Rural areas of the country have vulnerabilities to the coronavirus and limited resources to respond to the pandemic.
The first wave of the coronavirus disease 2019 (COVID-19) pandemic inundated urban areas such as New York and Detroit, now rural areas are getting overwhelmed, two infectious disease experts say.
The United States has become a global hotspot in the COVID-19 pandemic, with the most confirmed cases and the most deaths in the world. As of April 23, the country had experienced more than 849,000 confirmed cases and more than 47,000 deaths, worldometer reported.
This week, the Infectious Diseases Society of America held an online media briefing on the impact of COVID-19 on rural areas of the country. The situation in Nebraska is emblematic of how the pandemic is affecting rural communities, said Angela Hewlett, MD, MS, director of the Nebraska Biocontainment Unit, and an associate professor at University of Nebraska Medical Center.
"Nebraska, as a whole, looks pretty good. We do not have a lot of positive cases here. But when you break the numbers down by county, a completely different picture emerges. It's alarming!" she said.
The pandemic is exposing the disparity of healthcare resources between urban and rural areas, said Andrew Pavia, MD, chief, division of pediatric infectious diseases, University of Utah School of Medicine. "We have to appreciate that the resources that we have to fight this epidemic are not evenly distributed. The bigger cities have major medical centers, a capacity of specialists, and ICU beds. But when you get 50 to 100 miles out from the big cities, the situation is very different."
Rural areas susceptible to COVID-19 pandemic
While rural areas of the country have some advantages in battling COVID-19 such as built-in social distancing from the geographic dispersion of populations, there are many significant disadvantages, Hewlett said.
Small towns are close-knit communities that often have large social gatherings such as family events drawing people from several towns.
Industries in rural areas including meat packing companies and power plants are considered essential and require most employees to work on-site, so the ability to telecommute from home is limited. "In these industries, there are often lots of people working in very close contact, which is a set-up for perpetuating a disease like this that is spread from person to person," she said.
Smaller communities have smaller hospitals with limited capabilities such as few ICU beds and small stocks of ventilators.
Rural communities have small local health departments, which constrains essential pandemic responses such as contact tracing.
Poor rural communities are particularly vulnerable to the coronavirus, Pavia said.
"We have known for a long time that poverty is a strong indicator of poor general health. Poor people are more likely to have worse diets; greater risk of diabetes, obesity, and heart disease; and they get less care for chronic diseases. We know that all of those factors are risks of dying when you get infected with the coronavirus," he said.
In addition, Pavia and Hewlett said air transport of severely ill COVID-19 patients from rural hospitals to larger medical centers poses serious challenges. The problems include the potentially large number of patients who will need this service and concern over virus exposure of flight crews transporting COVID-19 patients during long flights in small aircraft.
Rural hospitals ill-suited to treat coronavirus pandemic patients
Most rural hospitals are overmatched in the struggle against COVID-19, Hewlett and Pavia said.
"In a rural area, you may have a critical access hospital, which is a hospital that may have 20 beds and possibly one ventilator, if that. They are just not equipped to deal with an influx of sick patients. They are used to caring for individuals within their community with conditions that a small hospital can handle," Hewlett said.
"In the West, we have many hospitals that are critical access and frontier hospitals, and they may have fewer than 20 beds. They may have no ICU beds, or two or three ICU beds, and they are not staffed 24/7. Those beds are used to help patients in the postoperative period," Pavia said.
Beyond the physical limitations of rural hospitals, staffing is a daunting challenge during the COVID-19 pandemic, they said.
"At some of these hospitals, they have done a good job at gearing up, but the staff is quickly overwhelmed. They have to be able to staff 24/7 for weeks at a time, and many of these communities barely have enough doctors and nurses to provide good primary care, let alone 24/7 ICU care," Pavia said.
Shortages of key pandemic specialists are common in rural areas, Hewlett said, noting there are only two infectious disease physicians in western Nebraska.
"There are multiple hospitals that do not have infectious disease specialists or critical care specialists. These are hospitals that typically do not need a critical care specialist to operate 24/7, seven days a week, and that is the need we are seeing with this disease. We have patients who are very sick and require ICU care over an extended period. … These are patients who often require several weeks of ICU-level support; and in small communities, that is just not sustainable," she said.
Healthcare workers are crossing state lines to alleviate staffing shortages during the coronavirus pandemic. What are the legal implications?
There are several legal considerations when licensed healthcare workers cross state lines during the coronavirus disease 2019 (COVID-19) pandemic, a healthcare attorney says.
