COVID 19 May 21

Perspectives on the COVID-19 pandemic from healthcare associations across the continuum

Medline gathered healthcare association leaders from across the continuum of care to share their experiences and lessons learned during the early stages of the COVID-19 crisis and their perspectives on ways the pandemic may change healthcare in the future.

First responders

Chris Way, Director at Large
National Association of Emergency Medicine Technicians (NAEMT)

“I’ve never been more proud of our entire healthcare system. Overall we’ve come together amazingly well, and it’s incredible to be part of that.”

Creative conservation of PPE

To make the most of limited PPE gear, Way emphasized the importance of minimizing the number of transports and minimizing the number of contacts anyone has with a single patient.

“We’re working with nursing homes to implement ways to keep patients inside those settings during the pandemic,” Way said. “Some facilities are using telehealth whenever possible or having providers come onsite, and that’s helping.”

He also mentioned that some fire departments and EMS providers have had to put entire shifts of personnel in isolation after entering homes of patients who had no COVID-19 symptoms, but who later tested positive.

“We’ve now adopted a policy of assuming every patient is positive for COVID-19 until proven otherwise,” Way said. “We send one person in to triage the situation and determine the level of PPE required, and then we send the others in.”

Staffing concerns

Way said acuity in EMS has risen, but overall call volume has dropped off, especially in areas that have not been hit as hard with COVID-19 cases.

“People don’t want to go to hospitals now – they’re scared of infection,” Way said. “So in most areas other than the East Coast or Seattle, we’re not in a crisis of needing more workers.”

He added that recruiting and retaining workers after the pandemic is going to be interesting.

“I think people are either going to be compelled to join the cause, or they’re going to say they don’t want to be any part of that,” Way said. “The next problem after the pandemic resolves could be convincing people it’s still OK to be in healthcare and it’s a desirable career.”

The importance of community collaboration

“I would tell anybody on the EMS side of things, partnerships with public health and hospitals and other first responders – law enforcement and fire departments – are key,” Way said. “Whether it’s now with COVID-19 or it’s the next issue or disaster, look to bolster those relationships.”

Takeaways for the future

When I teach incident command I talk about the Ice cream social concept: The first time you’re sitting there together with the police chief and the fire chief and the sheriff should not be in the midst of a disaster, whether it’s COVID 19, or the town is on fire or there’s been an earthquake,” Way said. “You should get to know each other long before that.”

He added that COVID-19 is a different kind of disaster that also pulls in acute and post-acute care, making all those relationships vitally important as well.

“Continue those relationships you’ve formed so if something like this happens again you’ll be more prepared,” Way said. “Use these opportunities to continue to improve care across the spectrum.

Hospitals and health systems

Michelle Hood, Executive Vice President & COO
American Hospital Association (AHA)

“I’m extremely proud of how we in the healthcare field are responding to this crisis together. We have a lot of faith in the dedicated men and women who are battling this pandemic, and we want to give them every support we possibly can.”

Clinicians working in hospitals are treating the most severe cases of COVID-19. Patients who are hospitalized are experiencing acute symptoms requiring oxygen, breathing assistance and in many cases, ventilator care.

Hood outlined ways the American Hospital Association is advocating for its members during the pandemic.

Conserving supply inventory

“We’re encouraging our members to use creativity and innovation to conserve supplies in every way possible,” Hood said. “We’re speaking with the CDC on a regular basis, brainstorming ideas to assist with optimal ways to practice conservation while also following best practices for infection control.”

Here are some of those ideas:

  • Direct healthcare workers to consolidate tasks so they limit the number of times they enter and exit COVID-19 patients’ rooms. Fewer visits translate into less PPE gear donned overall.
  • Cohort healthcare workers to cluster healthcare services for COVID-19 positive patients to avoid needing to re-mask and re-gown between working with affected and non-affected patients.
  • Make the most of telehealth techniques to monitor patients.

Ramping up supply production

Hood said the AHA has launched the 100 Million Masks program to encourage the domestic production of necessary medical grade supplies by manufacturers that have not been part of the supply chain in the past.

