On the COVID-19 Front Lines

As the first coronavirus wave hit New York City and Seattle in the spring, Dell Med clinical faculty and residents working at Dell Seton Medical Center at The University of Texas braced for impact. Leaders tried to predict whom COVID-19 would hit the hardest: Vulnerable groups included older adults, people experiencing homelessness and even health care workers themselves. Regardless, leaders knew Dell Seton faced a unique challenge.

As the primary safety net hospital in Austin, and the main teaching hospital of Dell Medical School at The University of Texas at Austin, Dell Seton treats many patients who face a lack of health care access, among other barriers to health. When Austin’s first COVID-19 cases cropped up, teams acted with the knowledge that their patients could end up being sicker than most.

But months later, when leaders began to analyze COVID-19 case data from the beginning of the outbreak, the extraordinary came to light: Dell Seton’s patients survived at twice the rate of other COVID-19 patients across the country.

The reason, says Kirsten Nieto, M.D., lies in the clinical team’s ability to implement innovative solutions on the fly while relying on existing partnerships with Austin communities. Nieto, an assistant professor of internal medicine and division chief of hospital medicine at Dell Med, oversaw a team of physicians and residents that led the initial inpatient coronavirus response.

From April to June, Dell Seton reached all-time highs in the number of health care resources needed to care for 269 COVID-19 patients, who all had a steep rate of overall illness. During this time, expected mortality included 9.8% of patients — yet the mortality rate from that period reached just 4.1%. Compared to 499 hospitals across the country, including 10 other safety net hospitals, Dell Seton’s mortality index was half the national average.

“We have patients who are sicker than most. Dell Seton has always embraced that challenge; our ability to do so has only been amplified during the pandemic,” Nieto says. “Our outcomes reflect our nimble internal working groups and our community partners.”

Rapid Response Within the Hospital Walls

Some patients with COVID-19 had never interacted with the health care system at all — much less received 30-day intubation in intensive care. Many Spanish-speaking patients also faced a language barrier, says Snehal Patel, M.D., assistant professor of internal medicine. Within a week, the hospitalist group formed a Spanish-speaking team to connect patients’ families with resources.

“We knew that in addition to addressing medical needs, addressing social needs was critical to patients’ and families’ ability to thrive during the pandemic,” Patel says. “Many patients didn’t know about resources such as food delivery or rent assistance, so part of our team’s job was to assess those unmet needs and to connect them with resources. This allowed our patients to continue to isolate after hospital discharge, and supported their families in ongoing quarantine.”

Pre-pandemic, Dell Med and its partners were already engaged in contextualizing inpatient health with larger social needs. So when the pandemic hit, Patel says, the hospitalist group was ready to move beyond “the typical medical model” with the knowledge that social and medical factors are inextricably linked. This mindset also shaped the way Dell Seton analyzed patients’ care needs beyond their hospital stay.

Care teams analyzed real-time national and internal data for patterns of patient symptoms, pre-existing conditions and social factors. This included understanding patients’ occupations to support immediate contact tracing work, studies that predicted when a patient might require complex care and rapidly evolving evidence around effective therapies.

They were able to stand up a set of best practices for patients with COVID-19 in just 10 days, with updates every seven days — a pace that Nieto says many are not accustomed to in health care.

“For example, we might look at the data and tell our team: ‘This week we are not using hydroxychloroquine because recent data shows it has negative outcomes,’” Nieto says. “Instead, we would decide to use an alternative treatment like remdesivir and come to a consensus about which patients should receive that treatment.”

After witnessing the success of real-time, evidence-based treatment plans for COVID-19 care, Nieto hopes they can serve as a catalyst for future health care transformations. She anticipates these practices being used post-pandemic to better serve other patient populations, like those with cirrhosis or gastrointestinal bleeds.

Outside the Hospital: Lifesaving Partnerships

Austin also saw lower COVID-19 rates than expected for people experiencing homelessness. Considering the heightened risk in close quarters of camps and shelters, this low spread was surprising, says Tim Mercer, M.D., assistant professor in Dell Med’s Department of Internal Medicine and a primary care physician with CommUnityCare’s Healthcare for the Homeless program. Mercer participated in the City of Austin’s efforts to coordinate emergency protective lodging, also known as “pro-lodges.”

One Austin motel-turned-pro-lodge served as a facility for discharged COVID-19 patients who didn’t have a space to safely self-isolate, while five others provided socially distanced shelter. Physicians like Mercer within CommUnityCare Health Centers helped develop criteria for triage based on medical risk.

“We took over 320 of the most medically complex folks experiencing homelessness and got them immediately to a safe place where they could have access to health care,” Mercer says. “ECHO played a huge role in coordinating this proactive strategy.”

The Ending Community Homelessness Coalition, an Austin agency that coordinates funding for housing efforts, bridged hospital and outreach services. ECHO leaders met with CommunityCare team members weekly, and helped form a larger, monthly workgroup that included Dell Seton physicians to discuss COVID patients’ medical and housing needs. If patients didn’t have a place to safely self-isolate upon discharge, ECHO connected them with a pro-lodge.

“One of the silver linings of this pandemic was the relationships we built,” says Nicolina Kozak, housing for health systems manager at ECHO. “By leveraging pre-existing relationships, we were able to maintain a constant flow of communication.”

Identifying — & Aiding — COVID-19-Related Food Insecurity

Even without a COVID-19 diagnosis, many Austin residents felt its effects: A research team led by Megan Gray, M.D., and Ana Avalos, M.D., partnered with CommUnity Care Health Centers found that food insecurity affected local families an average of 47% of the time between April and August — and sometimes as often as 70%. COVID-19 surges correlated with higher rates of self-reported food insecurity.

Similar to what their colleagues at Dell Seton saw, Gray and Avalos found that patients were often more socially complex than medically complex.

“They were already vulnerable before the pandemic — and now, families are experiencing more than just lack of funds to buy food,” Gray says. “They’re dealing with isolation, worried about meeting the needs of themselves or their children and experiencing instability in the job market. It’s likely to get worse this winter as cases rise in our community.”

Separately, Dell Med students found themselves uniquely equipped to help. Good Apple, an Austin-based produce delivery service co-founded by fourth-year student Zack Timmons, was already focused on serving those experiencing food insecurity: Each box of fresh produce purchased allows the team to deliver another box to someone in need.

And as COVID-19 began to spread in Travis County, Timmons and his colleagues used their existing infrastructure to launch the “Stay Home, Stay Healthy” program — offering emergency grocery delivery to those who were most at risk of contracting the virus, like older adults.

“The challenge of addressing food insecurity is often not a problem of production — in fact, there is plenty of food in the Austin community,” Timmons says. “The greater challenge is building an effective system to deliver that food to people who need it the most, and I’m excited to team up with local organizations to do our part in that. We have a responsibility to help our most vulnerable neighbors, and that’s especially true in uncertain times like these.”