Chronic illness management in COVID 19 era: An experience from primary care center

The COVID 19 pandemic questioned the continuous and comprehensive management of chronic illness. The new health guidelines and limited resources challenged primary care centers in their service delivery. A new local guideline become a timely need to overcome the challenges. This article is briefly narrating the local guidelines which was prepared by the University Family Health Center, Kondavil.


Introduction
The chronic illness was defined by the centers for disease control and prevention for disease as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both (1). The long-lasting characteristic of chronic illness require continuous and comprehensive supervisions, observations and/ or care thus primary care centers play an important role in chronic illness management (2). 165 articles that detailed 157 studies were included. There were few studies with Health Care Organization (1.9% of studies. In Sri Lanka, the primary care centers deliver the services as Out Patient Department  well as vital examinations for patients were stopped because of the fear about spreading the infection. That paved the way to 'Twin Epidemic' condition by developing complications due to sedentary lifestyle and missed clinical follow-ups (6).
Developing an effective chronic illness management plan at the primary care level according to the new health guidelines with the available limited resources is a timely need to provide the services. The success of the new management plan depends on user friendly approach of the patients and staff. Therefore, involvement of both staff and patients will help to develop an effective management plan for chronic illness which can be achieved by using Participatory Action Research (PAR) methodology.
The objective was to formulate an effective chronic illness management plan at primary care level during COVID 19 pandemic

Methodology
It is a situational based case study. The participatory action research methodology was applied to develop an effective chronic illness management system with the limited resources in the FHC, Kondavil. It is an approach in public health research where the researchers and participants work together for the betterment of their living community. It is a qualitative research method which has three major repeating actions -engagement, empowerment and reflection (7).
The study population is all the patients who are registered for NCD clinic in FHC, Kondavil and the staff. Patients who are registered under palliative care n= (20) were excluded from the study. The total population size was 180.
Purposeful sampling technique was used to select the sample of participants because of the limited resources and to collect rich and effective information (8). Therefore, expert patients were selected for the patient welfare society as forum which has 9 members. All the staff (8) of FHC, Kondavil were selected as another forum. Routine clinical information was considered as the data for the research.
The sudden lockdown and the new health guidelines for COVID 19 not only became a challenge for the staff but engaged to find out the opportunities. The virtual focus group discussions were conducted with the staff and patient welfare society members via Viber and WhatsApp conference calls. They were empowered to find out the solutions for the action plan development. The reflection of implemented suggestions was taken as engagement to empower the staff as well as patients. The cockscrew cycles of engagement, empowerment and reflection were continued until developing an effective chronic illness management practice at primary care level in COVID 19 era.

Results and discussion
Brief discussion about the development of an effective plan for chronic illness management at primary care level during COVID19 era The clinic was conducted as Out Patient Department (OPD) until March 2020 -before lockdown. In order to prevent the COVID 19 spread in community, the medications were delivered without doing vital examination in the clinic. Home delivery of the medications was arranged for infected locations. The effectiveness was reflected as poor in the management of chronic illness.
It became the 1st challenge and engagement to initiate an effective management plan. The OPD system had changed to an 'Appointment' system. Therefore, all 200 patients were divided into 4 major groups and each major group was divided into 4 minor groups to cover the clinic hours 8.am to 12 noon. A minor group with 10-15 patients were allocated per hour. The patients were empowered by clearly explaining and pasting their time allocation as a sticker on their clinic record book. Also, telemedicine was activated in order to connect the services over the phone consultation. Thus, facilitates unplanned visits, satisfaction to the patients with the new appointment system as well as prevent congestion.
The 2 nd challenge was how to provide a first line protection for patients as well as staff from the suspected COVID 19 cases visiting to the center. A handwashing tap system was arranged by the patient welfare society at the entrance of the center in order to facilitates the hygienic practices. Also, a triage system was developed at the entrance of the building. Health attender was trained to carry out the triage as well as patient's involvement was encouraged. The checklist of triage included temperature, symptoms and contacts with cases and suspected cases. The reflection of the pilot plan was discussed with staff and patient welfare society members of FHC, Kondavil. Patients involved and developed a permanent triage system at the entrance of the center. That facilitates to prevent the community spread as well as routine works of the FHC, Kondavil.
The 3 rd challenge was how to reduce the 'person to person' exposal time duration to avoid unwanted exposure for both staff and patients. This challenge empowered the staff to implement a plan for quick action not exceeded to 30 minutes with 1meter social distance. Therefore, the regular working station was separated for each tasks and time allocation was limited to maximum 10 minutes per station. The medications were already packed on the previous day of the clinic as individually and the outer cover was labeled with the particular patients' name, registration number and appointment time. That facilitates the quick move from the center and avoid unwanted long-term exposures. And it paved a way to run routine monthly follow-ups and drug delivery without fail.

Conclusion and recommendation
The study can be concluded that, appointment system (avoid congestion), triage (minimize the entry of infected cases), separated working stations (reduce the risk in the work place), self-care management at home level (prevent the chronic illness complication development) and proper resource management (overcome the inadequacy) at primary care level are the recommendation for an effective chronic illness management plan in COVID 19 era.

Conflict of interest
There is no conflict of interest.