Primary health care organization in the Covid-19 pandemic: scoping review

Silva, Breno Ribeiro Gonçalves da; Corrêa, Ana Paula de Vechi; Uehara, Sílvia Carla da Silva André

doi:10.11606/s1518-8787.2022056004374

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Sumário

Review • Rev. Saúde Pública 56 • 2022 • https://doi.org/10.11606/s1518-8787.2022056004374 copy

Primary health care organization in the Covid-19 pandemic: scoping review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

Mapping available scientific evidence on the organization of primary health care services and professionals during the Covid-19 pandemic.

METHODS

This is a scoping review that followed the Joanna Briggs Institute method. Articles published in Portuguese, Spanish, and English from January 2020 to January 2021 in the CINAHL, Lilacs, Medline, PubMed, and Web of Science databases were included.

RESULTS

We selected 24 articles that presented the reorganization of primary health care services and professionals to care suspected or confirmed Covid-19 cases. Coordination measures to tackle this disease in primary health care help to control its infection, especially by the active search for respiratory symptoms, the detection of new cases, and the monitoring of confirmed cases.

CONCLUSION

This study presents an overview of how primary health care services and professionals organized themselves to tackle the Covid-19 pandemic, addressing adjustments in infrastructure and care flows, such as establishing specific Covid-19 care units, separating infected and non-infected patients, using telemedicine as an alternative modality of care, and monitoring cases by applications and phone.

Primary Health Care, organization & administration; COVID-19, prevention & control; Health Human Resource Training; Review

Database	Search strategies
PubMed	(((covid-19[Title]) OR coronavirus[Title])) AND (primary health care[Title] OR primary care[Title])) AND organization[Body - All Words]; (((covid-19[Title]) OR coronavirus[Title])) AND (primary health care[Title] OR primary care[Title])) AND assistance[Body - All Words]; (((covid-19[Title] OR coronavirus[Title])) AND (primary health care[Abstract] OR primary care[Abstract])) AND assistance[Body - All Words]; (((covid-19[Title] OR coronavirus[Title])) AND (primary health care[Abstract] OR primary care[Abstract])) AND organization[Body - All Words]; ((((covid-19[Title] OR coronavirus[Title])) AND (primary health care[Abstract] OR primary care[Abstract])) AND healthcare professionals[Abstract]) AND organization[Body - All Words]; (((covid-19[Title] OR coronavirus[Title])) AND (Family Health Strategy[Abstract] OR family health[Abstract])) AND organization[Body - All Words].
Medline	TI (covid-19 OR coronavirus OR coronavírus) AND AB (primary health care OR primary care OR atenção primária OR primeros auxilios) AND AB (organization OR organização OR organización); TI (covid-19 OR coronavirus OR coronavírus) AND TI (primary health care OR primary care OR atenção primária OR primeros auxilios) AND AB (organization OR organização OR organización); TI (covid-19 OR coronavirus OR coronavírus) AND AB (primary health care OR primary care OR atenção primária OR primeros auxilios) AND AB (assistance OR assistência OR asistencia); TI (covid-19 OR coronavirus OR coronavírus) AND AB (primary health care OR primary care OR atenção primária OR primeros auxilios) AND AB (organization OR organização OR organización) AND AB (healthcare professionals OR profesionales de la salud OR profissionais de saúde OR profissionais OR profesionales OR professionals); TI (covid-19 OR coronavirus OR coronavírus) AND AB (Family Health Strategy OR family health OR Estratégia Saúde da Família OR Saúde da Família OR salud familiar) AND AB (organization OR organização OR organización).
Web of Science	TÍTULO: (covid-19 OR coronavirus OR coronavírus) AND TÍTULO: (primary health care OR primary care OR atenção primária OR primeros auxilios) AND TÓPICO: (organization OR organização OR organización); TÍTULO: (covid-19 OR coronavirus OR coronavírus) AND TÓPICO: (primary health care OR primary care OR atenção primária OR primeros auxilios) AND TÓPICO: (organization OR organização OR organización); TÍTULO: (covid-19 OR coronavirus OR coronavírus) AND TÓPICO: (primary health care OR primary care OR atenção primária OR primeros auxilios) AND TÓPICO: (assistance OR assistência OR asistencia); TÍTULO: (covid-19 OR coronavirus OR coronavírus) AND TÓPICO: (primary health care OR primary care OR atenção primária OR primeros auxilios) AND TÓPICO: (organization OR organização OR organización) AND TÓPICO: (healthcare professionals OR profesionales de la salud OR profissionais de saúde OR profissionais OR profesionales OR professionals); TÍTULO: (covid-19 OR coronavirus OR coronavírus) AND TÓPICO: (Family Health Strategy OR family health OR Estratégia Saúde da Família OR Saúde da Família OR salud familiar) AND TÓPICO: (organization OR organização OR organización).
Lilacs	covid-19 OR coronavirus OR coronavírus [Title words] and primary health care OR primary care OR atenção primária OR primeros auxilios [Words] and organization OR organização OR organización [Words]; covid-19 OR coronavirus OR coronavírus [Palavras do título] and primary health care OR primary care OR atenção primária OR primeros auxilios [Palavras] and assistance OR assistência OR asistencia [Palavras]; covid-19 OR coronavirus OR coronavírus [Palavras do título] and primary health care OR primary care OR atenção primária OR primeros auxilios [Palavras] and healthcare professionals OR profesionales de la salud OR profissionais de saúde OR profissionais OR profesionales OR professionals [Palavras].
CINAHL	TI (covid-19 OR coronavirus OR coronavírus) AND AB (primary health care OR primary care OR atenção primária OR primeros auxilios) AND AB (organization OR organização OR organización); TI (covid-19 OR coronavirus OR coronavírus) AND AB (primary health care OR primary care OR atenção primária OR primeros auxilios) AND AB (organization OR organização OR organización) AND AB (healthcare professionals OR profesionales de la salud OR profissionais de saúde OR profissionais OR profesionales OR professionals); TI ( covid-19 OR coronavirus OR coronavírus ) AND AB ( Family Health Strategy OR family health OR Estratégia Saúde da Família OR Saúde da Família OR salud familiar) AND AB ( organization OR organização OR organización ); TI ( covid-19 OR coronavirus OR coronavírus ) AND AB ( primary health care OR primary care OR atenção primária OR primeros auxilios ) AND AB ( organization OR organização OR organización ) AND AB ( nursing OR nurse OR nursing care OR nursing practice OR enfermagem OR enfermería ).

