Stories from the front line: The COVID-19 response, one year later

The global healthcare system will never be the same. The COVID-19 pandemic exposed the industry’s persistent shortfalls as well as new challenges. But it also highlighted healthcare workers’ grit and resilience. They have a new sense of confidence and cautious optimism. Partnerships will endure. Supply chains will be better equipped. Data analysis, combined with the right technology, will expand and improve care. Modern Healthcare checked in with the front-line caregivers we spoke to last year to see how they’ve coped and adapted.

Dr. Dixie Harris struck up a conversation with the driver who was taking her to her first shift at Northwell Health’s Southside Hospital on Long Island. He told her about his friend and fellow driver, a 40-year-old father of two young children, who died from COVID-19.

It was a sobering reminder of why Harris, a pulmonologist specializing in critical care at Salt Lake City-based Intermountain Healthcare, and 100 of her coworkers traveled to New York last April to help the overstretched staff. After more than two weeks, Harris and her peers returned to Utah with an intimate understanding of the virus and a renewed purpose, she said.

“Having the opportunity to do something of that magnitude was probably one of the best things I have done in my life,” Harris said. “When you stretch yourself outside of your comfort zone, it is a phenomenal experience.”

Going to another health system across the country and hitting the ground running boosted the confidence of Harris and the team. They grew closer, constantly checking in on WhatsApp and meeting up for meals when they could. Harris gained an appreciation for supply stockers who made sure staff had enough gloves and procedure packets. There are “people in the background who become the most important part of the team,” she said.

They were armed with best practices when they returned, guiding their colleagues in Utah, Nevada and Idaho through the most effective treatments and how to best manage patients on ventilators. They also served as each other’s support, debriefing and sharing stories as they reflected on their deployment, Harris said.

“Telling others what we heard and saw was incredibly impactful,” Harris said, adding that she is on a COVID-19 steering committee with the Veterans Affairs Department and University of Utah and is working with the Centers for Disease Control and Prevention on guidelines about “long-COVID.”

For the workers at Northwell and New York-Presbyterian, the Intermountain team gave them a much-needed reprieve, even if it was only for a moment.

“I thank you for the fact that I can put my head down now tonight and know that I have space and time tomorrow to do some really simple things that have gone by the wayside and mean so much—get sleep, cook a healthy meal, call my parents and have a full conversation, play with my baby, and get outside. It’s such a gift that you are giving and I thank you sincerely,” Dr. Erica Olsen, an emergency medicine physician at NewYork-Presbyterian Columbia, wrote to the Intermountain team.

Harris and her coworkers are hopeful that they can leverage their experience to continue to suppress the virus. They’re buoyed by declining numbers but recognize that the coronavirus is not going away overnight; up to 30% of nonhospitalized COVID patients have chronic symptoms including fatigue and shortness of breath, Harris said.

Harris and her fellow providers have been asocial, isolating to keep the virus away from their family and friends. Seeing her family, safely, will be the biggest comfort, Harris said.

“The ability to do that and know I can do it without endangering them will be such a relief,” she said.

Ochsner Health has downsized from three floors of COVID-19 units to one, but the infrastructure will act as a buffer in future emergencies, said Dr. Katherine Baumgarten, medical director of infection control and prevention at Ochsner.

While the New Orleans-based system had a pandemic play book to pull from with Hurricane Katrina and Ebola and swine flu outbreaks, it had to quickly build out isolation rooms last March that prioritized infection control and personal protective equipment rationing. When there isn’t a need for the COVID units, Ochsner will convert them to med/surg and intensive care.

“We will have the ability to flex up,” Baumgarten said. “We are now discussing the tipping point of when to change a unit from regular use to COVID.”

Ochsner also adjusted its PPE strategy. Last year, the health system relied on local producers of face shields, masks and gowns. Those partnerships will remain but the system also stockpiled equipment and is looking into other U.S.-based manufacturers, Baumgarten said.

“People often talk about when we will get back to normal. I don’t know if we ever go back to where we were two or three years ago, but hopefully we take the lessons learned and continue to evolve as this situation evolves,” she said. “I certainly feel more hopeful at this point.”

Meanwhile, Encompass Health, which runs 139 inpatient rehab hospitals, 241 home health and 82 home hospice agencies, went from using 3,000 to 4,000 N95 respirators a month to a high of 70,000, said Elaine Prince, vice president of operations support. The health system quickly ran through the roughly two-week supply of critical supplies at its hospitals.

