Maryland's Integration of Public Health and Primary Care During the COVID- 19 Pandemic: Case Study and Lessons Learned

Abstract

The Maryland Primary Care Program is a statewide advanced primary care program that works directly with practices to transform healthcare delivery by managing chronic disease, preventing unnecessary hospital utilization, and integrating with the public health system. The Maryland Primary Care Program has demonstrated how linking the public health system to primary care practices, paired with strategic financial and resource investments in primary care, can enable the delivery of high-value care and reduce acute hospital utilization. Such a system is especially prudent when responding to crises. Throughout the COVID-19 pandemic, the Maryland Primary Care Program was able to capitalize on existing infrastructure to quickly engage primary care in a robust pandemic response. Successes of this relationship included early and consistent communication channels, as well as coordinated resource distribution. In particular, this partnership allowed primary care providers, the most trusted source of healthcare in patients' lives, to directly provide patients with health information and vaccines. Now comprising more than 500 practices, this vaccine program uses data-driven reports to facilitate intentional vaccine outreach. The program has enabled a more equitable vaccine distribution system, resulting in over 400,000 vaccines administered in Maryland counties. The effectiveness of Maryland's integrated response indicates that partnerships between public health and primary care will result in an effective response in future times of crisis.

Introduction

The COVID-19 pandemic response across the United States has largely focused on individual-level actions, such as masking, testing, therapeutics, and vaccination.^1,2 Federal, state, and local jurisdictions have played a critical role in ensuring communities have adequate and equitable access to these resources.^2-4 The state of Maryland not only focused on individual-level actions but also provided guidance on community-level actions, in particular by leveraging primary care. Maryland is home to the Maryland Primary Care Program (MDPCP), an advanced primary care transformation program encompassing over 500 primary care practices statewide.^5-6 The broad span of the MDPCP allowed the state to systematically integrate primary care and public health activities. As the pandemic wore on, the relationship between primary care and public health grew stronger to the benefit of Marylanders. In this commentary, the impact of the integration of public health and primary care will be further explored to inform other states considering the integration of primary care and public health.

The MDPCP is a voluntary program created and managed by the Center for Medicare and Medicaid Innovation and the state of Maryland, with 2023 marking the beginning of the program's fifth performance year.^7-8 The MDPCP provides funding and resources to participating practices to support them in achieving healthcare transformation to team-based advanced primary care.⁸ Participating practices are directly supported by the Program Management Office of the Maryland Department of Health (MDH), including practice transformation coaches who work directly with practices to address questions, provide technical support, and coordinate resources.⁷ These designated practice transformation coaches serve as a direct connection between participating primary care practices and MDH.

In the MDPCP's first 4 performance years, primary care practices successfully used the additional investment and support to improve the rate of patient follow-up after emergency department visits by 75% and nearly tripled the percentage of beneficiaries enrolled in longitudinal care management.⁹ Additionally, practices have seen vast improvements in behavioral health integration, including implementation of screening, brief intervention, and referral to treatment workflows, an evidence-based approach to substance use prevention and intervention, in over 350 participating practices.⁹ In its first 2 years, the MDPCP also showed a cumulative program savings of approximately US$16 million.¹⁰ These encouraging health and financial indicators, along with strong quality measure performance, provide evidence supporting the value of integrating public health and primary care.¹¹

Beyond transforming primary care, the COVID-19 pandemic tested the effectiveness of the relationship between primary care and public health in Maryland during a real-time public health crisis.¹² Early on in the COVID-19 response, it became clear that the existing partnership between MDH and primary care practices was beneficial. As we approach the fourth year of the pandemic, it is important to evaluate the MDPCP's crisis response model and consider the successes, challenges, and lessons learned for future collaboration between primary care and public health.

Successes

Trusted Relationships Between Public Health and Primary Care Practices

The COVID-19 pandemic emerged during the MDPCP's second performance year (2020). At that point, MDH had been working for over a year to build relationships with nearly 500 primary care practices across the state. This work included support for care transformation, prevention, and other advanced primary care components. Thus, prior to the onset of the pandemic, MDH had built strong, trusted relationships with practices and providers in alignment with the American Board of Internal Medicine Foundation's Building Trust initiative framework.¹³ This was evidenced by the following testimonial feedback:

I just wanted to say that my coach […] has made it easier for me to understand and implement the process. It has been great knowing that there is someone behind me, whom I can call to guide me. (Provider at an MDPCP practice)

Patients have expressed their gratitude for the MDPCP […] program in their community and oftentimes ask me if this program exists in their family and friends' primary care facilities. Patients appreciate the resources and being able to directly speak with someone on their behalf with concerns at home that affect their healthcare. I have noticed with resources, patients are participating more with follow-up appointments and completing preventive measurements. (Patient liaison referral navigator at an MDPCP practice)

This existing trusted relationship between primary care practices and MDH established a solid foundation for an integrated pandemic response.

