Who are the vulnerable we need to protect before we open the economy? Common COVID-19 risk factors mean it could be you.

As we look left and right as to who may be at risk if they get COVID-19, some of us should be looking in the mirror. The data is showing that this virus is a low-risk event for almost everyone, but for those with specific health issues, the COVID-19 virus is very efficient at wiping them out in a matter of days regardless of age. The data is showing that underlying health conditions of high-blood pressure, obesity, diabetes and kidney disease significantly increase the risk of dying from a COVID-19 infection.

As US states start to re-open their economies, many of us are paralyzed because we still don't know if we fall into the Low, Medium or High risk category. Up until now we have been spoon fed limited data as we sit sheltered in our homes and apartments and waiting for the all-clear signal-- this is not sustainable. I have heard plans for "openers" to reopen the economy and plans from "closers" to keep the economy closed. Both sides of this argument are failing and will continue to fail. If we do not course correct the failure will be catastrophic for the economy and many thousands of people will needlessly die. 

I am proposing a third option that will allow us to more quickly and safely reopen the economy and dramatically reduce the number deaths. This option could be classified as "protectors" and we are calling this plan Project Safe Haven. Project Safe Haven is a dual approach to 1) Identify and protect those amongst us that are at the highest and lowest risk for COVID-19 and then 2) put a plan in place to protect the high-risk/vulnerable amongst us as the majority of the low-risk population works reopen the economy and go back to work.

We are in urgent need of a comprehensive plan to identify who among us are most at High risk as well as Low risk for negative COVID-19 outcomes. With better data in hand, we can come together on a plan to operate going forward. Would love to hear your thoughts.

As we search high and low for solutions to guide us through this chaos, I believe the simple answer lies right in front of us... Identifying and protecting the weak and vulnerable is the key to reopening the economy.

I apologize for the redundancy, but we must break from the current plan in place and shake up our thinking. If we just flatten the curve, the volume under the curve remains the same. In other words, just extending out the day that vulnerable people will die is not a worthy goal we should be pursuing. A better, albeit ambitious plan would be to accurately identify and protect the most vulnerable. This would lower overall deaths, which in turn would allow us to adjust the strategy from not just flattening the curve but rather shrinking the curve. Through a coordinated effort that leverages timely and accurate data, we would accomplish our dual objectives of reducing the overall number of deaths and rebuilding the economy.

The Project Safe Haven plan is a simple concept, backed by an ambitious plan to protect all the vulnerable population and simultaneously allow low-risk populations gets back to work. I am convinced we can accomplish these dual objectives of protecting the high risk and reopening the economy by providing each of us a personalized risk calculator to help us understand where we fall on the risk spectrum and then providing the education and support needed for the high-risk population. Providing both broad and focused support services to high-risk and vulnerable populations, would help them stay safe until a vaccine is developed or the low-risk population generates a critical mass of immunity.

I know this is a lot to get our heads around, but our current course and speed is driving us into a second great economic depression. My friend Mike Murray has accurately ascribed a war metaphor to the task ahead of us. Each citizen will have an important job in this battle. The identification, education, separation and support of Low, Med & High risk individuals in the community is key to protecting lives and saving the economy. Protecting the nursing facilities and assisted living facilities is the first step, but identifying the high-risk households goes far beyond nursing homes. This effort would require a public/private partnership that operates under the direction of each Governor’s office with four key areas of responsibility:

1) Data. Creating efficient and accurate data collection & decision models. (Open up the hospital source data to make better decisions) (Cost: Free! The cost for this stage should be free and many people would volunteer)

2) Identification. Give the data to data scientists to identify and risk-stratify individuals and households by risk: Low, Med & High. Provide people with a survey tool to help them self-identify their risk so they can make informed decisions. Here is a simple prototype of a survey tool we could build to stratify individual risk www.safehaventutah.org (Cost: Low to Free! Volunteers efforts will help defray much if not most of the costs.)

3) Education. Educate the Low, Med and High-risk households on how to engage and respond so that they can be supported and protected. (Cost: Free! Getting the right messages to the media so they can get the word out. Other education materials can be created if there is budget.)

4) Stay-at-Home Support. Connect with and support the vulnerable individuals and households by coordinating the delivery of groceries, medical prescriptions and services by various government agencies, non-profit groups, volunteers and churches so these high risk individuals can stay at home. (Cost: This phase could be very expensive, but I'm sure many people and businesses would jump in and volunteer.)

