A KHN investigation found that dozens of nursing homes and hospitals ignored official guidelines to separate COVID patients from those without the coronavirus.

The article was published on Thursday, September 10, 2020 in Kaiser Health News.

By Christina Jewett

Nurses at Alta Bates Summit Medical Center were on edge as early as March when patients with COVID-19 began to show up in areas of the hospital that were not set aside to care for them.

The Centers for Disease Control and Prevention had advised hospitals to isolate COVID patients to limit staff exposure and help conserve high-level personal protective equipment that's been in short supply.

Yet COVID patients continued to be scattered through the Oakland hospital, according to complaints to California's Division of Occupational Safety and Health. The concerns included the sixth-floor medical unit where veteran nurse Janine Paiste-Ponder worked.

COVID patients on that floor were not staying in their rooms, either confused or uninterested in the rules. Staff was not provided highly protective N95 respirators, said Mike Hill, a nurse in the hospital intensive care unit and the hospital's chief representative for the California Nurses Association, which filed complaints to Cal/OSHA, the state's workplace safety regulator.

"It was just a matter of time before one of the nurses died on one of these floors," Hill said.

Two nurses fell ill, including Paiste-Ponder, 59, who died of complications from the virus on July 17.

The concerns raised in Oakland also have swept across the U.S., according to interviews, a review of government workplace safety complaints and health facility inspection reports. A KHN investigation found that dozens of nursing homes and hospitals ignored official guidelines to separate COVID patients from those without the coronavirus, in some places fueling its spread and leaving staff unprepared and infected or, in some cases, dead.

As recently as July, a National Nurses United survey of more than 21,000 nurses found that 32% work in a facility that does not have a dedicated COVID unit. At that time, the coronavirus had reached all but 17 U.S. counties, data collected by Johns Hopkins University shows.

KHN discovered that COVID victims have been commingled with uninfected patients in healthcare facilities in states including California, Florida, New Jersey, Iowa, Ohio, Maryland and New York.

A COVID-19 outbreak was in full swing at the New Jersey Veterans Home at Paramus in late April when health inspectors observed residents with dementia mingling in a day room — COVID-positive patients as well as others awaiting test results. At the time, the center had already reported COVID infections among 119 residents and 46 virus-related deaths, according to a Medicare inspection report.

The assistant director of nursing at an Iowa nursing home insisted April 28 that they did "not have any COVID in the building" and overrode the orders of a community doctor to isolate several patients with fevers and falling oxygen levels, an inspection report shows.

By mid-May, the facility's COVID log showed 61 patients with the virus and nine dead.

Federal work-safety officials have closed at least 30 complaints about patient mixing in hospitals nationwide without issuing a citation. They include a claim that a Michigan hospital kept patients who tested negative for the virus in the COVID unit in May. An upstate New York hospital also had COVID patients in the same unit as those with no infection, according to a closed complaint to the federal Occupational Safety and Health Administration.

Federal Health and Human Services officials have called on hospitals to tell them each day if they have a patient who came in without COVID-19 but had an apparent or confirmed case of the coronavirus 14 days later. Hospitals filed 48,000 reports from June 21 through Aug. 28, though the number reflects some double or additional counting of individual patients.

COVID patients have been mixed in with others for a variety of reasons. Some hospitals report having limited tests, so patients carrying the virus are identified only after they had already exposed others. In other cases, they had false-negative test results or their facility was dismissive of federal guidelines, which carry no force of law.

And while federal Medicare officials have inspected nearly every U.S. nursing home in recent months and states have occasionally levied fines and cut off new admissions for isolation lapses, hospitals have seen less scrutiny.

The Scene Inside Sutter

At Alta Bates in Oakland, part of the Sutter Health network, hospital staff made it clear in official complaints to Cal/OSHA that they wanted administrators to follow the state's unique law on aerosol-transmitted diseases. From the start, some staffers wanted all the state-required protections for a virus that has been increasingly shown to be transmitted by tiny particles that float through the air.

The regulations call for patients with a virus like COVID-19 to be moved to a specialized unit within five hours of identification — or to a specialized facility. The rules say those patients should be in a room with a HEPA filter or with negative air pressure, meaning that air is circulated out a window or exhaust fan instead of drifting into the hallway.

Initially, in March, the hospital outfitted a 40-bed COVID unit, according to Hill. But when a surge of patients failed to materialize, that unit was pared to 12 beds.

