A Dedicated Clinic for COVID-19 Patients
How Stanford’s CROWN Clinic provides support after a COVID-19 diagnosis
Linda Barman, MD, associate director of the Stanford CROWN and Express Care clinic, turns on her computer and camera to begin a video visit with a patient who recently tested positive for the coronavirus. She starts with an assessment of the patient’s current condition, asking questions about her pulse oximeter reading and her temperature. Satisfied with the response, Barman begins to delicately probe the patient’s mental and emotional health: Has she been experiencing anxiety? What is her support like at home?
A COVID-19 diagnosis can be extremely nerve-racking, Barman explains. People are scared, and conversations like these can help patients manage their anxiety and distress.
This multilayered, specialized support is a hallmark of Stanford Express Care’s CROWN (care and respiratory observation of patients with novel coronavirus) clinic, which was designed to provide care for patients who have tested positive for the virus but don’t require hospitalization.
CROWN clinic staff is a multidisciplinary group that includes physicians, medical assistants, nurses, advanced care providers, and social workers
Here’s how the process works: A patient receives an initial COVID-19 diagnosis. This diagnosis is passed to CROWN clinic staff, who contact the patient to ask if he or she is interested in receiving care. Interested patients are immediately enrolled in CROWN’s treatment protocol, and their risk level is evaluated using a unique risk stratification system designed by Maja Artandi, MD, medical director of the Stanford CROWN and Express Care clinic, and the clinic team. They are then given access to a multidisciplinary group that includes physicians, medical assistants, nurses, advanced care providers, translators, and social workers. They are also sent a pulse oximeter to monitor their blood oxygen level and heart rate and provided a direct line to call with any concerns or questions.
CROWN staff follows up with their patients at regular intervals, increasing the frequency of check-ins for patients that they’ve deemed high risk. “If we see patients during a video check-in and they don’t look good,” Artandi says, “we bring them in for an exam. In addition to a thorough physical exam, we do x-rays, labs, EKGs, and we can start medications. We also assess whether they can recover at home or if we have to send them to the emergency room.”
The clinic celebrated its one-year anniversary on April 12, 2021. In a recent interview, Artandi and Barman recalled the early days of the pandemic and reflected on the ways their work at CROWN has reshaped their conception of teamwork and patient care.
Reports of coronavirus began to emerge from China in late 2019. By February 2020 awareness of the virus was growing, and by March the World Health Organization had declared it a global pandemic. What were those early days like?
Maja Artandi: The early days were difficult and exciting. In the beginning, when testing was limited, we had to get permission from the health department to test patients for coronavirus, and most of the time they said no. Stanford soon developed its own coronavirus test, and on March 3 we launched a drive-through testing site. It was one of the first in the country. On the first day of testing, I was out in the parking lot with the Express Care clinic manager, Chris Lentz, and we were scrambling to get everything set up. We started out with a Stanford umbrella and some room dividers to give patients privacy. It was very bare bones. But we ramped up quickly. It was wonderful to see how everyone came together in the early days to work on the same goal and how quickly things started to happen.
Linda Barman: I remember that first day we launched drive-through testing! People came out of the woodwork to help. People were taping signs on a table for us, running to get duct tape, and procuring supplies like room dividers for us.
Overnight, we also had to change our care template to mostly remote video. There was so much to figure out—we had to figure out the scheduling and how to triage patients. At the time, we were still learning about COVID-19. We thought everyone had a fever. We didn’t know that many patients lost their sense of smell. We had to come up with guidelines with very limited information. We were figuring out how to screen people, how to keep sick people out of the clinic, and how to protect our patients and our staff members.
What was the impetus for launching the CROWN clinic?
Maja Artandi: Once we had drive-through testing in place, we had all these patients who had received a positive test result. They were stuck. They didn’t know what to do about their diagnosis. They were incredibly scared because they didn’t know what was going to happen. They were isolated at home, they had no resources, and they had no one to talk to. We were also concerned that the emergency department would get swamped with coronavirus patients who were experiencing mild symptoms. And we were also concerned that coronavirus patients who were really sick might not realize how sick they were and wouldn’t go to the emergency room early enough, which could cause major complications. We launched CROWN to provide a space for all of these patients.
