This document provides a summary of a continuing medical education webinar on caring for key populations during the COVID-19 pandemic. It discusses guidance from the CDC and SAMHSA on treating patients with substance use disorders and those receiving medication-assisted treatment. It also reviews recommendations for caring for people living with HIV and those experiencing housing insecurity. The webinar focused on transitioning care delivery to telehealth when possible and ensuring access to medications and support. A case study was also presented and modifications to the treatment plan discussed in light of the pandemic.

1. Weitzman ECHO on COVID-19:
Caring for Key Populations
April 1, 2020

2. CME Credit
• Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State
Medical Society to sponsor continuing medical education for physicians. The
Bridgeport Hospital Yale New Haven Health designates this live activity for a
maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only
credits commensurate with the extent of their participation in the various
activities.
• This activity has been planned and implemented in accordance with the Essential
Areas and policies of the Accreditation Council for Continuing Medical Education
through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and
the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited
by the Connecticut State Medical Society to provide continuing medical education
for physicians.
• The content of this activity is not related to products or services of an ACCME-
defined commercial interest; therefore, no one in control of content has a relevant
financial relationship to disclose and there is no potential for conflicts of interest.

3. Weitzman ECHO on COVID-19
A Primary Care Perspective cont’d
Stephen J Scholand, MD
Infectious Disease Consultant
1 April, 2020

4. Objectives
- Update on epidemiology (2019-nCoV, SARS-CoV-2)
- Useful tool for understanding State by State disease
patterns
- Focus on special populations:
- HIV patients, Medication Assisted Treatment -
drug/substance abusers, Homeless/housing insecure
- Review some good news
- Remind everyone to continue the fight!

5. COVID-19 in the United States
174,476 cases 3/31/20 – up from 46450 cases last week (3/24/20) -
https://coronavirus.jhu.edu/map.html

6. Tool for local (by State) predictions
https://covidactnow.org/

7. Any good news?
• FDA allows hydroxychloroquine and chloroquine
• Diagnostic tests
– Abbott’s ID NOW COVID-19 (13 minutes or less)
– Cepheid’s GeneXpert test (45 min, 80 samples/time)
• More than 110 laboratories have begun testing
for COVID-19

8. Stay safe -- Stay up to date
• https://www.cdc.gov/coronavirus/2019-ncov/index.html
https://emergency.cdc.gov/coca/calls/2020/callinfo_030520.asp
• https://www.who.int/emergencies/diseases/novel-
coronavirus-2019
• https://covidactnow.org/
• https://coronavirus.jhu.edu/map.html

9. Marwan Haddad, MD, MPH
Kasey Harding, MPH
Dan Bryant, LPC
Caring for Key Populations In
the Time of COVID-19

10. Substance Use Disorder (SUD) &
Medication Assisted Treatment (MAT)
Guidance from CDC in times of COVID-19:
• Reschedule non-urgent outpatient visits as necessary.
• Use telemedicine, including telephone, where possible.
• Reach out to patients at higher risk for complications to
ensure adherence to medication and therapeutic regimens.
• Confirm sufficient refills; provide instructions should they become ill.
• Eliminate patient penalties for missed appointments or
cancellations.
HHS Office of Civil Rights has suspended enforcement of
HIPAA through waiving penalties for violations.

11. • Use outpatient treatment options to the greatest extent possible.
• With SUDs, inpatient and residential treatment has not been shown
to be superior to intensive outpatient treatment.
• Use telehealth or telephonic services to provide evaluation and
treatment of patients.
• For inpatient/residential programs remaining open:
– Care should be taken to consider CDC guidance on precautions in admitting
new patients, management of current residents who may have been exposed
to or who are infected with COVID-19, and visitor policies.
https://www.samhsa.gov/sites/default/files/considerations-care-treatment-mental-substance-use-disorders-covid19.pdf
Guidance from SAMHSA in times of COVID-19:

12. https://www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf
Medication Assisted Treatment (MAT)
Q: Can practitioner with a DATA 2000 waiver, working
outside the context of an Opioid Treatment Program (OTP),
treat new and existing patients with buprenorphine via
telehealth, including use of telephone if needed?
A: Yes! The patient will count against the practitioner’s
patient limit and must treat the patient in accordance with
any rules that apply to practicing with the waiver.

13. CHC MAT/SUD Program Guidance
1. Decrease patient in-person visits to the health center.
2. Extend refills to minimize risk of running out.
3. Suspend the use of vouchers.
4. Decrease the frequency of toxicology screens.
5. Switch behavioral health groups to individual therapy
support, through telehealth.
6. Use Recovery Care Coordinators
• to reach out to each patient by phone regularly.
• to aid in coordination of care.

14. HIV Care
• As of April 1, limited data available on risk of
COVID-19 in people with HIV.
• The risk from immune suppression is not known,
but with other viral respiratory infections, the risk
for people with HIV getting very sick is greatest in:
– People with a low CD4 cell count.
– People not on HIV treatment (antiretroviral therapy).
• People with HIV can be at increased risk of getting
very sick based on age and other medical
conditions.