Since then, a steady stream of virus patients have been admitted, he said, many testing positive only days after admission — and after they'd been in regular rooms in the facility.

From March 10 through July 30, Hill's union and others filed eight complaints to Cal/OSHA, including allegations that the hospital failed to follow isolation rules for COVID patients, some on the cancer floor.

So far, regulators have done little. Gov. Gavin Newsom had ordered workplace safety officials to "focus on … supporting compliance" instead of enforcement except on the "most serious violations."

State officials responded to complaints by reaching out by mail and phone to "ensure the proper virus prevention measures are in place," according to Frank Polizzi, a spokesperson for Cal/OSHA.

A third investigation related to transport workers not wearing N95 respirators while moving COVID-positive or possible coronavirus patients at a Sutter facility near the hospital resulted in a $6,750 fine, Cal/OSHA records show.

The string of complaints also says the hospital did not give staff the necessary personal protective equipment (PPE) under state law — an N95 respirator or something more protective — for caring for virus patients.

Instead, Hill said, staff on floors with COVID patients were provided lower-quality surgical masks, a concern reflected in complaints filed with Cal/OSHA.

Hill believes that Paiste-Ponder and another nurse on her floor caught the virus from COVID patients who did not remain in their rooms.

"It is sad, because it didn't really need to happen," Hill said.

Polizzi said investigations into the July 17 death and another staff hospitalization are ongoing.

A Sutter Health spokesperson said the hospital takes allegations, including Cal/OSHA complaints, seriously and its highest priority is keeping patients and staff safe.

The statement also said "cohorting," or the practice of grouping virus patients together, is a tool that "must be considered in a greater context, including patient acuity, hospital census and other environmental factors."

Concerns at Other Hospitals

CDC guidelines are not strict on the topic of keeping COVID patients sectioned off, noting that "facilities could consider designating entire units within the facility, with dedicated [staff]," to care for COVID patients.

That approach succeeded at the University of Nebraska Medical Center in Omaha. A recent study reported "extensive" viral contamination around COVID patients there, but noted that with "standard" infection control techniques in place, staffers who cared for COVID patients did not get the virus.

The hospital set up an isolation unit with air pumped away from the halls, restricted access to the unit and trained staff to use well-developed protocols and N95 respirators — at a minimum. What worked in Nebraska, though, is far from standard elsewhere.

Cynthia Butler, a nurse and National Nurses United member at Fawcett Memorial Hospital in Port Charlotte, on Florida's west coast, said she actually felt safer working in the COVID unit — where she knew what she was dealing with and had full PPE — than on a general medical floor.

She believes she caught the virus from a patient who had COVID-19 but was housed on a general floor in May. A similar situation occurred in July, when another patient had an unexpected case of COVID — and Butler said she got another positive test herself.

She said both patients did not meet the hospital's criteria for testing admitted patients, and the lapses leave her on edge, concerns she relayed to an OSHA inspector who reached out to her about a complaint her union filed about the facility.

"Every time I go into work it's like playing Russian roulette," Butler said.

A spokesperson for HCA Healthcare, which owns the hospital, said it tests patients coming from long-term care, those going into surgery and those with virus symptoms. She said staffers have access to PPE and practice vigilant sanitation, universal masking and social distancing.

The latter is not an option for Butler, though, who said she cleans, feeds and starts IVs for patients and offers reassurance when they are isolated from family.

"I'm giving them the only comfort or kind word they can get," said Butler, who has since gone on unpaid leave over safety concerns. "I'm in there doing that and I'm not being protected."

Given research showing that up to 45% of COVID patients are asymptomatic, UCSF Medical Center is testing everyone who's admitted, said Dr. Robert Harrison, a University of California-San Francisco School of Medicine professor who consults on occupational health at the hospital.

It's done for the safety of staff and to reduce spread within the hospital, he said. Those who test positive are separated into a COVID-only unit.

And staff who spent more than 15 minutes within 6 feet of a not-yet-identified COVID patient in a less-protective surgical mask are typically sent home for two weeks, he said.

Outside of academic medicine, though, front-line staff have turned to union leaders to push for such protections.

In Southern California, leaders of the National Union of Healthcare Workers filed an official complaint with state hospital inspectors about the risks posed by intermingled COVID patients at Fountain Valley Regional Hospital in Orange County, part of for-profit Tenet Health. There, the complaint said, patients were not routinely tested for COVID-19 upon admission.

One nursing assistant spent two successive 12-hour shifts caring for a patient on a general medical floor who required monitoring. At the conclusion of the second shift, she was told the patient had just been found to be COVID-positive.

