News

Push to devolve COVID care to GPs as Victoria faces huge caseload


Doug Hendrie


4/08/2020 5:19:03 PM

GPs will directly care for mild coronavirus cases under a new pilot program designed to reduce pressure on the health system as the state struggles with more than 7500 active cases.

Doctor on the phone.
GPs are set to begin treating mild coronavirus cases.

The move to decentralise care comes amid calls for clearer communication from state health authorities, and rising uncertainty among GPs over how best to manage COVID-19 patients in the community and referral pathways if patients deteriorate.
 
A pilot program run by cohealth community care went live this week ahead of an expected increase in referrals, with telehealth GPs and nurses based at an assessment centre in the Melbourne suburb of Footscray already assessing around 40 coronavirus patients isolating at home.
 
Under the pilot’s assessment protocol, those in need of acute care are referred to hospital, while those with mild symptoms have their care transferred to their usual GP – or to a participating GP for patients without a regular one.
 
Patients managed by GPs who then deteriorate can be escalated to hospital in the home management through the Royal Melbourne Hospital’s virtual ward, with their oxygen saturation able to be monitored remotely.
 
Up to 1700 COVID-19 patients are expected to pass through the system, which will cover most of Melbourne’s major hotspot areas in the north and west of the city, and outlying towns.
 
If successful, the pilot could be scaled up to the entire state.
 
The pilot brings together cohealth, the Victorian Department of Health and Human Services (DHHS), the North Western Melbourne Primary Health Network and the Royal Melbourne Hospital.
 
GP and medical epidemiologist Dr Nicole Allard is co-clinical lead at cohealth. She told newsGP the pilot represents a rapid shift towards decentralising care.
 
‘We taught GPs how to avoid and diagnose COVID, but we haven’t taught GPs how to manage the disease,’ she said. ‘We have to decentralise clinical management and make sure all GPs have the skills to assess and manage people with COVID.’
 
Dr Allard said the National Clinical Evidence Guidelines are excellent, with flow charts for mild disease. But she said the service planning focus to date has been on acute care, with ‘not enough’ on community-based care for mild disease.
 
‘Increasing GP involvement will only strengthen our system. This is the beginning of a model that can hopefully be applied across other areas in metropolitan Melbourne,’ she said. ‘This is the work that needs to be done.
 
‘As a GP, I have a lot of faith in general practice and its ability to respond to the public health emergency with which we are faced. It will draw strength to the response to have more GPs involved.’
 
The pilot emerged out of cohealth’s involvement in providing care to people affected by the hard lockdown of several inner-Melbourne public housing towers.
 
‘We set up pop-up clinics to provide primary care to people under that lockdown. That evolved into specifically caring for those who were still isolated due to COVID and that’s where the partnership with the Royal Melbourne Hospital started,’ Dr Allard said.
 
‘That was only a small geographic locality; now we have to look at a wider response.’
 
Dr Allard said GPs are excellent at upskilling themselves quickly to treat new diseases.
 
‘The best-case scenario is that people who are positive with COVID are supported through their illness, have access to both medical and welfare supports that are required to make good choices for themselves and their families, and that we identify early those who are deteriorating and refer them to acute services so they can get dexamethasone, which reduces mortality,’ she said.
 
RACGP Victoria member Dr Bernard Shiu told newsGP the pilot has come out of the ‘amazing job’ cohealth did in the towers.
 
‘It’s very important in this pandemic that we work with people. [Tackling the pandemic] requires more than legislation, it requires local relationships,’ he said.
 
GP and North Western Melbourne Primary Health Network Chair Dr Ines Rio told newsGP it has been ‘patently obvious’ GPs had previously not been brought into pandemic planning.
 
‘It’s now apparent to the [DHHS] that they need to include GPs more, and they are now genuinely trying hard to do so,’ she said.
 
‘This pilot means our first line of response for COVID-positive patients is a primary care response, with clear algorithms of care outlining when hospitals need to become involved and at what level.’
 
