San Diego County, covering 4,261 square miles and a population of 3.35 million, is home to the U.S. Navy and Marines, 18 federally recognized Indian tribes, diverse racial and ethnic groups, and the busiest international land-border crossing. Less than half the population is non-Hispanic White, 62.5% speak English only at home, and almost one-third of its residents receive Medi-Cal benefits (California’s Medicaid).  Live Well San Diego (LWSD) is the County of San Diego’s (County’s) vision for a region that is Building Better Health, Living Safely and Thriving1.  Although the County’s Health and Human Services Agency (HHSA) is not a direct provider of primary care or medical inpatient services, HHSA is an integrated agency that serves over 1.1 million residents through ongoing health outreach, education, and provision of public health, behavioral health, social services and child welfare services.   

On March 10, 2020, the County activated its Emergency Operations Center (EOC) to manage pandemic responses. The County established the Education and Outreach Branch within the EOC to provide community resources to LWSD’s nine Community Sectors and 13 sub-sectors. Each sector consists of public-private partnerships among County programs and community organizations. The Healthcare Sector, one of LWSD’s Community Sectors, includes sub-sectors containing medical providers, Federally Qualified Health Centers (FQHCs), Medi-Cal managed care plans, dentists, and behavioral health providers. The Healthcare Sector goal is to provide timely and accurate COVID-19 education to health professionals in all its sub-sectors. The strategy is to listen, engage, and support San Diego’s healthcare partners. To accomplish this goal, outreach and education activities include conducting listening sessions, facilitating virtual telebriefings, maintaining a dedicated website and publishing Health Professional newsletters. 

The Healthcare Sector began designing an Academic Detailing by Zip Code (ACDC) program to educate health providers how to help reduce countywide COVID-19 disparities by race, ethnicity, and zip code, even before California released its Blueprint for a Safer Economy, confirming higher test positivity rates in the lowest quartile of the Healthy Places Index (HPI).  Modeled after pharmaceutical detailing, academic detailing involves individualized contact between public health and clinical members of the Healthcare Sector’s Academic Detailing team and healthcare practices in San Diego to deliver tailored technical assistance and share the latest clinical guidelines. ACDC was designed for detailers to build relationships with their assigned healthcare practices through regular follow up. In September 2020, ACDC was piloted with healthcare practices in the zip code location with the highest rate of COVID-19 cases, hospitalizations, and deaths in the county. Continuous quality improvements were made to ACDC as it expanded to two additional zip codes exhibiting the greatest disparities. 

As of December 30, 82% (113/139) of healthcare practices in three zip codes have been successfully engaged. The Academic Detailing team has made over 275 calls and sent over 100 emails to healthcare practices. The Team provided resources in response to mutually identified needs and barriers. In addition, practices have subscribed to healthcare and dental providers newsletters, attended virtual telebriefings, connected with ACDC clinicians, and accessed other resources (e.g., financial, testing, temporary lodging).  

Poverty, access to healthcare, and affordable housing impact health. Certain communities are disproportionately impacted by COVID-19 because of testing barriers and a high proportion of essential workers.  While 33% of San Diego’s population is Hispanic, as of December 29, they accounted for 58% of cases, 56% of hospitalizations, and 47% of COVID-19 deaths, per weekly surveillance reports3 published by the HHSA Epidemiology Unit. According to San Diego County’s COVID-19 Equity Plan developed in October 2020, 39% of all COVID-19 cases lived in the lowest HPI quartile. To maximize impact and ensure awareness of available resources, ACDC targeted healthcare providers serving those living in the lowest HPI quartile, potentially reaching thousands of individuals for each healthcare provider detailed in populations with the highest COVID-19 disparities.    