The worker had worn only a surgical mask — not an N95 respirator or any form of eye protection, according to the complaint to the California Department of Public Health. The nursing assistant was not offered a COVID test or quarantined before her next two shifts, the complaint said.

The public health department said it could not comment on a pending inspection.

Barbara Lewis, Southern California hospital division director with the union, said COVID patients were on the same floor as cancer patients and post-surgical patients who were walking the halls to speed their recovery.

She said managers took steps to separate the patients only after the union held a protest, spoke to local media and complained to state health officials.

Hospital spokesperson Jessica Chen said the hospital "quickly implemented" changes directed by state health authorities and does place some COVID patients on the same nursing unit as non-COVID patients during surges. She said they are placed in single rooms with closed doors. COVID tests are given by physician order, she added, and employees can access them at other places in the community.

It's in contrast, Lewis said, to high-profile examples of the precautions that might be taken.

"Now we're seeing what's happening with baseball and basketball — they're tested every day and treated with a high level of caution," Lewis said. "Yet we have thousands and thousands of healthcare workers going to work in a very scary environment."

Nursing Homes Face Penalties

More than 40% of the people who've died of COVID-19 lived in nursing homes or assisted living facilities, researchers have found.

Patient mixing has been a scattered concern at nursing homes, which Medicare officials discovered when they reviewed infection control practices at more than 15,000 facilities.

News reports have highlighted the problem at an Ohio nursing home and at a Maryland home where the state levied a $70,000 fine for failing to keep infected patients away from those who weren't sick — yet.

Another facing penalties was Fair Havens Center, a Miami Springs, Florida, nursing home where inspectors discovered that 11 roommates of patients who tested positive for COVID-19 were put in rooms with other residents — putting them at heightened risk.

Florida regulators cut off admissions to the home and Medicare authorities levied a $235,000 civil monetary penalty, records show.

The vice president of operations at the facility told inspectors that isolating exposed patients would mean isolating the entire facility: Everyone had been exposed to the 32 staff members who tested positive for the virus, the report says.

Fair Havens Center did not respond to a request for comment.

In Iowa, Medicare officials declared a state of "immediate jeopardy" at Pearl Valley Rehabilitation and Care Center in Muscatine. There, they discovered that staffers were in denial over an outbreak in their midst, with a nursing director overriding a community doctor's orders to isolate or send residents to the emergency room. Instead, officials found, in late April, the assistant nursing director kept COVID patients in the facility, citing a general order by their medical director to avoid sending patients to the ER "if you can help it."

Meanwhile, several patients were documented by facility staff to have fevers and falling oxygen levels, the Medicare inspection report shows. Within two weeks, the facility discovered it had an outbreak, with 61 residents infected and nine dead, according to the report.

Medicare officials are investigating Menlo Park Veterans Memorial Home in New Jersey, state Sen. Joseph Vitale said during a recent legislative hearing. Resident council president Glenn Osborne testified during the hearing that the home's residents were returned to the same shared rooms after hospitalizations.

Osborne, an honorably discharged Marine, said he saw more residents of the home die than fellow service members during his military service. The Menlo Park and Paramus veterans homes — where inspectors saw dementia patients with and without the virus commingling in a day room — both reported more than 180 COVID cases among residents, 90 among staff and at least 60 deaths.

A spokesperson for the homes said he could not comment due to pending litigation.

"These deaths should not have happened," Osborne said. "Many of these deaths were absolutely avoidable, in my humble opinion."

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

The COVID-19 pandemic has resulted in steep declines in vaccinations.

This article was published on Tuesday, September 8, 2020 in Kaiser Health News.

By Carmen Heredia Rodriguez

Dr. Chris Kjolhede is focused on the children of central New York.

As co-director of school-based health centers at Bassett Healthcare Network, the pediatrician oversees about 21 school-based health clinics across the region — a poor, rural area known for manufacturing and crippled by the opioid epidemic.

From ankles sprained during recess to birth control questions, the clinics serve as the primary care provider for many children both in and out of the classroom. High on the to-do list is making sure kids are up to date on required vaccinations, said Kjolhede.

But, in March, COVID upended the arrangement when it forced schools to close.

"It was like, holy smokes," he said, "what's going to happen now?"

Schools play a pivotal role in U.S. vaccination efforts. Laws require children to have certain immunizations to enroll and attend classes.