As our state of Utah and much of the country are relaxing COVID-19 isolation and social distancing restrictions to reopen and rebuild the economy, we should do this in context of a comprehensive plan to allow the vulnerable to self-isolate for an extended period of time while empowering businesses to reopen and the low-risk population to get back to work. To win this war, the front line of the daily battle will be protecting the vulnerable. Each citizen will have important work to do, but the most difficult, lonely and tedious job to be done may be the continued isolation of those that are High-risk. The `community needs to rally around our grandparents, parents, siblings and neighbors who may be at High-risk for COVID-19 exposure.

One thing we can all agree on is that our current response of locking down the entire population is not sustainable and a new path based on new data that is now available should be immediately considered. As the new data is starting to paint a clearer picture of the subset of the vulnerable population that is being targeted by the virus, we can now mount an appropriate and more surgical response. Our response should be guided by ongoing research that would further stratify the population based on risk. For example, the current version of the CDC guidelines does not include hypertension, which according to peer-reviewed data is the number one comorbidity risk factor identified by the JAMA study. (Hypertension 56.6% of patients, high blood pressure)

A peer-reviewed article published on April 22, 2020 in the Journal of American Medical Association (JAMA) studied the outcomes of 5,700 hospitalized COVID-19 in New York City (see link below. The JAMA study identified that high-risk patients with two of the four underlying health conditions were 37 times more likely to die from a coronavirus infection than a patient without any of the four underlying health conditions.

Source: https://jamanetwork.com/journals/jama/fullarticle/2765184 Source: https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/

According to the JAMA study, in addition to increased age correlated with higher risk, the top four risk factors include:

1) High blood pressure - 56.6% of patients (hypertension)

2) Obesity - 41.7% of patients

3) Diabetes - 33.8% of patients

4) End Stage renal disease (Kidney) 

Additional factors published by other studies include lung and blood cancer and all stage IV cancers. As research and knowledge is rapidly evolving, other risk factors may come into view.

PROPOSAL

Establish a temporary public/private partnership (possibly an NGO) to coordinate the delivery of long-term support services to high-risk individuals/households. As many people do not know that they are at High-risk for COVID-19, Let's create a comprehensive plan to immediately: 1) Build a data modeling and risk stratification task force in coordination with the Utah Medical Association, Utah Hospital Association, Utah Health Department and leading national data scientists; 2) Identify, risk stratify and connect with at-risk individuals and households in Utah; 3) Assess household needs and educate them on how to respond; 4) Support High-risk individuals and households with dedicated care coaches, coordinating the delivery of services from various non-profit organizations, churches, government agencies and volunteers.

Technology Enabled Services Delivered by Care Coaches

While it seems like a herculean task to identify and support all of the vulnerable. I would argue that not doing so is not an option. Not everyone will need help, but everyone should be informed of the risks. Until we know where the front lines are, we won't know how and where to fight the battle. Better data will allow each one of us to better manage our personal choices.

For those that need help, one way to accomplish the task of long-term support and protection of the vulnerable population is through front-line “care coaches” that are supported by technology. A CRM would increase the efficiency of identifying at-risk individuals and assessing household needs and deploying needed services. Although there needs to be an initial health screening and needs assessment for individuals this could be coordinated with community health workers via telemedicine. Going forward, the vast majority of support would be educating individuals and coordinating non-health services to enable long-term compliance with isolation guidelines. These services could include everything from coordinating with individuals’ personal care physicians (PCP) for telemedicine needs, delivery of medicine and groceries, providing timely resources for COVID-19 testing if indicated, arranging for home care and connecting people with other support and affinity groups.

We need to reduce the politics and quickly eliminate our current technology and data silos in order to get on the same page and share the data across each State's various initiatives. Better data will allow us to more efficiently support citizens and businesses. A technology-enabled services approach could permit coordination and deployment of scarce resources to buffer the High-risk population from exposure for an extended period of time until a vaccine can be developed and/or herd immunity develops. While we have limited testing resources, we should allow public health officials to focus testing and screening resources on the front lines of all those who interact with the vulnerable population, including those in licensed skilled nursing facilities and assisted living facilities, delivery people, health care workers, public safety workers, immediate family members, retail and grocery.