Academic detailing has been effective in improving provider practices in areas ranging from diabetes and asthma to otitis media and acute bronchitis4. Office visits, typically conducted physician-to-physician, have been a successful strategy to influence physician practice. Academic detailing has also proved an effective method to increase physician recommendations of preventive care and public health measures, such as tobacco cessation5.  Despite the already maximized public health workforce and physical distancing safety measures, the Healthcare Sector discovered innovative ways to implement ACDC. After researching best practices and adapting to pandemic constraints, the Healthcare Sector creatively used resources and relied on new data reports and communications specific to COVID-19 to develop and continuously improve the project. In response to reports that persons living in high-risk communities may have less access to healthcare, ACDC disseminated life-saving information to a variety of trusted healthcare practices, including non-traditional providers, both primary care and non-primary care clinical specialists, urgent care centers, and emergency physicians. The impact of this information is demonstrated with one healthcare office that was contacted and introduced to the project. The following day, the physician called one of the clinicians in the Academic Detailing team for assistance with a 79-year old patient positive for COVID-19. With the physician’s knowledge of the patient and the ACDC team’s knowledge of resources available, they were able to work with the emergency department and refer the patient for monoclonal antibody treatment that was recently made available in San Diego.  

To quickly and creatively respond to COVID-19, first an ACDC workforce was identified. In published literature, nurses, physicians, and public health professionals were trained to visit with healthcare practices to discuss patient care guidelines. Given the scarcity of available clinical staff during the pandemic, the Healthcare Sector coordinated with the County’s EOC to recruit local Medical Reserve Corps (MRC) volunteers, a network of licensed professionals. The Healthcare Sector sought nurses, advanced practice providers, and physician volunteers to work 5-10 hours a week to contact and educate healthcare practices. Graduate student workers (GSWs) obtaining their Master in Public Health (MPH) were also recruited for multiple roles, including database maintenance, analytics, tool development, and direct interaction with healthcare practices, allowing for added support during a time of budget and supervisory constraints. 

Next, local tools and resources were compiled, including the County’s newly created Health Professionals COVID-19 website2, newsletters, surveillance reports, methods to request and optimize personal protective equipment (PPE), behavioral health resources, and vaccine and testing information. The Healthcare Sector also cultivated multilingual patient education materials that covered multiple topics to encourage isolation and quarantine practices, temporary lodging programs for individuals affected by COVID-19 to help them safely quarantine or isolate, unemployment and emergency rental assistance programs, and other local resources (e.g., food distribution sites). Links to Health Officer Orders and clinical guidance (e.g., quarantine and isolation guidelines, steps to take if a patient or healthcare worker is positive for COVID-19, school and childcare symptom decisions trees, reporting laboratory confirmed cases of COVID-19, and vaccination phases and processes to obtain vaccinations) were maintained.    

The Healthcare Sector designed and developed process documents (e.g. workflows and telephone scripts) and obtained tools (e.g. database, Microsoft [MS] Teams platform, and County-issued cell phones & email addresses) to support staff not accustomed to this type of work, to capture data/information shared, and to ensure that GSWs and MRC volunteers could adequately respond to practices’ concerns and questions. Adapting to physical distancing and COVID-19 safety protocols, all tools (including orientation slides, research articles, the database, and email communication templates) were accessible online via the MS Team platform and orientations and meetings were conducted virtually. First, training was required to access and navigate MS Teams, then County cellphones and email addresses were issued. The orientation included an overview of the outreach process to healthcare practices via phone calls and emails to provide current, evidence-based information to reduce incidence of positive COVID-19 cases and disparities in hospitalizations and mortality. Adjustments to tools were made based on the needs expressed by the team during weekly meetings. The Healthcare Sector then individually assigned healthcare practices to GSWs and MRC volunteers to build and strengthen relationships. All communications between the Academic Detailing team and the practices were conducted virtually, and each practice was offered the opportunity for clinical staff to connect with a clinician (including County medical leaders) to further discuss County and clinical guidance. 