Consistent Communication Between Public Health and Primary Care Practices

When COVID-19 began impacting Maryland, primary care providers turned to MDH for guidance, resources, and information. In turn, MDH gathered and curated key pandemic data and relevant clinical guidance to share through well-established lines of communication. At the earliest stages of the pandemic, MDH held daily webinars to provide trusted information and updates to practices, as well as an opportunity for providers to query public health experts on a host of topics.¹⁴ As the pandemic progressed, these webinars provided information on topics such as COVID-19 epidemiology, testing strategies, identification of vulnerable beneficiaries, safe office workflows, vaccine information and distribution, and health equity data.

From March 2020 through September 2023, MDH held over 125 webinars with over 20,000 total attendees.¹⁵ Attendees shared the following feedback on the webinars:

I think the program has been a great help guiding all of us through the COVID-19 crisis. I especially feel that the seminars that were provided to us at the beginning of the crisis were the most helpful. They helped my staff and I understand how to glide through this whole process, making this challenging time a lot smoother for everyone. (MDPCP provider)

These succinct update webinars for physicians have been extremely helpful. In particular, the updates on testing priorities, expectations of the ambulatory care providers, availability of PPE [personal protective equipment] with use priorities, and future strategies for reentry into society. (MDPCP provider)

MDPCP's leadership and practice coaches are dedicated to supporting providers succeed with their multiple training opportunities and weekly COVID-19 updates. It is clear that the team cares for the dedication of both patients and providers throughout the state of Maryland. (MDPCP administrator)

These webinars provided a trusted and current source of scientific and public health communication to providers in a time of misinformation and confusion.

In addition to holding webinars, MDH also distributed a weekly email update sharing succinct, need-to-know information. As of September 2023, over 1,350 primary care providers and support staff in Maryland subscribed to the weekly email.

The preexisting relationships and communication streams that had been developed through the MDPCP laid the foundation for rapid communication on the pandemic status and response from MDH to primary care providers.¹²

Coordinated Resource Distribution

Soon after MDH worked to share information and updates, the priority switched to facilitating the distribution of resources, such as personal protective equipment and point-of-care tests. Relationships were built within MDH in an effort to ensure that primary care practices would be able to request and receive supplies quickly and at no cost to practices. As of September 2023, over 325 primary care practices have received free point-of-care test kits (totaling over 137,000 tests) from MDH to rapidly diagnose patients. This resource was especially critical at a time when point-of-care tests were not readily available commercially.

Early on in the vaccine rollout, when vaccine supply was scarce, MDH advocated for the rollout of COVID-19 vaccines to primary care practices to reach their most vulnerable patients. As trusted healthcare providers, primary care practices were able to reach more vulnerable patients early and overcome patient hesitancy. In March 2021, Maryland became one of the first states to mobilize primary care practices in the vaccine rollout, which was only possible due to the existing foundational integration of primary care and public health.¹² When vaccines became more widely available, practice transformation coaches and other team members of MDH were able to work directly with primary care practices to onboard them as vaccinating sites.

As of September 2023, more than 520 primary care practices in Maryland have served as vaccinating sites and have collectively administered over 625,000 COVID-19 vaccine doses to Marylanders. This initiative includes rural and urban practices, independent practices and health systems, and practices in every county in the state. MDH routinely tracks primary care vaccination data, including cumulative vaccines administered and breakouts by race and ethnicity, enabling practices to analyze vaccine access and determine where gaps in care may exist.

For example, when vaccines were rolled out in 2021, it was evident that vaccine uptake in the Latinx community in Maryland was significantly lower than in other communities. Through established relationships, MDH had existing communication channels with many primary care practices, as well as visibility into the patient populations that these practices served. With this information, MDH was able to quickly identify primary care practices for a focused vaccine effort, particularly those that served primarily Latinx populations. MDH worked closely with these practices to ensure they had vaccine supplies, information and education, and other tools to bridge the gap and bring vaccines to an undervaccinated population. The team at MDH understood the importance of primary care and were therefore natural advocates for primary care practices to receive essential resources early, such as vaccines and point-of-care tests, instead of these resources only going to hospitals or pharmacies.