Last month, the Trump administration declared a state of emergency and changed federal rules to allow licensed healthcare workers to practice medicine across state lines. The move is designed to address shortages of healthcare workers as COVID-19 patients surge and hospital staff are sidelined by coronavirus infection.
To assess the legal implications of licensed healthcare workers crossing state lines, HealthLeaders recently spoke with Melissa Markey, JD, who is an attorney at Indianapolis-based Hall, Render, Killian, Heath & Lyman, P.C. In addition to specializing in healthcare law, she is a licensed paramedic.
The following is a lightly edited transcript of that conversation.
HealthLeaders: What is the new legal mechanism that allows licensed healthcare workers to cross states lines?
Melissa Markey: The federal declaration of emergency empowered state regulators to take the actions that are necessary to temporarily—during the emergency only—waive licensing rules so that licensed personnel from other states can come and help.
The reason why states maintain control over licensure is due to their desire to make sure that the healthcare professionals who are practicing in their state are adequately qualified and adequately trained, and they have not engaged in behavior that is not in the best interest of their citizens.
The waiver removes the ability of the state regulators to look at each professional individually and evaluate where they were trained, how long they have held a license, and what lawyers call character and fitness, which looks at things like whether healthcare workers have ever been convicted of a crime.
HL: How does the ability of licensed healthcare workers to cross states impact reimbursement for medical services?
Markey: On the federal level, the declaration of emergency allows Medicare and Medicaid to pay for the care that is provided by any licensed professional who has gone through the basic checks such as Drug Enforcement Administration registration.
The federal waiver is more about payment of services than licensure. Technically, states have the power to waive their own licensure laws under their own emergency management acts and other state laws. The challenge comes about because of the federal payment rules. If you don't have a federal order, then clinicians would have problems getting paid by Medicare and Medicaid. The federal declaration is mainly about dollars. The state declaration is mainly about the licensure law.
HL: How does crossing state lines impact healthcare worker liability?
Markey: There are a lot of different ways that you can volunteer to provide services, especially in this kind of disaster. Some of those ways of volunteering provide some immunity from liability and some of them don't provide any immunity.
You should check with your malpractice insurance carrier. You also should look at the laws of the state where you will be volunteering your services—you want to find out whether you would qualify under the Good Samaritan law for protection. You should also look at a state's emergency management law.
HL: How does crossing state lines impact workers' compensation?
Markey: It is important to check whether you will be protected through workers' compensation or some other protective scheme if you become injured or ill while you are providing services. This virus does not spare healthcare workers and they are becoming sick—sometimes very sick— with COVID-19.
Typically, a healthcare facility that is using volunteers from another state will confirm that their license is still valid, they will confirm any other criteria that they require to ensure that the healthcare worker is qualified, and they will try to confirm whether a physician holds hospital privileges. So, there is a process at the facility level.
Some volunteer healthcare professionals come through volunteer organizations such as the Medical Reserve Corps or the National Disaster Medical System. You volunteer ahead of time, you get cleared, your credentials are confirmed, then you can get to work right away because you have been pre-credentialed.
Depending on which pathway you go through, you may have liability and workers' compensation protections. For example, the National Disaster Medical System personnel are treated as temporary federal employees, and they are protected from liability and are provided with some workers' compensation protection.
HL: How do you check to see whether you have workers' compensation protection?
Markey: The most common place to find that information is under a state's emergency management act to see whether there is a provision for volunteers who come from outside the state to assist during a disaster.
HL: Would it be prudent to consult with a lawyer before volunteering your professional services in another state?
Markey: That's certainly an option. There also are resources available online from the federal Department of Health and Human Services—the assistant secretary for preparedness and response has some resources. The American Health Lawyers Association public interest group has resources that go through several considerations and outline some of the laws.
For healthcare workers, hospital grocery stores are a welcomed convenience during the coronavirus pandemic.
CommonSpirit Health is opening grocery stores at the organization's hospitals to help support healthcare workers during the coronavirus pandemic.
Many healthcare workers are under intense pandemic pressure, including work under stressful conditions in areas of the country where coronavirus disease 2019 (COVID-19) patients are surging, reassignment to critical care settings, and fear associated with possibly bringing the virus home to their families.
Chicago-based CommonSpirit, which operates hospitals and other healthcare facilities in 21 states, opened its first hospital grocery store on March 30. Since then, grocery stores have opened at two dozen CommonSpirit hospitals, and 22 more are set to open by the end of the month.