But this academic year, to prevent COVID-19 from spreading, many school districts have opted to start classes online. The decision takes away much of the back-to-school leverage pushing parents to stay current on their children's shots, said Dr. Nathaniel Beers, member of the Council on School Health for the American Academy of Pediatrics. If schooling is not happening in person, said Beers, who also led multiple roles in the District of Columbia Public Schools system, "it is harder to enforce."

Public health officials have relied on schools as a means to control vaccine-preventable diseases for over a century. Vaccination laws that require immunizations to enter school first emerged in the 1850s in Massachusetts as a means to control smallpox, as the Centers for Disease Control and Prevention has noted.

Every state requires children to receive certain vaccinations against illnesses like polio, mumps and measles before entering the classroom or a child care center, unless the child has a medical exemption. Some states allow people to opt children out of vaccinations for religious or philosophical reasons, although these exemptions have been associated with outbreaks of otherwise well-controlled diseases like measles.

"If they get behind or they don't get specific vaccines they need, kindergarten is a real catch point to get them up to speed and make sure they're up to date," said Claire Hannan, executive director of the Association of Immunization Managers.

At the local level, the responsibility of tracking whether students are compliant generally falls on the school nurse. If one is not present, a clerical worker or administrator does the job, said Linda Mendonca, president-elect of the National Association of School Nurses. Usually, school systems face a deadline for checking every child's record and reporting compliance to government health officials, she said.

How districts choose to hold noncompliant children accountable varies, Beers said. Some schools work with parents to set up appointments with a provider. Some isolate children in a classroom, he said, and some are so strict that "you can't even walk through the door unless you are appropriately immunized."

The COVID-19 pandemic has resulted in steep declines in vaccinations. In May, a report from the CDC showed a sharp drop in the number of orders submitted to the Vaccines For Children program, a federal initiative that purchases vaccines for half the children in the U.S. A second release revealed similar trends — vaccination coverage in Michigan declined among all milestone ages, with the exception of immunizations given at birth, which are generally done in a hospital.

Making Backup Plans

In Pennsylvania, for instance, the state health department in July suspended vaccine requirements for two months after the start of the school year. In addition to causing delays in doctors' offices, the state said, the pandemic may also prevent school and public health nurses from holding in-school "catch-up" vaccination clinics.

"The department cannot stress enough that as soon as children can be vaccinated, they should be," said Nate Wardle, press secretary for the state's health department, in a written statement. However, the lockdown order prompted by COVID meant "that there was a several month period in some parts of the state where well-child visits were not occurring."

Members of the American Academy of Pediatrics, the National Association of School Nurses and the Association of Immunization Managers said the grace periods are a prudent step to account for the pandemic's effect on pediatric care. The majority of children already have some protection from diseases from previous vaccines, they said.

Additionally, Beers acknowledged that closing schools — among other actions like restricting travel and shuttering large gathering spaces — make children less likely to contract or spread illnesses that typically incubate in classrooms. For example, according to CDC data, measles has essentially disappeared — 12 cases had been reported as of Aug. 19 this year, compared with 1,282 throughout 2019.

However, schooling will eventually resume in person, which will also bring back the risks of illnesses moving through classrooms, Beers said. And school systems may be less forgiving of children who enter the classroom without the needed vaccinations.

"What would be an immense shame is if schools reopen in person and children are back together and we start getting outbreaks of other diseases that are preventable based on immunizations," he said.

School-based health centers in New York are actively contacting parents about vaccinations. In Cooperstown, Kjolhede reached out to every superintendent soon after the lockdown in March to ask if the clinic could remain open. All but one said no.

The staff then set up telehealth appointments and phoned students who needed in-person care to arrange visits — including those who needed a vaccine before the start of this school year, he said. Luckily, the health center that remained open had a door that allowed patients to enter the clinic without walking through the school.

Several hours away, Dr. Lisa Handwerker is grappling with how to tackle the problem that hundreds of students across her six school-based health clinics in New York City have missed a required vaccine.

The city's health department gave her a list of students in her care who needed additional immunizations, she said. Over 400 children were missing the second dose to prevent meningococcal meningitis, generally given to teens and young adults ages 16 to 23. Because the department used data from the last academic year to compile the list, Handwerker has no information about new students. Some families left the city because of the lack of income and resources caused by the pandemic.

"We had difficulty with at least half of the kids on our vaccine list," Handwerker said. "Then when we reached families, they were reluctant to leave their houses."