Vaccine Tracker That Enables Data-Driven Vaccine Outreach

In addition to distributing vaccines directly, MDH collaborated with Chesapeake Regional Information System for our Patients, Maryland's health information exchange, to develop ImmuTrack, the state's vaccine data tracker.¹⁶ ImmuTrack receives a data stream from ImmuNet, Maryland's Immunization Information System, and presents these data on a practice-level dashboard, which allows providers to view the vaccination status of each of their patients and to see summary data at a population level disaggregated by key demographics. The tracker includes information on each COVID-19 vaccine dose that a patient has received and where the patient obtained that dose.

ImmuTrack has allowed primary care practices to access real-time data at a population level, filter their patient lists to identify patients who are unvaccinated or unboosted and need outreach, and plan immunization care accordingly. Changes in vaccine guidance have been translated into updates to ImmuTrack, further allowing providers to continue care based on the most recent guidance. ImmuTrack also has allowed practices to view their vaccine performance by various demographics—including race, ethnicity, age, and sex—compared with the state's overall and their peers' performance.

MDH was able to develop and roll out ImmuTrack by sharing state public health data down to primary care, enabling intervention at the primary care level.

Primary Care-Specific Technical Assistance Resources

Throughout the changing stages of the pandemic, MDH created technical assistance materials for primary care practices, specific to their role in the pandemic response.¹⁷ Early on, MDH recognized the need to support telehealth workflows and a transition to virtual care in primary care settings.¹⁸ The Maryland Department of Health thus provided infrastructure support, including access to free telehealth platforms, to ensure primary care practices could continue to see their patients and respond to the pandemic. In addition to providing infrastructure support, MDH also developed guides on telehealth so primary care practices could quickly begin telehealth services and prevent disruptions in care.

At the end of 2021, the MDPCP developed the Triple Play Strategy, a framework that communicates the 3 keys to COVID-19 mitigation in primary care: vaccines, testing, and therapeutics.¹⁸ These are essential activities that every primary care practice is encouraged and supported to perform.¹⁸ The Triple Play Strategy is a critical framework for focusing energy and resources amid an ever-changing landscape of COVID-19 variants.

MDH created specific technical assistance guides and materials to support primary care practices to implement the Triple Play Strategy. As guidance changed (eg, on vaccination eligibility, preferred therapeutics for referral), the team updated materials and guides to communicate up-to-date information for practices to quickly reference. MDH also developed, and assisted practices in implementing, many specific primary care tools to support the Triple Play Strategy, including a point-of-care testing guide, vaccine guides, a therapeutics technical assistance toolkit, communication tools (including 1-pagers), and social media templates.

Challenges

Administrative Burden

In addition to highlighting the successes, it is also important to consider the challenges posed by the pandemic on the relationship between primary care and public health. A challenge in integrating primary care into Maryland's pandemic response was the administrative tasks associated with primary care practices providing telehealth services, administering vaccines, offering testing, and providing or referring to therapeutics. For example, in order to become a COVID-19 vaccinating site, practices had to register as a site, obtain and report on proper equipment such as refrigerators, and report vaccine administration within 24 hours via their electronic health record system or secure upload. For therapeutics, providers had to fill out a detailed referral form to send a monoclonal antibody referral. While many of these administrative tasks were necessary to ensure safety and efficiency, the tasks were barriers for some primary care practices, particularly smaller practices that had fewer staff members and less infrastructure to handle the tasks. To facilitate primary care providers overcoming these barriers, MDH created simple instructional guides and provided 1-on-1 support for practices in completing tasks, such as registering as a vaccinating site. However, some primary care practices still had lower levels of pandemic response activities due to these administrative burdens.

Workforce Shortages and Turnover

Burnout has been a major challenge for the entire healthcare system throughout the COVID-19 pandemic.^19,20 The uncertainty around COVID-19 early on led to heightened concerns and anxiety among healthcare practitioners, and Maryland's primary care workforce was no exception. A study of burnout among US physicians, including primary care providers, found increased rates of physician burnout in the first year of the pandemic, with the highest study rates being among hospitalists and primary care physicians.²¹ As the initial uncertainty of COVID-19 began to wane, virus variants began to change more frequently and required a change in recommended treatment options. These frequent changes have also led to a level of uncertainty, and at times, providers were required to change protocols. Practices and primary care staff in Maryland were greatly impacted by burnout attributed to COVID-19, and MDH staff experienced this, but to a lesser extent. The unprecedented level of burnout in primary care led to increased turnover and a decreased public health workforce across the country, including in Maryland.