In addition, they are working with hospitals and health systems to partner and coordinate with businesses in their communities that may have the equipment and ability to help produce much-needed personal protective equipment.

Visit www.aha.org/100millionmasks for more information.

Emerging concerns

Looking to the days, weeks and months ahead, Hood is anticipating newly emerging concerns surrounding healthcare workers’ resilience and well-being as the pressures of this environment continue, possible prescription drug shortages and clinical healthcare provider financial issues.

Mental health. Based on past experience with 9/11 and other disasters, Hood said she is anticipating increased cases of post traumatic stress disorder (PTSD) among healthcare workers across the country due to the tremendous stress they are facing under the pandemic.

Possible prescription drug shortages. Hood also noted that certain medications are becoming more difficult to attain, including those that help patients on ventilators and respirators.

Reimbursement for hospitals and healthcare systems. Temporary waivers granted by the Center for Medicare and Medicaid Services (CMS) will help hospitals financially by reducing administrative barriers and payment delays, accelerating payments, issuing interim payments and settling claims for care already provided.

“We are hopeful that private insurers will implement similar policies so hospitals can continue to provide care,” she said.

Skilled nursing facilities and assisted living

Gov. Mark Parkinson, President
American Health Care Association (AHCA)/National Center for Assisted Living (NCAL)

“Within healthcare, we’ve always known what great work our people do. So during these times, it’s nice how the rest of the public is getting to see that and really embrace it. We all see the affection for everyone out there right now who is doing the really important and dangerous work.”

Financial relief

Parkinson is hopeful that the federal economic stimulus package will be enough to adequately cover most providers during the pandemic, particularly the skilled nursing facilities, which require the most financial assistance.

A 2% increase in Medicare payments will go into effect May 1. Under normal circumstances Parkinson said providers would be “high-fiving” each other over that level of increase, but during these times they need all the help they can get. He added that accelerated Medicare payments should solve short-term cash flow problems in heavily affected areas.

He also outlined how businesses with less than 500 employees, which make up about 15 percent of the skilled nursing and assisted living market, qualify for the SBA loan to grant program.

For businesses with more than 500 employees, Parkinson said the lift on withholding payroll payments for Medicare will amount to the equivalent of a zero interest loan for one to two years.

Addressing PPE shortages

Skilled nursing and assisted living does not have enough masks, according to Parkinson. He added that masks are the most important PPE items in skilled nursing and assisted living with the common denominator of with young care staff (potential carriers of COVID-19) working with vulnerable elderly residents.

“There’s probably PPE out there in some settings that just don’t need it right now,” he said. “Some states, for example California, have made remarkably bold and intelligent decisions about shutting their states down before the others, and they just won’t see the spread we’ve seen in New York, New Jersey, Connecticut and Massachusetts.”

Looking at projections from the Institute for Health Metrics and Evaluation (IHME), which Parkinson said seem to make sense, he believes states such as California won’t even come close filling their bed capacity.

That being said, Parkinson believes we can begin to feel comfortable about reallocating the PPE that’s out there in areas that won’t see the massive spread of infection and allocate it to areas that are battling COVID-19 on the frontlines right now.

“We will solve the PPE problem,” he said. “There are tons of supplies in the early stages of the supply chain, and they will be available in the next 60 days. So for the next 60 days, we just need to continue sheltering in place to mitigate the spread, and intelligently allocate the supplies we have. We will get there, but it’s going to take a little time.”

Concerns about patient recovery in skilled nursing facilities

Parkinson shared that governors from New York and New Jersey initially discussed ordering all skilled nursing facilities to accept COVID-19 patients after hospital discharge.

“The concern from some of the facilities was their lack of resources to keep infected patients isolated from vulnerable elderly residents,” Parkinson said.

So a consensus was reached that only properly equipped facilities will be accepting COVID-19 patients.

“We were able to influence modification of the orders so that COVID-19 patients are only being discharged to facilities that are prepared,” Parkinson said. “Those providers are creating COVID-only wings, and the states are providing them with plenty of PPE and plenty of testing so they’re equipped to handle the situation.”