A Shot at Normalcy

That wasn't the case for Tracey Wolf, a mother of two who visited the doctor recently to get her son Jordan vaccinated for measles, mumps, rubella and HPV before starting the seventh grade. He will be attending middle school in Dunedin, Florida, in person, said Wolf, 38.

It seemed nonsensical to keep Jordan, 13, from his classmates when he already plays baseball and hangs out with his friends, she said. His grades also slipped last spring when the COVID threat transformed his classroom into a computer.

She also took her 6-month-old Ethan for his immunizations. When asked whether she was afraid of going into her doctor's office, she replied, "Not more than going to the grocery store."

Regardless of whether a child starts school at home or in the classroom, immunization experts stressed the importance of vaccinating a child on time. The schedules factor in a child's stage of development to maximize the vaccine's effectiveness. That said, it is preferable that children get their vaccines from their regular doctor to prevent lost immunization records and additional shots, said Beers.

Yet on Aug. 19, the Department of Health and Human Services released a statement allowing pharmacists to provide childhood immunizations for children ages 3 to 18.

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

In time for the tail end of summer, many local governments are lifting restrictions to resuscitate tourism activity and rescue small businesses.

This article was published on Friday, September 4, 2020 in Kaiser Health News.

By Blake Farmer, Nashville Public Radio

Hopefully, summer won’t end the way it began. Memorial Day celebrations helped set off a wave of coronavirus infections across much of the South and West. Gatherings around the Fourth of July seemed to keep those hot spots aflame.

And now Labor Day arrives as those regions are cooling off from COVID-19. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, warned Wednesday that Americans should be cautious to avoid another surge in infection rates. But travelers are also weary of staying home — and tourist destinations are starved for cash.

“Just getting away for an hour up the street and staying at a hotel is like a vacation, for real,” says Kimberly Michaels, who works for NASA in Huntsville, Alabama, and traveled to Nashville, Tennessee, with her boyfriend to celebrate his birthday last weekend.

Lifting Restrictions for Summer’s End

In time for the tail end of summer, many local governments are lifting restrictions to resuscitate tourism activity and rescue small businesses.

Nashville, for instance, gave the green light to pedal taverns this week, allowing the human-powered bars-on-wheels to take to the streets again. “They’re not Nashville’s favorite group, frankly. But fairness requires this protocol change to take place,” Mayor John Cooper said, noting the city’s dramatic reduction in new cases. This week, the city also raised the attendance cap on weddings, funerals and other ceremonies.

Elsewhere, Virginia Beach tried to get some leniency for its struggling restaurants over the holiday weekend. But Virginia Gov. Ralph Northam rejected pleas from the mayor, at the encouragement of Fauci. The country’s top health official has encouraged governors to keep restrictions in place to avoid another holiday-related surge.

“Sometimes, as we start to lift restrictions, the impression that people get is ‘Oh, that must mean it’s safe,’” says epidemiologist Melissa McPheeters of Vanderbilt University. “We want to make sure we don’t give that impression, because this disease has not gone anywhere.”

Some communities have gone the other direction and reimposed restrictions, especially for the three-day weekend. Santa Barbara, California, has banned sunbathing to avoid another surge in cases.

Schooling Screws Up COVID Circles

There’s also a new X-factor with summer’s last holiday weekend. In many states, schools have resumed in-person classes. So families and friends meeting up are now more likely to expose each other to the virus, even if they tried to keep a tight circle over the summer.

“If those bubbles now have kids that went back to school and are interacting with others or they’ve gone back to sports and the bubble has since expanded, that ability to be safely together in a gathering is probably less likely,” says epidemiologist Bertha Hidalgo of the University of Alabama-Birmingham.

And yet, getting together safely — preferably outdoors — is still worth a try, Hidalgo says. She says people’s mental health needs a boost to get through the next few months.

“If you can do the safe things now before winter hits and that cold weather hits, then you’ll be more resilient to get through any bad times that may come,” she says.

In drivable destinations like Nashville that have welcomed visitors throughout the pandemic, tourism has not bounced back entirely. But on some weekend nights, the neon-soaked tourist district can draw a crowd.

This week, Vaj Vemulapalli and his girlfriend, of Dallas, turned back to their hotel after feeling uncomfortable with how tightly people were packed together.

“We crave the social interaction, the going out to bars and everything,” he says. “But at the end of the day, our general stance is it’s not worth getting [COVID-19] just to get a drink.”

