Transforming Patient Care With the Mobile Test-to-Treat Program

By Helena Keown, Sarah Liston, Nixxi Chen, Jacob Watkins, and Andy Cook

During an unprecedented health crisis like the COVID-19 pandemic, adaptability has been a key to keeping communities safe. NYC Test & Treat Corps’ mobile testing program has been a prime example of changing course to address an ever-evolving public health event, pivoting creatively as new needs emerge, and using our existing infrastructure and past successes to allow us to mobilize quickly.

The mobile program began in July 2020 with just 10 van-and-tent units supplementing the city’s COVID-19 testing program. Today, 87 testing vans deploy each day across the city, vans that have administered over 2 million tests since the program’s inception across more than 1,800 unique locations. From January 2021 through June 2022, this program model expanded to administer 275,000 COVID-19 vaccines at mobile vaccination sites.

Most recently, with COVID-19 treatments now available as another valuable tool to keep communities safe and healthy, Test & Treat used the same mobile model to expand access to the medication Paxlovid. Paxlovid is an oral antiviral medication targeting specific proteins of the COVID-19 virus to prevent viral replication. A course of Paxlovid is taken for 5 days, and has been shown to reduce the chance of hospitalization and death by 88%.

Mobile Test-to-Treat: A Brief History

To get this life-saving medication into more hands, Test & Treat designed the nation’s first mobile Test-to-Treat program, a one-stop-shop on wheels that allows for rapid antigen COVID-19 testing, evaluation by an onsite clinician, and the immediate prescribing and dispensing of Paxlovid – all at no cost to patients regardless of insurance or immigration status.

On June 30, 2022, the program officially launched with 3 mobile units. The units were parked directly in front of and operated in partnership with a trio of community pharmacies, where the provider on-board prescribed Paxlovid to positive, eligible patients, and our pharmacy partners dispensed the medication.

Over the course of July, the mobile Test-to-Treat fleet grew from 3 to 30 units operating in all 5 boroughs. By the first week of August, these units were not only able to test and prescribe, but also to dispense Paxlovid onboard — a true one-stop resource for COVID-19 treatment! The program has also been implemented aboard Test & Treat Corps’ eight mobile Street Health Outreach + Wellness (SHOW) units – a program focused on the medical care and treatment of unsheltered New Yorkers.

As of September 18, 2022, Mobile Test-to-Treat had administered more than 51,000 tests and prescribed Paxlovid to over 1,500 New Yorkers. Based on NYC H+H data from the initial roll-out of COVID-19 therapeutics, that’s as many as 85 hospitalizations prevented through this program within its first three months.

In October, Test & Treat will expand its mobile Test-to-Treat fleet from 30 units to a total of 75 units. In addition to rapid antigen testing, onsite clinical evaluation, and Paxlovid, these units will offer PCR testing, with the patient able to choose which type of test they want per visit.

Like the mobile testing program before it, mobile Test-to-Treat has equity at the core of its design. Patients are not required to present an ID, provide a home address, or have a smartphone in order to receive treatment and/or test results. Eliminating these requirements removes barriers that often prevent people from seeking and receiving the healthcare they all need and deserve.

Many factors are considered when selecting neighborhoods in which to locate mobile Test-to-Treat sites, including an area’s COVID positivity rate, uninsurance rate, and existing healthcare infrastructure (or lack thereof). Being a mobile program, we are able to follow the data and stand up resources where they are most needed at any given time, and meet people where they are, in a literal sense, by setting up at major thoroughfares, popular public areas, and community events.

Understanding Eligibility for Paxlovid

One of the most widespread misconceptions we have encountered about Paxlovid is that one must have ‘severe’ or ‘severe enough’ symptoms to start the medication. While it is true that a patient must have symptoms that onset within the last 5 days to be considered for Paxlovid, the medication can and should be started even if the patient only has mild symptoms. Taking Paxlovid early will help prevent the progression of the virus to a more severe illness.

Paxlovid eligibility is challenging to convey to the public in a simple, straightforward manner because eligibility hinges on a multitude of factors that can differ greatly from one patient to the next. There is no one-size-fits-all formula that applies to eligibility because it depends on everything from current medication regimen (including supplements) to medical history, lifestyle factors, and even a patient’s demographics.