Estimated At-Risk Population in Utah

Each state will differ, but based on existing Utah hospital data, it is estimated that approximately 12.5% or 400,000 Utahns are at High-risk for experiencing serious complications or even death if they contract COVID-19. A rough estimation is that 150,000 of those High-risk individuals in Utah are in need of immediate support services. Identifying exactly which individuals and households are at risk is key to implementing a plan.

The above numbers include people over age 65 (356K), many with hypertension or other comorbidities, and all adults with comorbidities (44k) such as lung disease, heart disease, and diabetes, including the underserved and minority communities that have seen higher rates of COVID-19 deaths.

2002 Olympic Model

The proposed model is similar to the model that the State of Utah utilized to execute a successful 2002 Winter Olympic Games and similar to SLOC would be set up as an NGO, independent non-profit organization. When the 2002 Olympics were stuck in a quagmire of corruption, confusion and politics, Utah implemented a public-private partnership to lead and coordinate the State of Utah’s Olympic efforts. The 2002 Winter Olympics were rated the most watched and most profitable winter Olympics in history. We should follow this successful pattern of a public/private partnership to leverage existing State resources where available and appropriate as well as private, business, church and volunteer resources. Initial call center resources could be a redeployment of existing business call center employees borrowed from Utah companies until an assessment of where and how to best staff up a long-term response team is performed.

The management of the program could come from a team that reports directly to the Governor’s office and the team could also be contracted inside a non-profit (NGO) to provide autonomy to operate and align interests. In summary, this approach would create an agile response framework that could coordinate the needed services that would come from volunteers and organizations, private sector, state and federal agencies and from various non-profit organizations. We need to stay at this until a vaccine and effective treatments become widely available or 60% of the general population develops immunity to the disease.

Data Trust

Key to enabling a rapid-response from a cross-organizational effort is the establishment of a shared data architecture called a “Data Trust.” This is similar to the shared data structure put into place for cancer patients using HealthTree.org. Sensitive health data gathered through Project Safe Haven Utah site would be owned by each participating citizen and participants can opt out of the system and ask for their data to be deleted. The aggregated individual and health data we need to be collected in a Data Trust with data security. Key stakeholders would be provided with access to de-identified data access based on contractual agreements that would be governed by a data-governance committee. The data would be shared with and used by key participating stakeholders on an as-needed basis. Through a series of tests, we have learned that initial assessments of individual health would need to be done on an anonymous basis so the individual would more likely answer the questions accurately. Once the individual chooses to reach out for additional help, they will need to share their health information which would be guarded under a data privacy policy.

Summary

Project Safe Haven could provide a structured framework to help direct and coordinate support resources, and as needed directly deploy any additional resources allocated by State government. The project can start with an initial small budget and can be scaled by increasing the reach to more individuals and by increasing the services offered. Private partnerships should be explored to cover much of the operating costs of the program while providing state tax credits back to supportive organizations for delivery of those services.

There has been a lot of complaining in the news media about "wasted money" on COVID-19 response initiatives. To date The State of Utah has received over $700 million dollars from the Federal Government for COVID-19 response. This money can't be spent on budget shortfalls nor can it be spent on helping out businesses-- It must be spent on COVID-19 response

As we strategically deploy resources to fight this invisible enemy, it is important to add some context. Compared to other states, the state of Utah is a relatively small state that has an annual GDP of $139 billion dollars. Pre coronavirus, Utah was generating $380 million dollars a day of output. If we spent $100 million or $200 million getting the state back to work it would an important investment into our future and the amount would be a rounding error on our annual GDP.

The Project Safe Haven budget anticipates that all employees would be hired directly by and NGO non-profit organization. However, if existing state agencies or private companies would be willing to temporarily re-assign employees to become care coaches, then the budget could be significantly reduced. The option of working with private companies to assign call-center workers to the project could also be explored. The State should consider offering private employers a tax credit if they were to wiling to assign a percentage of their call center workforce to become care coaches.

Three Phased Launch

The project should be launched in three phases. Although significant deployment of services would come in Phase III, the project should immediately start to test how to build direct relationships with individuals and test demand for services through pilots in various cities in Utah.

Phase I: First identify the High-risk individuals/households. (This requires access to the data)

Phase II: Build a direct relationship with each household and educate individuals on containment options

Phase III: Add needed services to support long-term isolation.

We cannot sit and wait another day for a plan to show up. Let's encourage our government leaders to adopt a plan like this or propose a better plan. If enough people support this grass roots approach, it will give our leaders the confidence to implement a plan saves lives and the economy.

Regards - Paul