Parkinson also mentioned that Governor Baker from Massachusetts and some other governors initially discussed allocating specific long-term care buildings as COVID-only facilities, but the numbers might not justify that.

Planning for the near future

“As a ray of hope, if the shutdowns continue through April and May, we will grind these numbers down very, very shortly,” Parkinson said.

“If the number of cases continues to decline over the next 30 to 60 days, then we need to strategize our plan for the next six months to a year about out how to proceed in the new world where there are still a limited number of coronavirus cases, and our population is still very vulnerable to infection. Our next hope is for a vaccine and treatments to mitigate the virus.”

Home care and hospice

William Dombi, President
National Association of Home Care (NAHC)

“I’m heartened that we’re already talking about the lessons we’ve learned and the infusion of education that will become a permanent benefit after this crisis.”

Creative conservation of supplies

Home care and hospice agencies have faced more of a struggle getting PPE supplies because they are erroneously not considered to be on the frontlines of the pandemic, according to Dombi.

Creative conservation efforts have included obtaining masks from tattoo parlors and nail salons, and even converting plastic trash bags into PPE suits.

“In terms of handling COVID-19 positive patients at discharge or diverting them from the hospital, home care agencies have been looking to hospitals to provide them with PPE,” Dombi said.

Staffing concerns

Unlike acute care settings, where patient volumes have been increasing, home care is seeing fewer patients overall across the country. Reasons include fewer elective surgeries and patients refusing care because of fears of transmission of infection into their homes.

“One large home care company recently put 750 staff on furlough because of lack of work,” Dombi said.

With a strong mindset toward worker safety and infection control, Dombi said many agencies are also placing workers on quarantine if they have any COVID-19 related symptoms or recent international travel.

Adjustments from CMS are helping

Dombi said he is hopeful that temporary CMS regulation waivers and financial aids such as SBA loans and accelerated payments will be beneficial for homecare and hospice organizations.

“It’s good to see that CMS is working quite quickly. In our conversations with them, they are making it very apparent that they want to continue to ensure access to care while keeping businesses operating,” Dombi said.

He also mentioned that CMS has changed the definition of homebound individuals during the pandemic. “Effectively anyone over age 65 is considered homebound because of their heightened risk of infection,” he said.

Under this temporarily revised definition, individuals can receive reimbursement for healthcare services at home that they previously were required to get at a facility on an outpatient basis.

HME providers

Thomas Ryan, President and CEO
American Association for Homecare

“HME providers are an integral part of the healthcare continuum, especially during these critical times. With our expertise in at-home respiratory care, we’re helping move patients out of the acute care setting to help prevent hospital overflow issues.”

As an advocate for HME providers Ryan knows all too well that they are often the forgotten heroes on the healthcare continuum.

“Our association has been focused on outreach to CMS, state Medicaid authorities, health agencies, governors, major third-party payers, MCOs, and Congress to push for policy changes to help HME operate more effectively and safely during these difficult times.” Ryan said.

He mentioned that the 2% increase from Medicare, some rural relief and a small measure of relief for non-CB areas and CMS relaxing documentation requirements and eliminating red tape of allowing in-home respiratory care is helping.

“But we’re definitely working in crisis mode right now,” he said. “We’re seeing a 350% increase in orders in the hotspots across the country. And the supply chain is essentially broken.”

Ryan said he recently received a call from the chief medical officer of a large hospital system reaching out for help because he couldn’t locate any oxygen for in-home use.

“I called nine providers in New York to get oxygen and beds, and it was very, very difficult,” Ryan said.

He added that suppliers are overwhelmed, and the cost of goods is high, not to mention added surcharges.

“I’m urging providers to partner with their local HME dealer,” Ryan said. “We are part of the solution and we can provide a great deal of assistance with respiratory care.”

A shout out to all HME providers

“We are a relatively large industry with a modestly sized advocacy association,” Ryan said. “HME providers, this is our time to shine. Please join the ranks of AA Homecare.”

To learn more, visit www.aahomecare.org. Download COVID-19 Checklist for HME Providers.