Deisell Martinez, PhD, MS, leader of nutrition services at CommonSpirit, says the health system launched the grocery store initiative to help support healthcare workers during the pandemic. "They were so strained and a lot of them found it hard to go to a grocery store at night. A lot of times, when they got to a grocery store, many of the items were gone."
Having grocery stores in hospitals also reduces possible exposure to the virus while shopping and helps address bias against healthcare workers, she says. "One nurse told me that when they get off work and go into a store in scrubs, they get looked at in a strange way. People feel they are bringing the virus with them."
Photo Credit: CommonSpirit Health
Establishing hospital grocery stores
The hospital grocery stores have been a low-cost venture for CommonSpirit because the stores have opened in existing cafés or dining areas, Martinez says. "These sites already had refrigeration, so we didn't have to bring in anything new."
The hospital grocery stores are financially neutral, she says. "What we are doing is taking our cost and transferring it to our employees. We are not making money or losing money. This is not about money. This is about fulfilling our mission. We have a mission of making sure we support our frontline healthcare workers."
CommonSpirit made three primary steps to establish hospital grocery stores, Martinez says.
1. The first step was ensuring there was a viable supply chain to stock the stores. "It started with making sure that we had a supply chain that would be able to sufficiently support the stores, so that the staff would not be disappointed with empty racks," she says.
2. Hospital food and nutrition service directors were contacted to see whether they were interested in providing the grocery store service. St. Joseph's Hospital and Medical Center in Phoenix volunteered to pilot the initiative.
3. A "playbook" was developed to help guide CommonSpirit hospitals through the process of opening and operating a grocery store.
Martinez says the offerings at the hospital grocery stores vary from site to site, but common items include toilet paper, disinfectant, paper towels, eggs, milk, pasta, tomato sauce, canned tuna, rice, flour, and sugar.
When the crisis level of the coronavirus pandemic passes, healthcare providers will need sophisticated strategies to restart elective surgery.
The American College of Surgeons (ACS) has released recommendations to guide healthcare providers when they resume elective surgery that has been put on hold during the coronavirus pandemic.
To boost resources for treating hospitalized coronavirus disease 2019 (COVID-19) patients, governors across the country have ordered hospitals to delay elective surgery procedures. Last month, ACS released guidance for determining which elective surgeries could be delayed appropriately.
Last week, ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries that have been delayed. "Evaluating and addressing each of these 10 issues will help facilities to not only optimally provide safe and high-quality surgical patient care, but also to ensure that surgery resumes and doesn’t stop again," the recommendations say.
The recommendations are highlighted below.
1. Know your community's coronavirus statistics
The maximum incubation period for the coronavirus is estimated at two weeks. There should be a decrease in incidence of COVID-19 cases for at least two weeks before elective surgery is resumed.
Monitor local COVID-19 statistics such incidence of new cases to detect a resurgence of the virus.
Consider setting a threshold for new cases of COVID-19 that would trigger putting elective surgeries on hold again.
2. Know availability of COVID-19 testing and craft testing policies
Monitor local COVID-19 testing availability and lab result times.
Craft testing policies for patients such as pre-operative testing of patients scheduled for surgery.
Craft testing policies for healthcare workers such as screening and testing guidance.
With false negative test rates as high as 30%, consider establishing retesting policies for patients and healthcare workers.
With fever and lung complications possible in the postoperative period, consider establishing retesting guidelines for symptomatic patients.
3. Personal protective equipment
Before elective surgery is resumed, there should be a stored inventory of PPE or a reliable supply chain for at least 30 days of operations.
PPE policies should be in place for COVID-19 positive patients, persons under investigation, and non-COVID-19 patients, including for high-risk procedures such as intubation.
Consider having all healthcare workers and staff wear appropriate PPE outside the operating room and having all patients wear cloth masks.
4. Know key healthcare facility capacities
A hospital's available resources should include peri-anesthesia units, critical care, diagnostic imaging, and lab services.
Consider new sites for elective surgery such as hospital spaces that were converted for COVID-19 care, including outpatient departments.
OR schedules should be set to accommodate a spike of electives surgeries such as performing procedures at night or on weekends.
Make sure there is sufficient capacity for preoperative, intraoperative, postoperative, and post-acute care.
5. Supplies capacity
Ensure there are adequate levels of surgical supplies and equipment such as implants and anesthesia-sedation medications.
Ensure a supply chain is in place for traditional or new vendors.