Author, year, and place	Objective	Type of study	Main results
Krist AH et al.¹⁸, 2020, United States	Presenting actions to be adopted by PHC during the pandemic, according to the protocol of the Centers for Disease Control and Prevention (CDC).	Descriptive study	The plan to tackle the Covid-19 pandemic in PHC was organized into six phases: 1) surveillance, notification, and monitoring of cases; 2) physical distancing, increasing virtual appointments, and postponing non-urgent appointments; 3) implementation of actions to flatten the epidemiological curve; 4) referral of only severe cases to hospitals; 5) care actions for convalescent patients; 6) addressing the consequences of the pandemic.
Morreel S et al.¹⁹, 2020, Belgium	Assessing the organization and characteristics of PHC appointments performed outside office hours and comparing them with those in the same period in 2019.	Observational study	By telephone screening, patients were classified as suspected or regular. All suspected Covid-19 cases were treated virtually, and, if necessary, referred to exclusive care units for Covid-19 suspected patients (Corona Units), or in home visits, or referred to emergency departments. In comparison with 2019, the workload increased due to phone calls, however, the number of face-to-face appointments decreased by 45%.
Fernandes LMM et al.²⁰, 2020, Brazil	Analyzing the adaptation of a PHC center in Recife, which improved its telehealth and remote monitoring.	Case report	Reorganization of the internal flow of the unit, by separating symptomatic from asymptomatic patients; discontinuation of collective activities; maintenance of the follow-up of patients with chronic diseases; telemedicine and remote monitoring; and active surveillance actions promoted by the health team in the territory.
Sigurdsson EL et al.²¹, 2020, Iceland	Analyzing how PHC in Iceland changed its strategy to tackle the Covid-19 pandemic.	Observational descriptive study	Early detection of suspected cases; effective screening; separation of symptomatic and asymptomatic patients; maintenance of activities aimed at maternity and childcare; change from face-to-face care to telemedicine; alternative office hours. Change in the 10 main diagnoses—immunization, depression, hypothyroidism, and low back pain were no longer among the 10 main diagnoses. These changes showed a very solid PHC, with great flexibility in its organization.
Dias EG²², 2020, Brazil	Discussing the management of care and health education in PHC to tackle the Covid-19 pandemic.	Experience report	Immediate identification of respiratory symptoms; space reserved to wait for an appointment; discontinuation of some care activities; telemedicine and telemonitoring; home visit or face-to-face care, if necessary; health education by radio, sound cars, flyers, posters, social networks, and phone.
Vieira DS et al.²³, 2020, Brazil	Developing an experience of organizational planning in nursing along with the family health team in a rural area of Igreja Nova, AL, during the Covid-19 pandemic.	Experience report	This study followed three strategies: •Community guidance on the problem of health prevention and promotion actions. •Permanent health education for the health team, in order to qualify professionals. •Organization of the provision of health services, establishment of an exclusive room to treat respiratory symptoms, and organization of the care of patients of programs in the unit.
Jacobson, NA et al.²⁸, 2020, Brazil	Addressing a collaborative effort to care for a community during the Covid-19 pandemic from the development of a clinic.	Experience report	The authors analyzed the adaptation of a clinic with PHC exclusively for Covid-19 patients. Nurses determined if patients would need emergency care or care at the Covid-19 clinic by a virtual evaluation, by Zoom. Later, patients had a face-to-face appointment scheduled at the specific unit. In order to maximize social distancing, the physical space was adjusted.
Saint-Lary O et al.²⁹, 2020, France	Analyzing how general physicians adapted their practices to ensure and maintain access to care during the epidemic phase.	Descriptive observational study	A total of 5,424 French general physicians were interviewed. Of them, 70.9% changed face-to-face care to remote care, 66.5% increased the number of remote appointments, and 42.7% created a specific flow for suspected Covid-19 patients. Of the 70.9% who adapted their practice, 91.7% used phones, 27.6% email, and 30.7% increased their use of video calls.
