveat for us to really utilizing for care coordination efforts, zoom and telemedicine, then other options to do outreach and ensure that we are still doing consults and supporting.

And we really, worked with our community partners, including like the two, one, one and other solutions as we saw people who were already, Working and navigating chronic conditions, which are complex in themselves. And now they had increased risk due to isolation, lack of access. They fell because of transportation, in some cases, and with our pediatric populations being seen in the school setting.

So we were fearful of those. So we did a lot of purposeful outreach and engagement across suppose steps to ensure that we were, Touching and letting people know that we're still here. It's just, it might be a different variety, but even I think the phone call and some of the hours reach done with some of the ACO, Stratifications and Epic.

And some of our electronic medical records really, tools gave us direction on who is at risk for not just COVID, but also for these isolation and high-risk conditions. So we did engagement and it was really, Great to hear the patients say, thank you for calling. Thank you for checking in on me. And, yes, I haven't been in, and here's why I haven't engaged.

And we were able to help support them and getting to the resources, even on a local basis in the rural setting to help them navigate whatever their individual need was. So I think, care coordination is even more important now than it ever was.

Michael Carrese: And what, what can you do about an obstacle like transportation or, people not having a safe place to live. And those, those are pretty big obstacles.

Lindsay: They are. And I think that's where really our hospital and community collaboratives and our in relationships and engagements have been key, not only prior to this, but even more so now where we look at how our communities are working with ahm, Patients who have in stable or unstable housing options or feel that they can't get to their substance use supports and how do we help bridge them.

And if it is truly just transportation, working with some of our transportation options that yeah. We weren't able to utilize before and getting creative. and I think it's been really impressive and watching and utilizing all the different waivers that have come in place. and these barriers that have been systematic for a long time and having those removed was huge.

So, some of the criteria is, and barriers that CMS guidelines and other things that were in place. That, again, we're under waivers right now, has been instrumental in us delivering care.

Michael Carrese: So Dr., you know, a lot of primary care is helping folks with, chronic conditions, to, to manage those as best as possible. So in this time of enormous disruption in people's daily routines and in many, many other ways, economic stresses and so forth, what is your message to people about how to stay on track with all that?

Dr. DeMuro: Yeah. I mean, certainly it's looking at each, patient truly as an individual and what are their coexisting medical conditions and, you know, what, what kind of testing do they have within the past six months? Because we can't really lump all diabetics together and say, you know what it's okay to wait this much longer for recheck on your lipid.

So your A1C, because some people, do need it sooner and we find the services to do that, but there are many where we can look at it and say, you know, and I know we might normally do that every three months, but every six months is fine, but we have other ways if I use the diabetic, for example, if they.

send me secure, glucose readings, and, we can use that technology. So just keep a little closer eye on him without doing the services that they have to come out for. so there's a lot of chronic conditions, even blood pressure readings for somebody with, hypertension, they can, they can send, we don't always need an office visit for those.

And sometimes just. Using technology to send those to us can be very helpful to keep up on that. You know, one of the surprising things that I saw was when a lot of people were home and out of work, there was still a big drop off on physical activity. And that was, that was a bit frustrating to see. A lot of people would come in with weight gain and say, you know, there was this.

The with COVID. I, I didn't, I didn't do as much activity, so, and I think that's a little overlay from just the mood and the stress that, that occurred with this. And it carried through to people’s active lifestyle.

Michael Carrese: Yeah. And also wintertime at the same time where some folks don't get out as much as other times of the year, Lindsey. I want to, you know, on that, complex conditions, topic, let me restate that. So, Lindsay, another thing I touched on at the beginning and haven't asked you about yet, and you mentioned briefly was folks dealing with substance use disorder.

There was obviously an epidemic of that in Vermont and around the country heading into the pandemic. And there's been a lot of concern that, you know, that's been overlooked somewhat, and that it's been more difficult for these folks to get the treatment they need. What can you tell us about that?

Lindsay: so we have a hub and spoke model throughout the state. and what we actually have seen is we've been able to continue from the, Matt team as medication assistant therapy, team, the nursing and the social work component have been able to navigate through using, telemedicine, telephones, zooms, anything they can to continue.

Engagement with those patients and walk them through the resources. We were at a period, right? Where resources were shifting all the time of who was open when they were open and how they were delivering care. And we took on that burden of navigating. What are the resources, what is available and making sure that we were communicating with our patients that we were caring for?

Right. And within that we are, as patients have been pulled in more and more into the clinics in person, we're navigating how best to support those patients, that a tele visit or telephone isn't enough and they need additional in-person supports. And how can we do that safely? And with the guidelines that doctor Damara was speaking of and implementing those.

So we can make sure that all the patients get the support they need through this. And I will say that there are. The advantage or the silver lining through it as well is we were struggling with some of our patients who are rural and receiving this therapy and connecting them because of the transportation in and out and driving.