Conduct an inventory of existing supplies and check expiration dates.
There should be adequate cleaning supplies, particularly for areas where care is provided to COVID-19 patients and persons under investigation.
6. Healthcare worker staffing
There should be adequate multidisciplinary staffing for routine and expanded hours.
Assess coordination of key staff members, including surgeons, anesthesiologists, nurses, and housekeeping.
Have contingencies in place for staff members who test positive for the coronavirus.
Assess the level of stress and fatigue among healthcare workers who have been providing frontline care during surges of COVID-19 patients.
Consider mitigation efforts for workforce shortages such as enlisting retired surgeons to work as first assistants.
7. Create governance committee
A governance committee can make real-time decisions for several pivotal issues, including PPE, pandemic assessment, patient backlog, and safety and quality.
The governance committee should be multidisciplinary, including surgeons, anesthesiologists, and nurses.
At least during the elective surgery ramp-up period, the governance committee should meet daily.
8. Patient communication
Consider creating a multidisciplinary committee to manage patient communication.
There are several crucial patient communication topics, including procedure prioritization, coronavirus testing policies, PPE use, and advance directives.
9. Prioritization of surgery
Key stakeholders such as surgeons, anesthesiologists, and nurses should participate in ramp-up planning, including the collaborative formation of principles and frameworks for surgery prioritization.
The prioritization process should be adjustable to local, regional, and national epidemiological trends and changes in COVID-19 care. The prioritization process should also take a facility's resources, priorities, and patient needs into account.
The prioritization process, principles, and framework should be transparent to hospitals, healthcare workers, and the public. The benefits of transparency include reducing ethical dilemmas.
There are multiple considerations in developing the prioritization process, including a list of canceled and delayed procedures, a strategy for phased opening of ORs, PPE availability, and issues related to increased OR volume.
10. Ensure safety and high value in all five phases of surgical care
Optimal care in the preoperative phase includes considering the use of telehealth.
Optimal care in the immediate preoperative phase features reviewing surgery, anesthesia, and nursing checklists for possible revisions related to COVID-19 positive patients and other considerations.
Optimal care in the intraoperative phase includes guidelines for staff during intubation.
Optimal care in the postoperative phase includes adherence to standardized care protocols.
Optimal care in the post discharge phase includes post-acute care facility availability and safety.
When healthcare organizations administer drive-thru testing, they limit virus exposure inside their facilities.
A Philadelphia-based urgent care provider has a four-step process to offer patients drive-thru coronavirus testing.
Diagnostic testing has been a pain point in the country's struggle to manage coronavirus disease 2019 (COVID-19). Testing of individuals who suspect they have been infected with the coronavirus is crucial to limiting the spread of COVID-19. Testing also is widely viewed as a key component of any strategy to reopen the country's economy.
In Philadelphia and three communities outside the city, vybe urgent care started offering drive-thru coronavirus testing in mid-March, President and CEO Peter Hotz says. The service is billed to all insurance carriers, including Medicare, Medicaid, and commercial carriers, and most insurers have waived patient co-pays, he says.
"We wanted to make sure that our urgent care centers could continue to treat non-COVID-related patients. So, we wanted to make sure our centers were as safe as possible. By limiting the number of positive or suspected positive patients who are entering our centers, we can continue to see other patients," Hotz says.
There are four primary steps in vybe's drive-thru testing process, he says.
1. Telehealth triage
To start the process, patients go to vybe's website and register for a virtual visit. There are two teams of staff members who conduct the virtual visits.
"The first team does all the patient registration, check-in, and virtual triage—they get patient history and symptoms. Then a clinician—either a physician, physician assistant, or nurse practitioner—joins the call and conducts a clinical evaluation with the patient. The clinician determines with the patient whether testing is warranted, and we figure out the closest center for testing. Then a note is sent to the center notifying the patient is coming in for a test," Hotz says.
If it is determined that the patient has a non-COVID-19 condition, medication can be prescribed during the virtual visit, he says.
2. Administering coronavirus test
The coronavirus testing is conducted in an urgent care center's parking lot, Hotz says. "When the patient arrives, they call the center, and a staff member goes out to the car in full protective gear. The patient stays in the car, identification is checked, then the test is conducted."
Medical assistants administer the bulk of the tests, he says.
3. Lab work
Depending on the patient's insurance carrier, test samples are sent to one of two diagnostic testing companies for processing—Quest or LabCorp, Hotz says. "Initially, lab results were taking anywhere from five to seven days to come back to the urgent care center. Now, it is taking two to three days."