The US primary care workforce had been declining for a few years, which was further exacerbated by COVID-19.²² It is important to note that a large proportion of the current primary care workforce is nearing retirement ages, indicating that there likely will be another large decline in this critical area of healthcare soon. An American Medical Association study published in 2022 indicated that a large portion of excess annual healthcare spending was attributable to primary care provider turnover, further exemplifying the impact of this issue.²³

The turnover of primary care providers and support staff impacts not only overall healthcare expenditures, but it can also increase stress and burnout among staff members who stay at the primary care practice. COVID-19 directly inflated burnout in primary care, which increased turnover and workforce shortages. Limited staff in primary care practices impacted the practices' ability to perform public health response activities, such as administering COVID-19 tests in the clinic and providing vaccines, which further restricted the practices' capacity to respond to COVID-19 and other future outbreaks.

Lower Than Predicted Uptake of Short-Term Vaccination Campaigns

Many of the technical assistance and resources shared by MDH were effective tools for primary care practices. One component that was less effective was short-term vaccine campaigns. MDH launched a handful of monthlong vaccine campaigns. The aim was to mobilize practices to conduct outreach to unvaccinated or unboosted patients and facilitate vaccine appointments through a concentrated, short-term effort by providing data on practices' vaccination rates and targeted goals for outreach to vulnerable populations. Although these campaigns resulted in additional vaccinated and boosted patients, the vaccination rates during the campaigns were only slightly higher than those during noncampaign months, failing to reach ambitious targets set by MDH and preventing the department from reaching its goals for Marylanders to receive lifesaving vaccines. Supporting practices to continue vaccination outreach and administration in alignment with other primary care delivery seems to be a more appropriate and effective approach than relying on time-limited public health-run campaigns.

Moving Forward

Over the past few years, the pandemic response in Maryland has constructively utilized primary care to provide a well-informed and supported ground-level response to COVID-19. This is largely due to the foundation established by the MDPCP, which has created a strong relationship between public health and primary care.^8,11 Early in the pandemic, MDH was able to quickly fill an information gap, which created a positive reinforcement loop between public health and primary care. The increased COVID-19 information and support led to a stronger partnership, a key component of Maryland's pandemic response.

A critical component of the successful response included the relationship with Chesapeake Regional Information System for our Patients, which allowed MDH to use a data-driven lens when creating resources for practices. Real-time data from ImmuTrack enabled MDH and providers to view an accurate snapshot of vaccine uptake. Equity reports on vaccine uptake also allowed MDH to identify gaps in vaccine access, in turn resulting in equity-focused responses.

Over the past few years, the MDH team has grown in order to better support the pandemic response. It now includes dedicated team members who are subject matter experts in vaccines, testing, and therapeutics. These team members have expanded COVID-19 education for primary care, including clinic workflows, US Centers for Disease Control and Prevention recommendations, and use of data, including data from ImmuTrack.¹⁶ Additionally, this expanded team is able to focus on resource deployment, respond to inquiries, and address any issues.

In addition to the successes of this strategic response, there were also lessons learned. MDH ensured commercials and larger educational efforts were available in both English and Spanish. In future public health responses, it will be critical to ensure all patient-facing educational materials are available in multiple languages, beyond just English and Spanish.

A major lesson learned from looking back at this pandemic response is the importance of building a strong relationship between primary care and public health, both during and outside of crisis scenarios. Establishing this relationship before the crisis scenario of the pandemic allowed a swifter and more streamlined crisis response. The integration of public health and primary care will serve Marylanders well for future pandemics, but this can also be applied in other public health work areas, such as diabetes and hypertension prevention. Additionally, the COVID-19 pandemic shed light on the impact of individuals' social risks, such as food insecurity and housing instability, on outcomes. This is an area ripe for solutions that involve partnerships between public health and primary care and will be a major focus for practices moving forward. Integrating these 2 cornerstones of healthcare is a critical step in improving and sustaining the healthcare delivery system in the United States. Moving forward, the success of Maryland's framework of primary care integrated with public health can serve as a model for other state and local public health entities.

Conclusion

Maryland's integration of primary care with the state public health department during the COVID-19 pandemic successfully enabled the primary care workforce to contribute to the public health response. Integrating these 2 cornerstones of healthcare is a critical step in improving and sustaining the healthcare delivery system in the United States. Notably, the success of Maryland's framework of primary care integrated with public health can serve as a model for other state and local public health entities. As many states are taking legislative or regulatory steps toward increasing funding for primary care, this is a timely opportunity to include elements of public health and primary care integration into the nascent statewide programs.

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