The CROWN clinic has cared for hundreds of patients and dealt with constantly changing care guidelines and treatment protocols. What do you think has made your team so successful?
Maja Artandi: It was essential that everybody on the team had the same level of input. We developed the protocols, and our wonderful team of medical assistants, nurses, and providers all gave their feedback. There was really no hierarchy; we all worked closely together. Every person on the team was invested in the outcome, and everybody wanted to improve the workflow. It was fun to work that way, and decisions could be made quickly. Everyone volunteered to put their health at risk because they just wanted to help patients. I think that’s incredibly memorable. I’m so lucky to be part of a group like that.
Linda Barman, MD, checks a vehicle during drive-through COVID testing
Linda Barman, MD (in blue scrubs), reviews patients’ status with (from left) patient care coordinator Coralia Alvarado, MS; clinical nurse Teresa Yip, RN; and patient care coordinator Brittany Barkey
In winter, the Bay Area experienced a surge of COVID-19 cases and hospitalizations. How did your team handle a large influx of patients?
Maja Artandi: In January 2021, we suddenly had more than 100 patients in our clinic. We had to change our workflows within a few days and had to readjust to take care of everyone who needed care—including many patients who didn’t speak English. To address the surge, we temporarily changed our risk stratification system to prioritize high-risk patients. We raised the age cutoff from 65 to 70 for our moderate-risk patients, who received more frequent follow-ups and video visits by MDs or APPs. We also reprioritized who we proactively reached out to. This allowed us to care for all our patients.
A positive COVID diagnosis can be unsettling. Did you find yourself connecting with your patients in a different way?
Linda Barman: There’s a lot of intense emotions around a positive COVID-19 diagnosis. Every visit you have is going to be at least a half hour long. Everyone has questions and needs a lot of social and emotional support. We were always working with patients to figure out ways that they could stay safe and keep their families safe. One thing that I found incredibly touching is the length that all of our patients would go to protect their family members. I remember one patient, a single mom with an 8-year-old son, wore her mask 24 hours a day for 14 days straight. She never took it off because she wanted to keep her son safe.
Maja Artandi: Typically, a patient comes in, has some medical concern, you diagnose, you order the test, and you tell them exactly what’s going on. With COVID-19 it’s so different. You’re on a journey with the patient.
In addition to being the physician, I was the respiratory therapist because I would help many discharged patients wean off their oxygen. I was the social worker. I was the counselor because they were scared and they had so many questions. Each patient visit was very long, but I felt that we did a lot of good. When you talk to someone for 30 minutes and you try to help them—there’s a real connection there. You have to listen and understand what they’re going through.
Many of our patients didn’t have adequate health insurance. I couldn’t send them to a mental health provider. So we did a lot of listening. We also saw a lot of people who have long-term COVID-19 symptoms and are just exhausted and fatigued, and we validated what they were feeling and acknowledged them. Just being there with the patients and calling them on a regular basis made a big difference.
Meet the CROWN Clinic Team
Maja Artandi, MD Linda Barman, MD Kendell Cannon, MD Lucy Kalanithi, MD Thanh Khong, PA-C Mirella Nguyen, NP Sofia Posada, PA Tiffany Purvis, MS, PA-C Kelly Sanderson, NP Malathi Srinivasan, MD Tem Woldeyesus, MD Hannah Wright, PA-C
Lauren Byrne, RN Jeannette Davila, RN Kevin Gelasio, RN Caroline Milford, RN Shannon Tunnell, RN Glen Velilla, RN Enrique Yalung, RN Teresa Yip, RN
Leah Bailey, RN Amber Bonema, BS Christopher Lentz, RN Aileen Santos, RN
Coralia Alvarado, MS Monica Barajas Brittany Barkey Sarah Chung Gloria Corona Heidi Coty Katherine Cummings Marissa Guzman Lizett Leon Robert Martinez Jesus Mendoza Asefash Rivera Isamar Rodriguez Maria Tunchez Manry Valena, CCMA-AC
Heather Filipowicz, MS Megan Mahoney, MD Kirsti Weng, MD, MPH
Richard Giardina, MPH