4. Communicating test results and treatment plans to patients
For negative results, the patient is contacted via phone call by a medical assistant or another staff member. For positive results, a clinician makes the call, Hotz says.
"Our clinicians call back with positive results because patients tend to have more questions. The clinicians give specific guidance and follow-up instructions as if the patient had come in to see us physically. We send them information on COVID-19 and the things to watch out for—we make sure they are monitoring their ability to breath and their fever."
He says many coronavirus patients self-quarantine at home and do not require further care. Most patients whose symptoms progress are directed to go to the hospital, but some patients without underlying conditions have chest X-rays at an urgent care center to check for pneumonia, Hotz says.
"The overwhelming majority of patients are just staying home, self-monitoring, and self-treating, Fortunately, only a small percentage of patients are seeking care in a hospital. Those who are seeking that higher level of care are typically older, typically have underlying health conditions, and need to have a hospital level of care."
Surges of coronavirus patients, patient deaths from the virus, and hospital cutbacks due to financial pressures during the pandemic strain workforces.
As the coronavirus disease 2019 (COVID-19) pandemic threatens to surge hospital patients in Missouri, Children's Mercy is launching initiatives to support the wellbeing of the organization's employees.
With coronavirus patients surging beyond New York, the COVID-19 pandemic is straining healthcare organization workforces from coast to coast. The United States has more reported COVID-19 cases and deaths than any other country, at more than 644,000 cases and more than 28,000 deaths as of April 16, according to worldometer.
Kansas City, Missouri-based Children's Mercy established its COVID Employee Wellness Support Team to address a pressing need during the coronavirus pandemic, says Jennifer Bickel, MD, a practicing neurologist and COVID employee wellness officer at the hospital.
"The wellbeing of our caregivers is directly related to the wellbeing of our patients. There have been repeated studies showing that when healthcare providers—whether they are physicians or nurses—have problems with depression or burnout they are more likely to make safety errors and less likely to engage in a meaningful way with the patient," she says.
The wellness initiative is designed to formalize efforts to support the wellbeing of staff members during the coronavirus pandemic, Bickel says. "For everybody who goes into healthcare, one of our biggest callings is to be able to take care of people, and many of our colleagues are being drawn into taking care of each other. So, by developing the COVID Employee Wellness Support Team, we were able to develop an umbrella for how our employees can support each other."
How wellness support team works
Bickel says the COVID Employee Wellness Support Team features two dozen psychologists, clinical social workers, chaplains, and hospital leaders who have launched several initiatives.
Clinical specialty teams can set up virtual support groups
Mental health professionals can meet with employees one-on-one virtually or in-person to help them cope with fear, anxiety, and managing change
The Ronald McDonald Respite Room in the hospital is available to all employees from 11 a.m. to 11 p.m. to provide access to food, aromatherapy patches, meditation services, workout equipment, and wellbeing support services
Hospital mindfulness experts are leading employees through virtual guided meditation three times per day
A 10-minute meditation is conducted at the start of a daily COVID-19 planning call attended by about 100 hospital leaders
All of the hospital's information on wellbeing has been placed on a single web page that is available to the entire staff
Psychologists, social workers, and chaplains are conducting wellness rounds in the hospital emergency department and the neonatal intensive care unit
Planned initiatives include expanding respite rooms beyond the main hospital, offering one-on-one counseling sessions to affiliated community physicians, and conducting an American Medical Association COVID-19 wellness survey.
Wellness support team building blocks
Senior leadership was the key to creating the COVID Employee Wellness Support Team at Children's Mercy, Bickel says.
"Having executive leadership has allowed us to put together a team of our own compassionate experts—including psychologists, social workers, and chaplains—to help our employees. Then, we divided those experts to develop teams to work on initiatives," she says.
Drawing on internal experts at the hospital is an essential ingredient of the program, Bickel says. "This is not a time to bring in external consultants. Every hospital has established wellbeing initiatives, and you should build on those rather than break them down to form entirely new initiatives."
Hospitals in areas of the country that have not experienced a surge of coronavirus patients yet have the advantage of time to prepare themselves.
While coronavirus hotspots such as New York and Detroit are coping with patient surges, Valleywise Health is preparing for the challenge.
The coronavirus disease 2019 (COVID-19) pandemic is affecting states with varying intensity, with patient surges expected to roll out across the country in different time frames. For example, as of April 15, New York had nearly 200,000 confirmed COVID-19 cases compared to more than 3,800 cases in Arizona, according to Johns Hopkins University.