The pilot protocols cover:

  • patient education about the disease
  • infection control and ways to reduce infectivity
  • isolation requirements
  • support to tell close contacts to get tested
  • assessment of patient vulnerability and how unwell they are
‘This came out of us being involved in the lockdowns in the towers, when it became clear we needed a primary care response,’ Dr Rio said.  
 
Dr Rio said the plan was to roll out the pilot to cover all 1.7 million people in the North Western Melbourne Primary Health Network’s catchment area in coming weeks.

DANIELLE-MAZZA-7-Article.jpgMonash University’s Professor Danielle Mazza has called for a better interface between GPs and state health authorities.
 
‘We’re doing this because we’ve got most of the virus, but the models are applicable to the whole state – and need to be,’ she said.
 
Accessing COVID-19 lab results early is proving to be a sticking point, according to Dr Rio.
 
‘The policy should be that COVID tests are copied to the patient’s usual GP, but that is not happening at the moment,’ she said.
 
Until such time as the pilot is expanded, Dr Rio recommends the Healthpathways site for assessment and referral of suspected COVID patients.
 
The pilot comes as Victorian Premier Daniel Andrews announced that recent door-to-door checks by officials and Australian Defence Force personnel for more than 3000 people with the virus found more than 800 people were not at home as required.
 
Calls mount for clear GP treatment protocols and pathways
Monash University Professor of General Practice Danielle Mazza told newsGP guidance is sorely needed for GPs managing COVID cases.
 
‘I think we are, by default, managing mild cases. Who else is?’ she asked.
 
‘GPs are asking a lot of questions around procedures and communication.’
 
Professor Mazza called for a better interface between GPs and state health authorities, so the COVID-19 response covers primary care as well as communication to the public, and a focus on acute care in hospitals.
 
South Melbourne GP Dr Esther Belleli told newsGP it is vital that responsibilities over COVID-19 management are spelled out clearly, given the large numbers of patients currently living with the virus.
 
‘GPs need to understand how to manage their COVID-positive patients, with clear ideas around how to triage and escalate care,’ she said.

‘There are excellent clinical flowcharts by the national COVID evidence taskforce but the trouble is, as a GP, it’s challenging to work out where you sit and how those referrals should happen.’
 
Dr Belleli said one key issue is picking up patients who have begun to shift from mild to moderate cases.
 
‘Mild cases are those with no lower respiratory tract infection, while moderate are defined in part as oxygen saturation levels below a specific amount,’ she said. ‘The challenge is that GPs sit in the middle of that space and we need to pick them up before they begin to crash.
 
‘Everyone assumes that GPs would oversee mild cases and severe go to hospital, but we need clearer guidance for patients in the middle ground at high risk of deteriorating, but who may not be there yet.’
 
Dr Belleli wants the cohealth pilot to be ‘scaled up and rolled out’ as soon as possible.
 
‘We don’t all have to individually come up with our own ad hoc responses,’ she said. ‘This has come so fast, and for DHHS the scale has become so huge that they need to use the entire health workforce and provide more robust advice to primary care.’
 
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Dr Arshad Hussain Merchant   5/08/2020 7:00:16 AM

Another scapegoat excercise where GPs are drag into where specialist care cannot be provided to population.
One humble suggestion is to use army reserve paramedics and doctors and nurses to look after age care and COVID population. This will allow primary care what they do best without compromising their own health.
GPs are own business so if they will get sick or has to go in isolation, there is no financial support to survive whereas defence reserves are already paid and are covered through defence pension and compensation


Dr Michael Keng Sin Lee   5/08/2020 7:53:04 AM

For GP a to help we need hydroxychloroquine, zinc , Zithromax, dexamethasone. These have been used successfully in US for early cases of Covid. Also PPE


Dr David James Maconochie   5/08/2020 9:37:40 AM

This is one of the most stupid ideas I have seen this year.

