Evaluation of a novel community-based COVID-19 ‘Test-to-Care’ model for low-income populations

Background: After a COVID-19 diagnosis, vulnerable populations face
considerable logistical and financial challenges to isolate and
quarantine. We developed and evaluated a novel, community-based approach
(‘Test-to-Care’ Model) designed to address these barriers for
socioeconomically vulnerable Latinx individuals with newly diagnosed
COVID-19 and their households. Methods: This three-week demonstration
project was nested within an epidemiologic surveillance study in a
primarily Latinx neighborhood in the Mission district of San Francisco,
California. The Test-to-Care model was developed with input from community
members and public health leaders. Key components included: (1) provision
of COVID-19-related education and information about available community
resources, (2) home deliveries of material goods to facilitate safe
isolation and quarantine (groceries, personal protective equipment and
cleaning supplies), and (3) longitudinal clinical and social support.
Newly SARS-CoV-2 PCR-positive participants were eligible to participate.
Components of the model were delivered by the Test-to-Care team which was
comprised of healthcare providers and community health workers (CHWs) who
provided longitudinal clinic- and community-based support for the duration
of the isolation period to augment existing services from the Department
of Public Health (DPH). We evaluated the Test-to-Care Model using the
Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM)
Framework and drew upon multiple data sources including: programmatic
data, informal interviews with participants and providers/CHWs and
structured surveys among providers/CHWs. Results: Overall, 83 participants
in the surveillance study were diagnosed with COVID-19, of whom 95%
(79/83) were Latinx and 88% (65/74) had an annual household income
<$50,000. Ninety-six percent (80/83) of participants were reached
for results disclosure, needs assessment and DPH linkage for contact
tracing. Among those who underwent an initial needs assessment, 45%
(36/80) were uninsured and 55% (44/80) were not connected to primary care.
Sixty-seven percent (56/83) of participants requested community-based CHW
support to safely isolate at their current address and 65% (54/83) of all
COVID-19 participants received ongoing community support via CHWs for the
entire self-isolation period. Participants reported that the intervention
was highly acceptable and that their trust increased over time – this
resulted in 9 individuals who disclosed a larger number of household
members than first reported, and 6 persons who requested temporary
relocation to a hotel room for isolation despite initially declining this
service; no unintended harms were identified. The Test-to-Care Model was
found to be both acceptable and feasible to providers and CHWs. Challenges
identified included a low proportion of participants linked to primary
care despite support (approximately 10% after one month), and insufficient
access to financial support for wage replacement. Conclusions: The
Test-to-Care Model is a feasible and acceptable intervention for
supporting self-isolation and quarantine among newly diagnosed COVID-19
patients and their households by directly addressing key barriers faced by
vulnerable populations.