"We have been very blessed in Arizona to have the time. We have not seen the large influx of patients like they have in New York or Detroit. So, we have been able to benefit from their experience to make sure that our plans are ready if we experience that type of surge," says Michael White, MD, executive vice president and chief medical officer of Phoenix-based Valleywise Health.
The health system features an academic medical center and 11 community health clinics.
Current modeling predicts Valleywise Health will be able to accommodate a COVID-19 patient surge, he says.
"In the models that we are seeing in Arizona, as a community in Maricopa County we would be able to handle that volume of patients both from a personal protective equipment and a ventilator perspective. If the models change, then my answer will change."
The health system has been preparing for an expected surge of COVID-19 patients for several weeks, focusing primarily on Valleywise Health Medical Center's emergency department and critical care capabilities.
Emergency department preparations
In response to the COVID-19 pandemic, screening and triage protocols in the emergency department are crucial, White says. "We are planning for how we can efficiently screen and triage individuals who may be able to have their care maintained in an ambulatory environment or at home, versus those who may need admission to the hospital for further care," he says.
The medical center's emergency department has established two tracks for incoming patients—one track for patients with respiratory symptoms that could indicate coronavirus infection and another track for patients with non-respiratory acute complaints, White says.
"If a patient has a respiratory complaint, they get triaged into a track where we have staff who have elevated levels of personal protective equipment who can perform COVID-19 testing," he says. Patients who have other acute medical conditions see clinicians who treat "routine patients" who need emergency care.
In addition, the medical center has reconfigured emergency department space to have a designated area to provide critical care to seriously ill COVID-19 patients, White says.
Critical care preparations
The medical center has also concentrated on increasing ICU capacity, he says. "We have already begun to identify new spaces within the acute care hospital to keep patients together who have COVID-19 so we can treat them with ventilators in a critical care capacity."
White says the medical center has already converted the facility's step-down pediatric unit to an adult unit that can treat COVID-19 patients. Other areas that can be converted to provide critical care to COVID-19 patients include procedural space, pre-operative areas, post-anesthesia care units, operating rooms, and ambulatory clinics embedded in the hospital, he says.
In addition to repurposing space for critical care, the medical center is preparing to expand the facility's critical care workforce, White says.
"We will work very closely with our critical care partners and our medical staff to develop a team-based approach. We will have intensivist teams that could supervise hospitalists who could provide basic critical care. The same approach will apply to nursing, where nurses with intensive care training and experience will work with nurses who may not have critical care experience but can do some of those functions while being overseen."
Supporting medical staff
At Valleywise Health, another key facet of preparing for a COVID-19 patient surge has been initiatives designed to support the healthcare workforce, White says.
"We have done a lot of work preparing our staff in relieving their anxieties [such as] making sure there is adequate personal protective equipment. We have done a lot of education on the use of PPE."
Communication is an essential factor in supporting the healthcare workforce, he says.
"We have been transparent with our COVID-19 incident command—we do a daily briefing. We also do a daily newsletter that goes out to the entire staff."
He continues, "One of the early teams we created was an employee engagement and morale team that has done a number of events and other outreach to the staff within the medical center and all of our outlying clinics to make sure we are able to provide support to them. We are entering our third week of that outreach."
Other supportive efforts include displaying employee artwork and deploying mobile tool kits and carts that have snacks and supplies, White says.
Preparing for the worst
If a COVID-19 patient surge is overwhelming, Valleywise Health has established protocols for transferring patients to other health systems and rationing care, White says.
The care rationing protocol has been developed in consultation with other Arizona health systems and Valleywise Health's ethics committee, he says.
"We have that protocol in place in case we need to use it. Most of it is evidence-based around what has been established by the Society of Critical Care Medicine and previously published for these types of situations. There is some modified scoring about what the chance of recovery is based on presentation and comorbid conditions to determine medical utility."
White views care rationing such as a shortage of ventilators as a doomsday scenario that he hopes never comes to pass. "There would be some really tough decisions that we would have to make and grapple with. They would be terrible decisions for us to have to make to decide whether we are truly overwhelmed and how we are going to deliver care."
Behavioral Health Concierge offers telebehavioral services to the Providence health system's employees and their dependents.
Renton, Washington-based Providence health system has launched a telebehavioral health initiative to address mental health issues among the organization's employees and their family members.