When a patient with COVID is admitted to hospital he goes into an isolation ward and is cared for by staff who only treat COVID patients and do not then immediately go and cross infect non-COVID patients.

A single GP has the potential to cross infect hundreds of patients per day in his surgery. Many of these patients will have co-morbidities (that is after all why they are there) and will do badly.

If this is so blindingly obvious to me, how is it that those making up policy on the fly are so oblivious.


Dr Jane Alyson Aroha Wehipeihana   5/08/2020 9:56:45 AM

Oh no. Will we be provided PPE? Will there be an MBS item number? How about deploying the Armed Forces medics also. GPs are under funded, under pressure already.


Dr Michael Leonard Taylor   5/08/2020 10:39:24 AM

This is fundamental GP care for our patients
The government should allow those positive to COVID to be enrolled by their GP and Practice for 12 months of comprehensive coordinated care. The DVA model would be a good start.


Dr DK   5/08/2020 11:09:44 AM

Dr Michael Keng Sin Lee , where are you getting the idea that hydroxychloroquine has been shown to be effective (it hasn't) or that dexamethasone is appropriate for early COVID-19 (when its use is meant to be in advanced cases)? I am also not aware of zinc or azithromycin being found to offer any significant benefit. Why do you insist that they are necessary for GPs treating mild COVID-19 cases?

Of all the things that GPs can offer, accurate information about what works and what doesn't work is one of the most important. Please don't recommend treatments without a sensible basis for them.


Dr Konrad Kangru   5/08/2020 11:42:31 AM

Safe, structured and consistent clinical management of Covid19 in the community is THE key to the successes of NSW & Qld so far. Patients need confidence that, once diagnosed, they are not being left to fend for themselves battling a terrifying condition without the support of their loved ones. Please colleagues, make this program happen..


Dr Nell De Graaf   5/08/2020 1:25:32 PM

Well what a surprise-GPs may actually have a role to play in managing mild Covid care after all.
I for one want to know what funding GPs would receive for providing this care and upskilling ourselves and am not keen to expose myself to visiting any Covid positive patients unless I was paid a specialist staff salary rate with super and leave etc entitlements.
Otherwise nothing but telehealth would I do and not at the insulting mandatory bulkbilled rates either!


Dr Anthony Wai-Ip Chiu   6/08/2020 12:03:17 AM

"When a patient with COVID is admitted to hospital he goes into an isolation ward and is cared for by staff who only treat COVID patients and do not then immediately go and cross infect non-COVID patients.

A single GP has the potential to cross infect hundreds of patients per day in his surgery. Many of these patients will have co-morbidities (that is after all why they are there) and will do badly."

That's exactly why we need telehealth! We mustn't ever forced into seeing COVID face to face!

Telehealth is a must. But of course it has limitations.

If we are charged with the important task of "picking up patients who have begun to shift from mild to moderate cases", patients must be equiped with thermometers, home BP monitors and oximeters.

In addition, we need access to cutting edge telehealth technology like ResAppDx. This is a particularly valuable cough analysis tool available on the Coviu telehealth platform which is ~90% accurate in diagnosing LRTI and pneumonia


Dr Katherine Louise Hall   7/08/2020 8:02:26 AM

I agree Dr Anthony Wai-Ip Chiu.
This needs to be a TH service which will work best if patients are given access to, at a minimum, a home O2 sats monitor.


Dr Esther Belleli   8/08/2020 12:36:56 PM

As GPs we have established relationships with our patients, knowledge and TELEHEALTH. If patients have the tools at home to support remote assessment and we have the right back up and support from local hospitals to inform our decisions, then we can manage this problem as well, and safely keep patients at home. Whole patient care is part of our brief.


Dr Gobind Singh Duggal   9/08/2020 8:19:30 PM

As suggested GP's managing mild cases of Covid 19 , I think it will be helpful if clear protocol for GP's to manage Covid 19 is created and passed on.