As the pandemic evolved, so did ACDC’s clinical messages. Initially, the Academic Detailing team’s primary caution was for providers to follow patients closely after diagnosing COVID-19, especially persons at high risk. This recommendation was essential given the delayed presentation to care in non-Caucasians, as evidenced in other cities by increased deaths at home and in the emergency department. Then local data demonstrated a full day lag between onset of symptoms and specimen collection for testing among Hispanics as compared to Caucasians. The Academic Detailing team updated messaging to encourage healthcare practices to test persons at first onset of symptoms. Current barriers for providers include obtaining and administering monoclonal antibody treatment and COVID-19 vaccinations. The Academic Detailing team is connecting practices with these resources while simultaneously working with County Medical Leadership to ensure equitable allocation of these life-saving modalities. ACDC’s agility in adapting to change helps ensure its relevance and success. 

Responses to the COVID-19 pandemic, including health equity activities, were developed in collaboration and coordination with community partners under the LWSD vision. LWSD is based on the premise that only through a collective effort, in which individuals, organizations, and government work together toward a shared purpose, can meaningful change be achieved in a region as large and diverse as San Diego County. In alignment with the Healthcare Sector’s goal to provide timely and accurate COVID-19 education to health professionals in all of its sub-sectors, ACDC followed the Healthcare Sector’s defined strategy to: 

- Listen: Identify, listen to, and motivate healthcare partners to cooperate in the “3S” (Staff, Stuff, and Structure) approach of disaster management. 

- Engage: Cross-thread, ensure alignment of messaging with the County, and provide timely  response to questions and feedback.  

- Support: Provide relevant and credible information using effective channels.   

By listening to, engaging with, and supporting health professionals, the Healthcare Sector aims to improve knowledge and understanding of COVID-19 clinical guidelines, treatment, and infection control. ACDC assists clinicians educate their patients and staff about best practices to prevent community spread of COVID-19, thus contributing to improving the health of San Diegans. Throughout the pandemic response, the Healthcare Sector’s Academic Detailing team participates and facilitates communications and activities with: 

- Other EOC Community Sectors, such as Business and Employers; Cities, Government, and Tribal Nations; Community and Faith-Based Organizations; Homeless and Shelter; Long-Term Care and Residential Facilities; Military and Veterans; Older Adult and Disability Service Providers; and Childcare and Schools. 

- Committees with community and local government participation, such as the Health Equity Task Force, Emergency Preparedness, and Health Promotion.  

- Chief Medical Officers, Chief Nursing Officers, and Chief Dental Officers of local practices and FQHCs, the Hospital Association of San Diego and Imperial Counties (HASDIC), and the San Diego County Medical Society (SDCMS). 

- Dental providers and the San Diego County Dental Society (SDCDS).  

- Healthy San Diego, a Medi-Cal consortium consisting of a unique partnership of consumers, providers, Health Plans (Aetna Better Health of California, Blue Shield of California Promise Health Plan, Community Health Group Partnership Plan, Health Net Community Solutions, Inc., Kaiser Permanente, Molina Healthcare of California Partner Plan, Inc., and UnitedHealthcare Community Plan), State Department of Healthcare Services/Medi-Cal Managed Care Division, and the County’s HHSA.  

- Local professional associations, such as: San Diego Chapter of the American Academy of Pediatrics, San Diego Chapter of the California Optometric Association, Philippine Nurses Association, San Diego Association of Family Physicians, San Diego Black Nurses Association, and San Diego National Association of Hispanic Nurses. 

The planning and implementation process was developed through engaging with health professionals and incorporating their feedback. A detailed set of procedures, process maps, database, dashboard, and scripts were created to support this project. Feedback from the Academic Detailing team led to improvements in ACDC as well as the Health Professionals website, newsletters, telebriefing, and listening sessions. The MS Teams ACDC platform served as the source of truth for all documents and was utilized to access the database, scripts, correspondence with healthcare practices, and training information. To maintain continuity and support longitudinal relationships between the Academic Detailing team and their assigned healthcare practice (in addition to building credibility and maintaining security), Academic Detailers were provided County-issued cell phones and email addresses to share with each of their assigned practices.  