Minimum Criteria

To start, there are minimum criteria that every patient must meet before they can even be considered for a Paxlovid evaluation. These include:

• Positive SARS-CoV-2 test
• Age 18 and over; Or ages 12 – 17 and weighing at least 40kg/88lbs
• Symptoms consistent with mild to moderate COVID-19 with onset occurring within the last 5 days
• Has one or more risk factors for progression to severe COVID-19
• Not requiring hospitalization due to severe or critical COVID-19 at the initiation of treatment
• No known or suspected severe renal impairment or hepatic impairment
• No history of clinically significant hypersensitivity reactions

Next Steps in Eligibility

Once all of the above criteria are met, the clinician must next consider other factors before eligibility can be determined, including the patient’s:

• Medical history and current medication regimen (including OTC medications and supplements)
• Age (there is an elevated risk for severe COVID for age 50+ and a high risk for ages 65+)
• Lifestyle Factors (e.g. being sedentary and/or a smoker)

Considering Demographics

In addition to the above, it is important for the clinician to also give due consideration to a patient’s demographics. Some people are at increased risk of getting very sick or dying from COVID-19 because of where they live or work, or because they can’t get healthcare. This includes many people from racial and ethnic minority groups and people with disabilities.

All of the above varying factors underscore the importance of being able to provide patients with detailed, personalized medical consultations with onsite clinicians at each and every mobile Test-to-Treat unit.

Special Considerations

Reduced dosing of Paxlovid is recommended for patients with mild to moderate renal and/or liver disease. Paxlovid in a reduced-dose package is available from the manufacturer.  Alternatively, the dispenser can reduce dosing by removing certain pills from the blister card and taping over them.

There are a number of drug-drug interactions associated with Paxlovid, requiring that a clinician conduct a thorough review of all medications and supplements that a patient takes prior to prescribing. In some scenarios, it may be necessary to reduce or pause the dosing of a patient’s routine medication while the patient takes Paxlovid. Doing so makes it possible to safely administer Paxlovid and avoid drug-drug interactions.

Program Evolution

A number of valuable programmatic changes were implemented along the way to help streamline the process, better serve our patients, and to get the word out about this life-saving treatment to the community at large.

Pre-Assessment of Symptomatic Patients

To better target and triage the patients who should be immediately evaluated for Paxlovid eligibility, a pre-screening plan has been developed. Each patient presenting at a mobile Test-to-Treat unit is greeted, the reason for their visit is established, and the patient is asked whether they have any COVID-like symptoms and, if yes, whether their symptom onset has been within the last 5 days.

If the answer to both of those pre-screening questions is “yes,” the patient is flagged to the advanced practice provider (APP) for a consultation and will be pre-evaluated for Paxlovid eligibility so that if they test positive, the medication can be immediately prescribed and dispensed.

First Dose On-the-Unit Protocol
In addition to evaluating for, prescribing, and dispensing Paxlovid, onsite clinicians also guide patients about how and when to take Paxlovid. To familiarize patients with medication dosing, onsite clinicians now give patients the option to take their first dose right onsite. This allows the patient to go through the process of opening the package and taking a dose of the medication under the guidance and supervision of a clinician – helping to familiarize the patient with what to do once they are home and taking the medication on their own.

Telehealth
Making telehealth available to mobile Test-to-Treat patients increases the number of COVID-positive patients who can be evaluated for Paxlovid eligibility – especially in the case of patients who may have left the mobile Test-to-Treat site prior to receiving their positive test result and/or positive, but asymptomatic patients who later developed symptoms.

Treating Minors
Paxlovid eligibility starts at age 12 and, in addition to all of the usual minimum criteria, requires that a patient between the ages of 12-17 weigh a minimum of 40 kg or 88 pounds. To ensure that those young patients meet the weight requirement to take Paxlovid, scales were added to all of the mobile Test-to-Treat units.

Community-Based and Faith-Based Organizations
Building partnerships with community and faith-based organizations has been pivotal to the success of the mobile testing and mobile vaccination programs. Continuing that work, the mobile Test-to-Treat program leverages those relationships with community partners to educate the public about Paxlovid treatment via trusted messengers, as well as spreads awareness about the availability and accessibility of this free, life-saving resource.

Looking Forward

Carrying forward the learnings and successes of the past two and a half years of pandemic response, the mobile Test-to-Treat program is the newest example of using existing resources creatively to meet current needs. As the program continues to see the needs of the patients who arrive at mobile units, new changes will be adapted to improve care delivery and to better serve the community.