Majeed A et al.³⁰, 2020, England	Assessing the response of primary health care for Covid-19 in the National Health Service (NHS) in England.	Descriptive observational study	Change from face-to-face care to remote care; care of suspected or confirmed Covid-19 patients in specific clinics; implementation of home visits specific for Covid-19 care; complete computerization of all National Health Service units; use of electronic medical records; online access of patients to health services (such as making appointments, asking for prescriptions, and seeing medical records); electronic sending of prescriptions, directly to the pharmacies of the patient’s choice.
Al Ghafri T et al.³², 2020, Oman	Assessing experiences and perceptions of PHC health professionals during the Covid-19 pandemic in relation to medical response experiences, sociocultural and religious reforms, psychological impressions, and lessons learned.	Qualitative and phenomenological study	Rapid reorganization of PHC services; use of technology; challenges of working in the Covid-19 pandemic; changes in social and religious standards; emergence of gaps in the access of vulnerable groups to health care; emergence of psychological disorders due to social distancing; management of corpses; exhaustion of health professionals; risk of exposure; and development of epidemiological and public health capacities, improving access to health care.
Blazey-Martin D et al.³³, 2020, United States	Developing an innovative population management approach to remotely manage Covid-19 patients.	Experience report	An algorithm was used to guide screening decisions, including the frequency of contact with patients, depending on the day of the onset of symptoms and risk factors, and identify clinical findings that showed if patients were safe to stay at home or required further evaluation. These interventions, when performed on time, reduced the demand of hospitals and emergency care.
Verhoeven V et al.³⁴, 2020, Flandres	Assessing the consequences of the Covid-19 outbreak experienced by physicians on the front line on the core competencies of family and community medicine.	Experience report	Screening and appointments performed by phone for all patients; clinical decision-making focused on respiratory evaluation and screening; impairment of acute care due to the change of focus to only Covid-19 and patients that did not seek care for problems that were not related to Covid-19; postponement of chronic care.
Karim SI et al.³⁵, 2020, Saudi Arabia	Analyzing the strategies adopted to reorganize PHC during the Covid-19 pandemic in a hospital in the capital of Saudi Arabia.	Experience report	Services were adapted based on surveillance and case detection, clinical management, prevention of the spread, and maintenance of essential services. These changes were made by the Department of Family Medicine and all appointments started to be performed remotely, by WhatsApp and virtual clinics. Moreover, new means of communication, such as websites, portal messages, and social networking, started to be used.
Motlhatlhedi K et al.³⁶, 2020, Botswana	Assessing the action of family health physicians during the pandemic.	Descriptive observational study	Family health physicians were responsible for infection control, disease prevention measures, identification of cases, dissemination of information, and continuity of medical care, especially for patients. The use of WhatsApp has expanded to include online webinars, as well as to disseminate information about Covid-19 from various sources and the national coordination center.
Sinha S et al.³⁷, 2020, United States	Evaluating the implementation of a video care program at a large academic PHC clinic in New York.	Case study	In total, 1,030 video appointments were performed for 817 patients. Of them, 42% were due to Covid-19 symptoms and 58% due to acute or chronic conditions. Most patients were young adults, women, and people with commercial insurance. The degree of satisfaction was high (mean of 4.6 on a 5-point scale [SD = 0.97]).
Joy M et al.³⁸, 2020, England	Assessing the responsiveness and prioritization of the type of PHC appointment for older adults during the Covid-19 pandemic.	Cross-sectional study	The rate of phone and video appointments more than doubled during the study period (106.0% and 102.8%, respectively). Face-to-face appointments decreased by 64.6% and home visits by 62.6%. This process coincided with national policy changes. The relative increase in the number of appointments was associated with people taking ≥ 10 medicines in comparison with those who did not take any.
Al Ghafri T et al.³⁹, 2020, Oman	Assessing responses to PHC units from January to April 2020, including public health measures in Muscate, Oman.	Descriptive study	The number of appointments decreased from 115,324 in January to 109,719 in March 2020. Essential services were guaranteed in all health centers, especially for vulnerable groups, women, and children. Health centers were opened for 24 hours to ensure the force of testing and isolation. Telemedicine and virtual communications were adopted. Campaigns on the importance of social distancing and hand hygiene were promoted.
