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    Countless lives in Tennessee were forever changed on March 3, as a series of tornadoes destroyed homes, businesses and lives in North Nashville, Lebanon and Cookeville, as well as nearby areas.

    Ty Webb, MD, a practicing physician with Cumberland Family Care PC and chief medical officer of Tennessee’s only physician-owned accountable care organization (ACO), had been on his way to a conference in Arizona when disaster struck and had to get back to the community before airlines began shutting down flights, in lieu of the spread of coronavirus throughout the United States.

    Though Tennessee didn’t have as many identified cases of COVID-19 at the time, Webb and the Cumberland team understood it was only a matter of time before people traveling to cities would bring COVID-19 to the rural communities they serve.

    When Webb returned from Arizona, “it was like a different world,” he said. His team had built a plan to transform their offices to protect staff and patients alike, including converting an employee-only entrance as a new sick-patient entrance, and cordoning off the exam rooms and office immediately adjacent to it so that well visit patients could still be seen in another area of the building.

    The staff asked patients to stay in their cars to check in via phone. Once ready, a door monitor was stationed to screen patients as they came in — taking their temperature and asking about COVID-19-related symptoms — before bringing them to an exam room.

    With a closed medical spa adjacent to the office in a separate building, the Cumberland team converted the space — normally used for a massage therapist and aesthetician — for patient screening and wellness visits.

    New approaches: Telehealth and “fresh air visits”

    With all this change afoot, White County was hit with another storm two weeks after the tornado, which necessitated several days of work to clean up damage in the area. Through all this upheaval, patient volume dropped substantially — as low as about 40% of normal levels.

    Thankfully, it was around the regulatory waivers were implemented, allowing the practice to begin offering telehealth services, which substantially helped the practice stay afloat. “Primary care practices typically run on extremely thin margins, razor thin — if you take a 10% drop in visits, [it’s] going to threaten the viability of a practice,” Webb said.

    In addition to the critical role of telehealth to boost patient volume, the Cumberland team put up a carport on the side of the office for curbside visits, which they called “fresh air visits.” Typically, two kinds of patients showed up for these visits:

    1. Sick patients whom they didn’t want in the building to reduce exposure risks
    2. Patients who didn’t want to come into the building due to exposure worries who otherwise required a physical examination that didn’t lend itself to a telehealth visit.

    Additionally, telehealth was not an option for some patients, given that bandwidth and internet access remain limited in many of the rural areas served by Cumberland. The all-independent, primary care ACO — composed of family physicians, internal medicine physicians and some pediatricians — has offices in 27 counties in Middle Tennessee, but data shows that it actually covers patients in 77 of the state’s 95 counties, or roughly 500,000 patients. As Webb noted, any one physician may see patients from a seven- or eight-county region.

    On the same page

    What Webb found startling about the ACO’s response to COVID-19 was the uniformity across so many physician clinics, especially with how rapidly the country was reacting to the pandemic. “The information was changing literally about twice a day,” Webb said. “It was far too rapid to effectively communicate with everybody all at once. … [Yet] we saw all of these physicians and their staffs independently make the same decisions to protect their staff and their patients,” such as creating sick entrances and enforcing mask usage.

    “As we started talking with one another over the course of that first week and a half, we found that everybody did it all at once,” Webb added. “By nature, a rural practice has to be very diligent … and because of that, everybody was ready to move forward at the same time.”

    That resilience was also reflected in efforts to have masks made locally and bringing in sanitizer being produced by the Jack Daniel’s Distillery, as well as helping to cover some employees’ expenses after some were displaced from homes damaged by the storms.

    Webb said this focus on the team drove so much of the work. “Team strength is everything,” Webb said. “Medical care is complex. … Even though it's romantic to think that one doctor and one nurse can take care of a community, that's not the way it works. It requires a team to take care of patients, and we find that physician-led teams are the most effective teams.”

    Webb credited the nonphysician providers, his practice administrator and dozens of employees to keep operations and care delivery going despite the resource limitations for rural primary care. The right mix of leadership, organization, community and flexibility made the difference, he noted. “We've got wonderful people,” Webb said.

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