The Atlanta Long COVID Collaborative: A Multi-Health System Long COVID Coordinated Care Model Serving a Diverse Metropolitan Population

Project Summary Long COVID is a highly prevalent disease that can lead to significant impairments in quality of life and function. Poor care coordination has been identified as a key barrier to optimizing health outcomes in Long COVID, resulting in increased healthcare costs and delays in care delivery. These challenges have profound impacts on underserved, minority populations that have a long-standing history of poor access to affordable, quality healthcare. Limited acceptance of Long COVID among clinicians and members of the community contributes to delays in diagnosis and impacts triage to appropriate services. High rates of anxiety, depression, and PTSD are observed in this population and behavioral health services are often limited and disjointed. The Atlanta Long COVID Collaborative leverages the city's coordinated COVID-19 and Long COVID response, and brings together major academic and healthcare institutions in the Atlanta metro area, including Emory Healthcare System, Grady Healthcare System, and Morehouse School of Medicine (MSM). Atlanta is rich in diversity and is home for key COVID-19 at-risk populations including African American and Hispanic populations, underserved communities, and those with significant preexisting comorbidities. Our site is uniquely suited to engage clinical and community stakeholders from our well-established Atlanta RECOVER infrastructure, and from our Grady and Emory Long COVID clinical network. This project aims to increase access to care, improve person-centered care coordination, and expand multidisciplinary networks and behavioral health support. This will be achieved by 1.) increasing primary Long COVID care access through expanded in-person and virtual visit capacity and increasing provider-based referrals through a coordinated education series, 2.) adding dedicated care coordination, social services, and language interpretive staff, 3.) expanding the existing Long COVID-specific subspecialty network and establishing multidisciplinary case conferences to improve collaboration and expedited care of complex cases, 4.) integrating dedicated behavioral health staff and implementing behavioral health and rehabilitation group series, 5.) engaging community support systems including patient advocacy groups and community alliances to improve access to and retention of care and to ensure Long COVID perspectives are integrated into this comprehensive patient-centered medical home (PCMH) model. Clinic evaluation activities will be iterative and include ongoing quantitative and qualitative evaluation of 4 key element domains, including Long COVID care access, person-centered care, multidisciplinary and behavioral health network access, and evidence-based medicine.