Open Door Family Medical Center has implemented a unique “patient tracing” system that provides patients who have recently tested positive for COVID-19 with emotional, psychological, and social support, and other follow-up care.
The program’s focus is around community health needs and bridging gaps in patient knowledge, and is not to be confused with contact tracing, which is being conducted by the Department of Health and is intended to follow up with COVID positive patients to identify potential contacts.
“Many of our patients are uninsured, underinsured, and face language and cultural barriers, and have become increasingly vulnerable as a result of the COVID pandemic,” said Lindsay Farrell, president and CEO of Open Door. “We view patient tracing as a way to build a more resilient community.”
The Federally Qualified Health Center’s patient tracing program is a coordinated effort between the Open Door’s Medical Behavioral Health Clinicians (MBHC) and Patient Advocacy staff, with Covid-positive patients telephoned immediately after they receive a diagnosis. Clinicians hand off patients to the MBHC, who explore additional needs, while the Patient Advocate schedules necessary testing for other household members who may have been exposed.
“With patient tracing we’ve developed a proactive approach that engages families and provides them with any additional support they might need, while reducing fear” said Andrea Ruggiero, Vice President, Community Health at Open Door, who developed the program with Shonny Capodilupo, the center’s Senior Director of Behavioral Health. “We assess for social determinants of health, such as food insecurity or housing needs. Do they have someone who can care for them at home? Do they have masks, a thermometer? What is their emotional state? Can they self-isolate? Do they need others in their family tested?”
Patients are contacted by telephone once diagnosed. Follow ups are performed by virtual visits either through video or telephone. Digital literacy is also assessed and support is provided on how to sign in to the telehealth session or how to use the patient portal. Patients who have self-isolated may receive needed food deliveries. MBHC and Patient Advocates prepare patients for phone calls from DOH on contact tracing.
“We are involved from the beginning, so patients don’t feel scared or anxious,” said Ruggiero. “We want our families to feel they have the resources and the knowledge to take care of themselves and others.”
Since the program began in mid-March, volunteers have delivered more than 16,000 pounds of food, including fresh produce, to Open Door patients, with another 130 bags of food picked up at Open Door sites. As of May 28th, Open Door has performed more than 4,000 viral tests, and has had 1,556 positive results. Along with another 156 patients who tested positive in outside facilities, Open Door has cared for 1,712 patients with SARS-CoV-2.
“We know that many people are struggling at this time and we want to be responsive to this,” she said. “Our staff has the training and resources to help support these vulnerable patients and families at a particularly difficult time.”
Open Door Family Medical Center’s mission has remained consistent since 1972: to provide high-quality health care that’s affordable, accessible and efficient.
Today, the Federally Qualified Health Center cares for over 60,000 adults and children every year in Westchester, Putnam and Ulster counties – with more than 300,000 patient visits and over 400 babies delivered annually – regardless of ability to pay. In addition to primary medical care, Open Door offers integrated dental care, pediatric care, women’s health care, behavioral health care, and wellness programs in its Ossining, Port Chester, Sleepy Hollow, Mount Kisco, Brewster, Mamaroneck locations, eight School-Based Health Centers in the Ossining and Port Chester school districts, dental van, and a dental practice is in Saugerties.