County and community organizations provided input to the prioritization and identification of ACDC’s implementation by zip code and healthcare practice. Reports produced by the HHSA Epidemiology Unit identified the rates of incidence of COVID-19 cases, hospitalizations and mortality by zip code. SDCMS and SDCDS shared the demographic information of every healthcare practice within each of these zip codes. After reviewing the program idea with the EOC and local professional organizations, the detailer’s script was shared with an Infectious Disease specialist at a FQHC for feedback. Then ACDC was piloted with one Primary Care Practice providing Medi-Cal services in the most disadvantaged zip code. Feedback was incorporated with County clinical guidance and community resources. To develop key ACDC messages, the team considered the challenges of these disproportionally affected communities, such as healthcare access, affordable housing, burden of chronic disease, and food insecurity.  

To implement Academic Detailing, the Healthcare Sector leveraged existing partnerships and processes with the County. The approach included recruiting MRC volunteers and soliciting help from GSWs and unpaid graduate student interns. An effort to identify additional GSWs and volunteer interns was initiated through the EOC and San Diego State University’s partnership to connect current public health students to County internship programs, as well as with the County’s Human Resources to offer temporary, part-time paid positions to interns who had completed 12 weeks of unpaid work with the County. This innovative process secured two additional graduate students, who would have ended their engagement with the County otherwise. 

Partnerships and collaborations were integral to ACDC’s success. As of December 30, the Healthcare Sector has exchanged 38 communications via listening sessions and email correspondence with local professional associations, participated in 13 Healthy San Diego COVID-19 Task Force meetings, facilitated 15 dental provider telebriefings, as well as distributed 70 newsletters to healthcare, dental, and maternal, child, and adolescent health providers and Healthy San Diego. In addition, the Healthcare Sector has facilitated 41 telebriefings with FQHCs and Tribal clinics which have resulted in expanded partnerships and collaborations with behavioral health providers, Medi-Cal Managed Care Plans, HASDIC, SDCMS, and community health workers. Through early establishment of a dedicated generic email address, the Healthcare Sector has also responded to more than 1,300 inquiries from County and community partners, ensuring a consistent point of contact for any questions.  The Academic Detailing team formed partnerships that fostered bi-directional communication with provider practices in order to ensure that every aspect of ACDC was conducted with a health equity lens. 

In August 2020, the County released COVID-19 incidence, hospitalization, and mortality data stratified by race, ethnicity, and zip code. Since zip codes with the highest rates were consistent, the Healthcare Sector team brainstormed ways to reduce these rates and disparity, and ensure outreach and education to healthcare providers. ACDC adapted published Academic Detailing methods to COVID-19 restrictions, including virtual detailing, limited staffing, and acknowledgement that trusted health advisors extend beyond physicians.  

Continuous improvements were made throughout implementation of Academic Detailing. The project concept and script were shared with a frontline Infection Disease specialist at an FQHC experiencing testing positivity rates twice the county average, and who also volunteers in COVID-19 equity efforts at the Centers for Disease Control and Prevention. He and another FQHC Infectious Disease specialist approved the concept and message to healthcare practices: No longer recommend that patients with COVID-19 symptoms go home and wait until they have trouble breathing before contacting their health provider. Persons served in these zip codes as well as non-Caucasians have higher rates of hospitalization and mortality, therefore need closer follow up.  

As testing access became more available and County testing sites became located in areas of highest risk, data from HHSA’s Epidemiology Unit revealed that persons of color had up to a 24-hour greater delay between symptom onset and test specimen collection. The detailer’s message was adapted to request that persons with symptoms be tested as soon as possible and isolated and quarantined appropriately. As additional resources from the County Board of Supervisors were approved, the script was modified to emphasize availability of public health hotel rooms, rental and food assistance for persons who could not isolate and quarantine safely on their own, and stipends for those who were not eligible for sick pay during isolation and quarantine.   