The service—Behavioral Health Concierge—has been in high demand during the coronavirus disease 2019 (COVID-19) pandemic. Surges of COVID-19 patients across the country including thousands of patient deaths have strained the mental health of many healthcare workers.
Telehealth visits through Behavioral Health Concierge have spiked during the COVID-19 pandemic, Todd Czartoski, MD, Providence telehealth chief medical officer, told HealthLeaders. "We have seen our highest volumes to date during February and March," he says.
Providence operates 51 hospitals and more than 1,000 clinics in Alaska, California, Montana, New Mexico, Oregon, Texas and Washington state. Behavioral Health Concierge started last year in Montana and Washington, and the program is set to expand to other states this year, Czartoski says.
The health system has stepped up promotion of Behavioral Health Concierge during the COVID-19 pandemic, he says. "It is being promoted on multiple internal communication channels. We also just built a page that includes a stress meter that directs people to various mental health resources, depending on their level of stress."
More than 1,600 visits have been conducted since the program launched, Czartoski said.
How Behavioral Health Concierge works
Employees and their dependents access Behavioral Health Concierge by calling a telephone number to set up an appointment with a licensed counselor, he says. Appointments are offered on a same-day or next-day basis seven days a week from 7 a.m. to 8 p.m.
Visits can be conducted in a phone call or through a video connection, Czartoski says. "For phone visits, the counselor calls the user directly. For video, users will click on a link from either their computer or mobile device to start the video visit. In addition to counseling visits, we offer computerized cognitive therapy, which can be completed on the user's own time."
The initiative was designed to address healthcare worker burnout and other mental health-related issues, he said. "We are collecting data on caregiver burnout and retention to quantify the financial gains of the program."
Behavioral Health Concierge has improved access to mental health services for Providence's healthcare workers and their families, Czartoski says.
"In many regions where Providence has a presence, mental health providers are scarce and hard to access, fueling the need for more in-house mental health services across Providence's map. Behavioral Health Concierge provides virtual counseling to caregivers and their dependents to increase access to critical services in a way that best fits busy schedules and needs. These counseling sessions are based on a brief yet intensive evidence-based therapy model."
Behavioral Health Concierge is funded through a grant and the Providence Caregiver Assistance Program, he says.
Coronavirus patients who are severely ill often need someone to make care decisions on their behalf.
During the coronavirus disease 2019 (COVID-19) pandemic, it is critically important for people to have healthcare proxies, a palliative care expert says.
People can assign someone to serve as a healthcare proxy when they are unable to make care decisions on their own. This arrangement is essential during the coronavirus pandemic for patients and their caregivers because treatment for severe COVID-19 cases involves mechanical ventilation and sedation.
Healthcare organizations should encourage their patients to have healthcare proxy documents, says Kosha Thakore, MD, director of palliative care services at Newton-Wellesley Hospital in Newton, Massachusetts.
"Even outside of COVID-19, it should be standard of care for us to approach patients about having a healthcare proxy because it allows us to take much better care of patients. It is heightened in the age of COVID-19 because what we are seeing are conversations about who patients want to make decisions on their behalf and who can speak to their values and goals," she says.
A healthcare proxy can play an essential role in COVID-19 critical care, Thakore says.
"There are people with COVID-19 who are at very high risk of having poor outcomes. So, we need to start having conversations as early as we can about a patient's values and goals. You need to have a conversation about which interventions really meet a patient's values and goals if they are not going to result in the patient having a good quality of life or an ability to continue being independent. These are the types of conversations we are needing to have urgently in a crisis."
Critical care interventions may not be in a patient's best interest and healthcare proxies can make these kinds of decisions when patients are incapacitated, she says. "Sometimes, putting a patient through intensive care is not going to accomplish the patient's goals, so we need to have conversations with people to avoid doing care that may not be beneficial to patients and may harm them."
The absence of a healthcare proxy can place care teams in an extremely difficult situation, Thakore says.
"The laws for this situation vary from state to state. In Massachusetts, how decisions are made is based on the imminence of the patient's condition. If the patient is in an imminent state, and the attending physician and another physician both feel critical care would be futile—it would not result in prolonging life or saving the patient—then it is up to the discretion of the attending physician to make a decision in the moment."
For incapacitated Massachusetts patients who do not have a healthcare proxy and are not in an imminent medical state, a hospital must go to the courts and petition for a guardian to make decisions on the patient's behalf, she says. "This can result in significant delays in care and misuse of medical resources. Under those circumstances, the patient can be in limbo for several weeks."