15. • Maintain social distancing, handwashing.
• Postpone routine, non-urgent office visits.
– Use telemedicine including use of telephone.
– Plan needs to be in place for staying in touch (video/phone/text/portal).
• Ensure at least 30 day supplies of HIV medicine and other medication and
supplies; ideally 60-90 day refills.
– Do not switch to PI-based regimens.
• Consider delaying HIV viral load monitoring up to an extra 6 months if virally
suppressed and no concerns.
• Encourage maintaining a social network remotely.
• Prioritize COVID-19 testing in those with high fever or signs/ symptoms of lower
respiratory tract illness due to high rates of cardiovascular disease and lung
disease and high prevalence of smoking.
• Ensure up-to-date vaccines, esp. against influenza; bacterial pneumonia.
HIV Care
CDC/IDSA/HIVMA Guidance

16. Individuals Experiencing Housing Insecurity
• Individuals living in a shelter, supportive
housing or unsheltered
• Seasonal or Migrant Agricultural Workers
• Formerly Incarcerated, parolees
POSSIBLE HIGHER RISKS
Congregate living
Density of service sites
Higher prevalence of medical
conditions
DIFFERENCE IN TRAJECTORY
Cases beginning more recently
Peak of cases will be later
Outbreaks tend to be
extremely localized

17. CDC Recommended Considerations
• Limit visitors in shelters and service delivery sites
• Use emergency operations communication plan
• Communicate efficiently with local health department
• Provide adequate access to sanitation and hygiene supplies and educate
staff and clients OFTEN
• MINIMIZE shelter density quickly
• Provide screening and medical assessment
• Isolate symptomatic clients immediately
• Plan for staff shortages
• Minimize staff face to face interactions
• Identify and monitor high risk clients
• Ensure good practices of environmental cleaning in all common areas

18. Behavioral Health & COVID-19
• According to SAMHSA
– 26.2% of homeless individuals have a severe
mental illness
– 34.7% have a chronic substance use disorder
• We are all feeling increased stress during this
time even if we don’t struggle with a pre-
existing mental health condition.

19. Behavioral Health & COVID-19
• There’s some reason for optimism:
– During the Blitz in England during WWII there was
a notable decrease in psychiatric hospitalizations
– Overall mental health in the country seemed to
improve in the crisis
• Part of what made this the case was the
increase in community connectedness so it is
unclear whether we will be able to see this
improvement given social distancing.

20. What Can I Do Today?
• During a crisis, it is inappropriate to continue
treatment as usual.
• Focusing on current stressors is a priority and
deeper MH work should be suspended or
postponed.

21. FACE COVID
• A model for dealing with current stressors from
the creator of ACT
– Focus on what’s in your control
– Acknowledge your thoughts and feelings
– Come back to your body
– Engage in what you’re doing
– Committed action
– Opening up
– Values
– Identify Resources
– Disinfect and distance

22. Case
• 50 yr old woman from PR
• Med Hx: HIV; opioid use disorder (OUD); HCV Rxed/Cleared
• Meds: TAF/FTC and DTG ; buprenorphine.
• Labs: HIV RNA <20; CD4 806/42% (December 2019)
• January 2020: relapse after many years
• February 2020: severe skin infection of left arm requiring
debridement and graft
• February 2020: lost housing; moved in with daughter
• March 2020: DCF banned her from daughter’s house
• March 2020: Hospitalized for overdose.

23. Usual Treatment Plan
• She was coming for behavioral health individual
therapy weekly.
• Seeing nursing weekly for tox screens,
adherence, and support/motivational
interviewing.
• Seeing me monthly for HIV care and
buprenorphine management.
THEN:
• COVID-19 precautions implemented statewide.

24. COVID-19 Pandemic Mitigation in Place
BUT:
• Severe relapse on opioids, with recent
overdose, on MAT
• Depressed
• Homeless
• On HIV medication, among other meds

25. Decisions
• Inpatient/residential vs. outpatient for OUD
• How support her given she is currently
requiring as much support as possible
– In-person visits vs. telephonic
• Does she require testing for HIV VL, Hep C,
toxicology screening?
• Housing issues?
– Shelter vs. residential program vs. daughter’s

26. Treatment Plan
• Case manager: daily phone calls
• Therapist: weekly phone visits
– Decided on OUD residential treatment
• Nurse: weekly phone visits
– HIV medication adherence
– wound management
– buprenorphine adherence and management
• MD: telephonic visit reinforcing treatment plan
• Bed became available at a program; entered after
COVID screening with complete lockdown.

27. Case
• Signed herself out 1 week ago; got in fight with staff member.
• Upon leaving, called case manager.
• Nursing telephonic visit set up immediately; nurse called MD.
• MD: sent in refill for buprenorphine immediately for 14 days.
• MD: sent in 90 days of HIV meds.
• Therapist: phone appointment next day.
• She is calling another program daily; at daughter’s house.
• Case manager speaks to her almost daily.
• Phone visit with me scheduled next week.
– I may order labs (VL/genotype)

28. 28
Free COVID-19 eConsults
• We will automatically submit any questions from the
Q&A that we didn’t address today – be on the lookout
for a reply!
• Operational and Clinical Questions
• For all Safety-Net Primary Care Practices
– FQHC, FQHC-look alike, Migrant Clinicians, Healthcare for the
Homeless, Free Clinics
• Consults addressed by ConferMED’s expert specialists
• Submit consults and questions via the ConferMED
website: www.ConferMED.com
• Receive a rapid response by email
* This initiative is supported by

29. 29 * This initiative is supported by

30. Thank You!
www.weitzmaninstitute.org/coronavirus