Those crowds have limits, though, as Kimberly Michaels and birthday boy Marcus Robinson discovered. They arrived in Nashville fashionably late, masked up and ready to responsibly party. But after they checked into their hotel, they discovered that everything has to shut down by 10:30.

“It’s crazy. It was like the twilight zone,” Robinson says. “We went in [to the hotel], the streets were full. Got dressed, come downstairs. Like, where did everybody go? Like, did something happen? But we didn’t know, because we’re not from here.”

Still, as time goes by, some travelers are willing to take more risks to get back to activities that feel normal.

Suzette Ourso lives outside New Orleans and flew to Nashville for her first out-of-town trip since the pandemic hit. She says she’s cautious, wearing her mask whenever near anyone else.

“I keep hand sanitizer in my purse now. That’s something I’ve never really done before,” she says. “But you can die tomorrow riding in your vehicle. So you can’t live your life in fear, either.”

Ourso has a trip to the beach planned for later in the month.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

This announcement comes in response to Trump's executive order last month calling for improved rural health and telehealth access.

This article was published on Friday, September 4, 2020 in Kaiser Health News.

By Sarah Jane Tribble

Knowing it may be met with some skepticism, the Trump administration Thursday announced a sweeping plan that officials say will transform health care in rural America.

Even before the coronavirus pandemic reached into the nation’s less-populated regions, rural Americans were sicker, poorer and older than the rest of the country. Hospitals are shuttering at record rates, and health care experts have long called for changes.

The new plan, released by Health and Human Services Secretary Alex Azar, acknowledges the gaps in health care and other problems facing rural America. It lists a litany of projects and directives, with many already underway or announced within federal agencies.

“We cannot just tinker around the edges of a rural healthcare system that has struggled for too long,” Azar said in a prepared statement.

Yet, that is exactly what experts say the administration continues to do.

“They tinker around the edges,” said Tommy Barnhart, former president of the National Rural Health Association. And, he added, “there’s a lot of political hype” that has happened under President Donald Trump, as well as previous presidents.

In the past few months, rural health care has increasingly become a focus for Trump, whose polling numbers are souring as COVID-19 kills hundreds of Americans every day, drives down restaurant demand for some farm products and spreads through meatpacking plants. Rural states including Iowa and the Dakotas are reporting the latest surges in cases.

This announcement comes in response to Trump’s executive order last month calling for improved rural health and telehealth access. Earlier this week, three federal agencies also announced they would team up to address gaps in rural broadband service — a key need as large portions of the plan seek to expand telehealth.

The plan is more than 70 pages long and the word “telehealth” appears more than 90 times, with a focus on projects across HHS, including the Health Resources and Services Administration and the Centers for Medicare & Medicaid Services.

Barnhart said CMS has passed some public health emergency waivers since the beginning of the pandemic that helped rural facilities get more funding, including one that specifically was designed to provide additional money for telehealth services. However, those waivers are set to expire when the coronavirus emergency ends. Officials have not yet set a date for when the federal emergency will end.

Andrew Jay Schwartzman, senior counselor to the Benton Institute for Broadband & Society, a private foundation that works to ensure greater internet access, said there are multiple challenges with implementing telehealth across the nation. Many initiatives for robust telehealth programs need fast bandwidth, yet getting the money and setting up the necessary infrastructure is very difficult, he said.

“It will be a long time before this kind of technology will be readily available to much of the country,” he said.

Ge Bai, associate professor of accounting and health policy at Johns Hopkins University in Baltimore, noted that telehealth was short on funding in the HHS initiative. However, she said, the focus on telehealth, as well as a proposed shift in payment for small rural hospitals and changing workforce licensing requirements, had good potential.

“We are so close to the election that this is probably more of a messaging issue to cater to rural residents,” Bai said. “But it doesn’t matter who will be president. This report will give the next administration useful guidance.”

The American Hospital Association, representing 5,000 hospitals nationwide, sent a letter to Trump last week recommending a host of steps the administration could take. As of late Thursday, AHA was still reviewing the HHS plan but said it was “encouraged by the increased attention on rural health care.”

Buried within the HHS announcement are technical initiatives, such as a contract to help clinics and hospitals integrate care, and detailed efforts to address gaps in care, including a proposal to increase funding for school-based mental health programs in the president’s 2021 budget.

A senior HHS official said that while some actions have been taken in recent months to improve rural health — such as the $11 billion provided to rural hospitals through coronavirus relief funding — more is needed.

“We’re putting our stake in the ground that the time for talk is over,” he said. “We’re going to move forward.”