How healthcare proxy arrangements work
In Massachusetts, healthcare proxy documentation is relatively straightforward and does not require the assistance of an attorney, Thakore says. The basic elements of a healthcare proxy document are the identifying information of the patient—their full name and their date of birth—then the designation of someone to make decisions on the patient's behalf if they are unable to make decisions.
"At minimum, you need one person to be a proxy; but, ideally, you should select one person and an alternate in case the first person can't make decisions on your behalf. Then you need the signature of the patient and two witnesses—neither of whom can be listed as a proxy on the document," she says.
Once a proxy form has been completed, it should be entered into the patient's medical record, Thakore says.
"In our health system, you supply the form to your primary care physician, then the document is scanned into the electronic medical record so it can be accessed by all providers. If the document is completed in the hospital, we also scan it into the electronic medical record."
As long as a patient is fit to make medical decisions, it is never too late to complete healthcare proxy documentation, she says.
"If patients are in the ER and can speak for themselves, then you can address a proxy document in a somewhat urgent manner. Whenever someone enters our ER, they receive a screening question about whether they have a healthcare proxy. When we get into trouble is if someone without a proxy comes into the hospital and they are no longer able to make decisions for themselves."
Establishing a healthcare proxy should not be a stressful process, Thakore says.
"It is about encouraging conversations between patients and their loved ones about what matters most to them, their goals, and quality of life. Ultimately, what a proxy document does is give a gift to your loved ones so they know what decisions you want made on your behalf if there is a situation where you can't make your own decisions. It is like insurance. We hope we never have to use it, but it is always good to have."
Allegheny Health Network has set patient access strategies for hospitals and primary care.
Allegheny Health Network is pursuing a multipronged strategy to maintain patient access during the coronavirus disease 2019 (COVID-19) pandemic, the health system's president and CEO says.
In hotspot states such as New York, the COVID-19 pandemic has severely strained hospital and primary care capacity. Many other states such as Michigan, New Jersey, and Louisiana also are facing daunting capacity challenges. The United States leads the world in reported COVID-19 cases at more than 468,000 as of April 10, according to worldometer.
HealthLeaders recently talked with AHN President and CEO Cynthia Hundorfean to see how the Pittsburgh-based health system is managing patient access as the number of COVID-19 cases rise in Pennsylvania. Before joining AHN, she was chief administrative officer at Cleveland Clinic. Hundorfean earned her executive master of business administration degree from Weatherhead School of Management at Case Western Reserve University in Cleveland.
The following is a lightly edited transcript of HealthLeaders' conversation with Hundorfean.
HealthLeaders:What are the biggest hospital and primary care access challenges that AHN is facing in the COVID-19 pandemic?
Hundorfean: On the hospital side, the biggest challenge is preparing for a surge with an unknown timeframe and severity. We continue our planning efforts around supplies, personal protective equipment, beds, and staffing. Challenges around testing supplies continue.
On the primary care side, we do not have or anticipate access challenges. We have converted nearly 80% of our primary care visits to virtual (video, telephonic or e-visits) so that sick patients are able to be seen safely.
HL: How are you planning to triage hospital and primary care access if you experience a COVID-19 patient surge?
Hundorfean: We are working to ensure that we have as many beds available as possible. This means opening all licensed beds, converting existing sites of care—such as ambulatory surgery centers, and working with local leaders to secure locations for alternative hospital sites.
From a primary care perspective, we are able to temporarily and safely defer some chronic and well care to open up access for acute care needs. We also have initiated 24/7 on-demand virtual visits for acute care.
HL:How are you managing hospital access for COVID-19 patients?
Hundorfean: We are following Centers for Disease Control and Prevention guidelines with regard to our screening and treatment protocols of confirmed or suspected COVID-19 patients to minimize the risk of transmission and protect the health of our caregivers and other patients in the facilities. Caregivers are equipped with the recommended personal protective equipment, patients are in isolation rooms, visitation is prohibited, and enhanced cleaning protocols of clinical spaces have been implemented.
HL: How are you managing hospital access for non-COVID-19 patients?
Hundorfean: We have followed CDC guidelines and postponed all non-emergent surgeries. We have also postponed most wellness visits or moved these to a virtual setting. Ensuring the safety of non-COVID-19 patients in our hospitals is a top priority. We are utilizing negative pressure rooms for those patients who are COVID-19 positive or suspected positive, and we continue to follow strict protocols to avoid cross contamination.