ACDC expanded to additional zip codes according to their rate of incidence and weekly surveillance reports. Since September 23, Academic Detailing has been implemented in zip codes 92154, 92173, and 91911 along the southern border with Mexico. Lessons learned included exploring various pathways to connect with non-responsive healthcare practices (e.g., eliciting response from MRCs and County medical staff given their clinical background and title, and obtaining feedback from HHSA Regional Directors who are knowledgeable about the neighborhoods they serve); shortening the script or utilizing attention-getters to capture interest; understanding the limited time healthcare personnel have; developing email templates for efficient and consistent messaging to healthcare practices; collaborating with Information Technology Services to improve the database tool for usability and reports; and developing desk aids for future references.  

Although initial plans focused on detailing private practices, outreach expanded to hospitals, FQHCs, and Medical Groups through personal emails to Chief Medical Officers with a “forward ready” email to share with their staff. FQHC clinical leaders made this recommendation during a FQHC, Tribal Clinics, and County telebriefing, and it was universally appreciated. This approach was utilized when outreach expanded to behavioral health providers subcontracted by County Behavioral Health Services. The initial 99 healthcare practices in the three zip codes expanded to 137 from positive feedback, continued relationship building, and consistent and timely messaging.    

As of December 30, 2020, the Academic Detailing team made over 275 calls and sent over 100 emails to healthcare practices, subscribed 30 recipients to dental and healthcare provider newsletters, and connected six offices to a clinician for technical assistance regarding infection control. The team has also responded to practice needs and challenges including obtaining PPE and cleaning supplies, staffing, low patient volume, multilingual patient resources, testing information and locations, and current guidance. The team has received positive feedback for providing a concise summary of available resources and the increased engagement with healthcare practices via phone and email.  

Although there are multiple factors, the disparity between time of symptom onset to the time of test specimen collection by race and ethnicity has decreased from 3.2 days in November to 2.4 days as of December 29 among Hispanic/Latinos. Although there is limited outcome data, Academic Detailing has allowed for sharing of resources and clinical tools in county areas with the highest health inequities. Additionally, expanding communications to medical, dental, behavioral, acupuncture, chiropractic, dialysis, home care, and urgent care facilities is likely to be sustained by HHSA’s Public Health Services.  

ACDC has led to meaningful public heath impact. Individual offices have expressed appreciation for the personal contact, and have benefited from resources for staff and patients. Each office detailed has a direct phone number and email address to contact the Healthcare Sector with questions. The offices have utilized access for challenges, including assisting family members of deceased patients to cross the US Border to care for family members with COVID-19, connecting to centers administering monoclonal antibodies, and coordinating with the Emergency Department for patient care. 

ACDC was piloted with the goal of empowering healthcare practices in San Diego county’s most vulnerable areas. The goal is to improve community health by responding to the needs of San Diegans who live in areas at highest risk of being infected with COVID-19 and being hospitalized and dying once infected. The program has been successful in bridging gaps among healthcare providers, patients, and available resources as demonstrated in the following examples of unexpected partnerships, unsolicited requests for academic detailing, and notes of appreciation: 

- Castillejos Eye Institute expressed the “huge blessing” of receiving PPE after expressing a serious need for gloves and sanitation supplies.  

- By conferring with HHSA’s Central and South Regional Director, a healthcare office was able to connect a patient with the Mexican Consulate’s Protection and Humanitarian Permits/Permissions to cross the border to tend to needs of their father’s recent passing and care for her family members.  

- Best Start Birth Center, a healthcare office that was outside of the prioritized zip codes but requested academic detailing through the Healthcare Sector webpage, was connected to PPE and antigen testing “changing the dynamics of how [they] serve and keep [them] much safer… feels like the County sees us and is doing everything they can to keep us safe.”