And some do not have the ability to drive and need public transportation. There's a lot of other factors and this actually allowed. Increased and enhanced engagement with those patients that actually really benefited them. So, I think for all the hardships it's shown, it's also shown that the maturity of the program and was able to meet the, the flexibility that needed to be happening.

Michael Carrese: You know, I'd like to get just a general assessment from each of you about how you think, your communities or your areas of focus in terms of populations are doing with this. And then I want to do a little bit of a look ahead, but Dr. DeMuro what you know, with all of this that we've been talking about, where do you think things stand in terms of the folks that, that rely on Elizabeth tack community hospital and UVM health network in your region?

how are they doing.

Dr. DeMuro: Yeah, I think people are doing well. Actually, if, if you had to paint this scenario prior to this occurrence and say what we would expect, I would say things. Better than I thought people have certainly embraced the notion of protecting themselves by wearing the mask and protecting others. when I talk about things like zoom and tele-health, I didn't know how many people would push back on that.

And I didn't have a single patient that found those things frustrating. If anything, they loved it, they embraced it. They wanted to keep using those technologies. So I've been quite pleased with how our community has. So responded to this and, and I think they recognize that if they all work together, it does make for a much, a much safer environment.

Michael Carrese: Lindsay. What's your big picture. Look at this.

Lindsay: I would agree. And I think where my takeaways really are from the big picture is the hospital and community collaboration and relationships and leveraging of what each of us has. Bring to the table and do really well, has been key and managing all of us and all of our patients and our families and our personal lives as well.

And I think having the school's back in session that, yes, there were many. Different flavors of how people feel about that. But having our kids being seen and getting assessed and getting screened and, food security in place, all of those things have been, great and highlighting the relationships between all of the state functions, our County functions schools.

It's been pretty awesome to watch everybody work together on this mission of each other. And, So I would agree overall. I would say it is as positive as that. I think it could be with the circumstances of, such a huge amount of change management happening during, you know, crisis management.

Michael Carrese: So looking ahead as we're wrapping up here, you know, we're speaking at the end of September, that means in our region, winter starts in about 10 minutes and there's a lot of concern about. Flu season about additional spikes with coronavirus. I want to get a sense of, you know, where you're at, thinking about that and were what you would say to, the people of this region about heading into the winter,

Dr. DeMuro: Why I think that, yeah, I think that just wearing the mask common sense would be, it should make the flu season safer. the problem is I've had some patients who think. Well, we're all wearing masks. Maybe I don't need the vaccine. So that's, that's been a conversation where I'm struggling with a little bit.

A lot of people are embracing the idea of getting the flu vaccine, but some people just look at it a little differently. So just trying to educate them on things safe in that regard. I think, you know, if, if there's no significant of the virus, our next three to four months, regarding spikes in general, prevalence will probably be the same as what we've seen over the last few months.

And I think we're all just eagerly waiting for vaccine. And I think most people in the medical community feel that's, what's going to be the real game changer here. you know, and then the other interesting part of the conversation is. Dealing with so much political misses information that, that patients bring into the office visit and want to discuss.

And, and there's a, there's a desire to stay away from that stuff as much as possible, but at the same time to educate patients and say, here's what we know from a science standpoint. let's be careful about learning things from our, cable channel news sources.

Michael Carrese: So, Lindsay, it sounds to me that, you know, a lot of systems relationships are in place to have gotten, folks through this, to this point. And you can rely on that, I assume, going forward. Is there anything else you think that is needing or that you guys are trying to build or work on? as you head into these next few months,

Lindsay: I think with every decision that I'm making it in guiding of my teams is really, do we still have the built-in flexibility? Cause I have decided that my crystal ball is not working very well these days. And so I think being flexible for whatever the world is gonna throw at us is really important.

So I think we also learned that we can't be too rigid. Right. Where do I can't say a hundred percent X needs to happen? you have to have that flexibility of like, okay, if we do have to go back more to more, to more remote to be able to safely provide care, what does that mean? Like, so we, paint ourselves into a corner.

So I think I'm incorporating flexibility during this time is really important. And I agree with everything that he just shared of like, Wear the mask use common sense. do the research, understand your sources? And I think we also will continue our outreach. Right. of recognizing those who are missing appointments, those who've missed their annual follow ups and we were already worried about their care, currently.

And how do we do purposeful engagement to make sure that everybody's brought into the fold and not avoiding of the healthcare system? Cause that would be awful.

Michael Carrese: Yeah, right. You don't want that. And it does seem to me like Fletcher, flexibility's a good watch word for everybody involved on the provider side and the patient side as well. I'm afraid to say left and leave it there, but I want to thank you both very much for being with us today. We've been talking to Dr.

Rob DiMuro medical director of primary care at the university of Vermont health network, Elizabeth town, community hospital, and Lindsay Morris director of care coordination for the UVM health network. Thanks very much.

Dr. DeMuro: Thank you.

Michael Carrese: For more information, please visit UVM health.org/coronavirus. Thanks for listening.