Population Health is Now Public Health


COVID-19 is here to stay. In the meantime, hospitals' roles are greatly expanding.

Bruce Hamory, MD

10 min read

Editor’s Note: The following article is part of an ongoing series offering our strategic advice and expertise on what healthcare industry stakeholders should do immediately in response to the rapidly evolving novel coronavirus (COVID-19) pandemic.

Providers and hospitals, whose contact tracing activities before COVID-19 historically focused quite narrowly on provider regulatory compliance, are now serving their greater communities and complementing other institutions’ health missions along the way. Now operating according to expanded health department guidance during COVID-19, the greater healthcare industry is monitoring the infected for worsening clinical conditions that require hospitalization and treatment. However, current and future pandemic requirements regarding contracted population management – something once focused on identifying and treating those needing preventative care or those at risk of deteriorating health – too aggressively identify and isolate those individuals actively infected with COVID-19. Actions like locating those who may have the virus before quarantining and testing them, although well-intended to stop the spread, limit an organization’s financial exposure to expensive COVID-19 hospitalizations.

Hospitals must do whatever’s reasonable and necessary to reduce the number of COVID-19 patients requiring hospital care. As states reopen, many are requiring hospitals to maintain a fixed level of open beds to handle expected fluctuations in COVID-19 admissions. These capacity requirements are often 20 to 30 percent of the hospital systems’ intensive care units and adult medical-surgery bed capacity. This requirement may be enough to lower a hospital operating margin below a profitable level. 

Two Key Considerations

For a hospital and/or a health system, three levels of COVID-19 protection must be provided. First, is protection for employees while they work. Second, is protection for employees and their families while they’re going about their personal lives. Third, is improving and maintaining your community’s health. But achieving these goals depends on how well you’ve planned for the following two realities: 

1. Hospitals’ roles will expand to fill public health infrastructure gaps.

The short-term ability of local health departments to test people and contact trace for those infected will continue to be limited by testing availability and shortage of trained staff. Hospitals must continue assisting local health departments by performing testing on symptomatic and asymptomatic individuals to speed up diagnoses. Hospitals must also become more active in contact identification and tracing. 

Why is this necessary when it wasn’t needed for other contagious diseases? To help answer this question, consider past health practices for notifiable diseases. In the recent past, a provider’s duty was limited to notifying the local public health authority. It was the health department that performed contact tracing, implemented quarantine, and treated both an initial case and his or her corresponding contacts. For example, regarding a standard sexually transmitted infection or case of pulmonary tuberculosis, just a few days of delay for test results and in the notification of the health department about results (and therefore also a delay in initiation of contact tracing) did not greatly affect disease control because of a relatively slow infection spread.

However, for COVID-19, state health departments have noted reports often come back at least four days late. This is a significant delay! The virus has a short incubation period. It spreads efficiently through respiratory secretions. The incubation period (time between exposure and symptoms of infection) averages 5.2 days in 65 percent of people who exhibit symptoms. But the time from exposure to detecting the active virus in respiratory tract secretions is generally reported as between two to three days, meaning a person has potentially been infecting people for two days before diagnosis. The virus is then generally excreted for a further two to four days after symptoms. This means any significant delay in reporting the index patient and any delay in the timeliness of public health response would fail to quarantine the index patient. It also means there’s been a failure to identify and isolate any close contacts during their period of most active viral excretion (and their potential to infect more people).

Hospitals and providers must continue identifying both symptomatic and asymptomatically infected people and to do some limited contact identification within their sphere of operations and data availability. 

2. COVID-19 is here to stay.

COVID-19’s continuing circulation in all communities is expected, with likely outbreaks of more clinical cases at periodic intervals for the next several years. Infections will not end immediately following a city, state, or regions’ efforts to achieve “the new normal.”

As hospitals and health systems plan for reopening their facilities to elective procedures, they are planning to exclude patients with respiratory symptoms from undergoing procedures or being seen in the outpatient areas except for urgent on emergent conditions. They are also planning to test all patients scheduled for a procedure with a rapid test for COVID-19 ribonucleic acid (RNA) by polymerase chain reaction (PCR) or an antigen test (when available) either immediately before the procedure, or the evening before it. They will likely continue to test all patients seeking emergency room services before admission.

In performing these tests or in referring patients with appropriate symptoms for testing, many patients will be found to have active COVID-19 infection. Hospitals will certainly identify and isolate their exposed staff and any inpatients inadvertently exposed to an unrecognized case as part of their standard infection control measures. Because of the very tight timeline to quarantine actively infected patients, and to identify and isolate close contacts, it will be optimal if health systems testing patients perform the initial identification of contacts in a home setting, and in any health setting(s) where patients are seen without precautions being taken. Their families and the people with whom they come face-to-face with must also be identified and notified.

Contact tracing should extend beyond the home so that places visited by, the patient and his or her close contacts can be identified and immediately reported to health authorities. It’s relatively simple for a healthcare provider to obtain this for the patient at the time of the positive test a list of contacts or areas of presence (such as eating establishments) during the relevant infectious period and to report those to the health department with the report of the index case. It is also possible for the health system to notify its high-risk patients of an elevated rate of COVID-19 cases in the community and remind them to take extra precautions.

The health system can simplify its internal contact tracing by using its patient registration and electronic record capability to identify patients and staff potentially exposed at the time of the index patients’ visit(s) and to monitor them closely for evidence of illness during their self-quarantine period.

The Key to Slowing the Spread

Implementing these measures in conjunction with state and local health departments will provide an immediate “brake” on virus spread and result in better protection for other patients, healthcare staff, and the community. Major benefits will include a lower rate of infection requiring expensive hospitalization for any members whose care is capitated, and a lower number of patients admitted for COVID-19 needing expensive isolation measures while displacing other patients. It’s these focuses that are critical for positive change.