Bressy S⁴⁰, 2020, Italy	Assessing the experience of PHC management to tackle Covid-19 in Italy during the beginning of the pandemic.	Experience report	Technological support and remote approach are essential to assess Covid-19 primary care. The use of telemedicine and the aid of technology allowed an efficient monitoring of patients at home, reducing inadequate hospitalizations, as patients were referred to a hospital only when necessary.
Mantovani W et al.⁴¹, 2020, Italy	Assessing the organization and the role of the Department of Prevention of the Local Health Unit of Trento in the prevention of the dissemination and management of Covid-19, according to general physicians and pediatricians during the initial phase of the pandemic.	Observational descriptive study	More than 80% of physicians notified patients. The waiting time for phone interviews, epidemiological investigation, and availability of isolation progressively decreased from an average of six days to 0.4 days in the 12th and 16th weeks of 2020, respectively. The cumulative weekly notification rate of new cases ranged from 3.54 to 6.84 cases per 1,000 inhabitants in the 12th and 16th weeks, respectively. From the epidemiological investigation of 1,471 probable cases, 2,514 close contacts were identified and, in turn, quarantined at home.
Duarte RB et al.⁴³, 2020, Brazil	Assessing the actions of nurses working in the Estratégia Saúde da Família (ESF – Family Health Strategy) with regard to the role that community health agents played along with the population during the Covid-19 pandemic.	Experience report	The role of community health agents is to be a mediator between health teams and the population, developing guidance actions on the functioning of preventive services and self-care related to Covid-19 in the territories where they work. Nurses also play an important role in the training of community health agents regarding the reorganization of the work process during the pandemic and the appropriate use of personal protective equipment.
Ximenes Neto FRG et al.⁴⁴, 2020, Brazil	Assessing strategic actions of care coordination, monitoring, and surveillance of Covid-19 cases in PHC.	Experience report	This study highlighted the importance of horizontal social isolation and home isolation of positive cases, the use of digital technologies to disseminate actions on the prevention of Covid-19 and implementation of telemedicine, the strengthening of intersectoral actions among health, education, and social assistance, and the structuring of the Rede de Atenção à Saúde (RAS – Health Care Network).
Coma E et al.⁴⁶, 2020, Spain	Analyzing the effect of the Covid-19 epidemic and lockdown measures based on health care quality indicators and the control of chronic diseases.	Retrospective descriptive study	In total, 34 quality indicators were evaluated and 85% and 68% of them showed negative results in March and April 2020, respectively, when compared with the same period in 2019. Regarding treatment, monitoring, and chronic disease indicators, 100%, 80%, and 90% of them presented negative effects, respectively.
Garg S et al.⁴⁷, 2020, India	Determining the preparation of PHC units for the provision of safe outpatient services during the Covid-19 pandemic in India.	Cross-sectional study	This study assessed 51 PHC services and identified problems in infrastructure and infection control. Care for chronic non-communicable diseases, immunization, prenatal care, and maternal and child health were the most affected areas. On the other hand, in screening sites for flu symptoms, the number of appointments increased.
Danhieux K et al.⁴⁸, 2020, Belgium	Evaluating how PHC services aimed at chronic conditions was affected during the pandemic in Belgium.	Qualitative research	The health care organization changed, starting to focus on suspected Covid-19 cases and the use of telemedicine, and decreasing the provision of care for chronic conditions. Most professionals interviewed did not perform risk stratification and active search for patients at higher risk—telemedicine was used to evaluate and prescribe medicines and not to monitor chronic conditions. The provision of care for chronic conditions was sharply discontinued.

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[1] Correspondence: Sílvia Carla da Silva André Uehara Universidade Federal de São Carlos Rodovia Washington Luis, s/n, km 235 Caixa Postal 676 13565-905 São Carlos, SP, Brasil E-mail: silviacarla@ufscar.br