Encompass partnered with Medline to bolster its reserves, centralize its distribution centers as well as purchase more supplies from domestic manufacturers. Medline is now manufacturing face masks at its Lithia Springs, Ga., plant.

“We’ve built in some flexibility,” said Prince, adding that Encompass is creating a full-time position for supply chain resiliency and vendor management.

The industry should be able to move quicker, Baumgarten said. Ochsner and its peers had to work with state and federal agencies to interpret and act on new data on an hourly basis. They had to redeploy both healthcare and nonhealthcare workers to meet the demand.

In addition to on-the-fly adjustments, the pandemic has solidified the importance of cleanliness, infection control and addressing mental health issues, Baumgarten said.

Part of the evolution hinges on recognizing what we lost, she said.

“We need to work through the grief that we didn’t have time to process—the grieving of people we lost and the way of life we had,” Baumgarten said. “We need to give ourselves a chance to grieve.”

Dr. Sanjay Kurani was at his daughter’s softball game in March 2020 when he got a call from one of his fellow doctors at Santa Clara Valley Medical Center.

The doctor told him there was a patient at the San Jose, Calif., facility who had an acute respiratory illness, but they hadn’t traveled internationally or knowingly been in close contact with COVID-19 carriers.

Kurani looked at all the people around him, realizing the potential impact of a virus that could easily and discreetly spread through communities.

“That is the moment when your heart sinks. You look at the sea and don’t know how big the tidal wave is that possibly already hit,” said Kurani, who eventually found out that about 11% of Santa Clara Valley’s patients were COVID-positive. “That was the other gut punch.”

Kurani and his coworkers set out to identify who was most vulnerable to COVID-19. They discovered that if patients are male, over the age of 60, have a body-mass index of at least 30 and have comorbidities like diabetes or heart conditions, they are more likely to get sick.

Patients who have fewer than three of those characteristics are extremely unlikely to require hospitalization. And 1 in 8 patients who meet at least three of the criteria will likely get very sick, Santa Clara Valley’s analysis revealed.

The data, disseminated with the help of the local public health department, informed stay-at-home policies that helped curb cases in Northern California.

The risk score still holds up after a year’s worth of data, Kurani said.

“What this taught us is that some of this data analysis is going to have to be done internally,” he said. “As much as we want to rely on the rest of academia and the scientific community, if we are all dealing with a novel pathogen again, it is unfair to ask them to develop analysis quickly because we are all learning at the same time.”

All the disparate sources of information and data were a major obstacle, Kurani said. Santa Clara Valley put together a team to vet the information, centralize it and guide policy decisions.

“There was this vacuum of science-based information,” he said. “Anytime you’d turn on the TV, there was so much information. I would tell people that it is unfair for the American people to try to determine what is signal versus noise.”

The medical center shared what it learned about COVID with area providers as well as county and state agencies, which leaned on each other more than ever before.

They shifted personal protective equipment and testing supplies based on demand. When one hospital was short on beds, another would pick up the slack.

“Even though we take care of the same communities, we’d sometimes operate in silos,” Kurani said. “At the end of the day, our problems became their problems, so we got ahead of it. I can’t stress how important the partnership with other hospitals, county leadership at the public health department as well as the state has been.”

While telehealth visits have dropped off from their peak from April of 2020, Providence is still planning to reconfigure its real estate and launch virtual care programs.

Telehealth accounts for about 20% of all clinic visits offered by the Renton, Wash.-based system, down from around 50% in mid-April mirroring national trends. While some medical groups are hovering around 40% of all clinic visits being delivered via video or phone, Providence expected telehealth utilization to level out around 25% across the system.

“We were hopeful we could create standards and practice patterns that get us to 40%,” said Jennifer Schaab, chief operating officer of the physician enterprise, adding that telehealth accounted for only a fraction of a percent of clinic visits pre-pandemic. “It’s not just patients who are asking for it. As a healthcare organization that is capital-intense, we’d love to see much more virtual visits so we don’t have to have as much brick-and-mortar space.”

Providence already consolidated some of its physician offices across its Southern and Northern California networks. Providence will continue to adjust its real estate footprint based on how many patients and physicians embrace telehealth, Schaab said, noting that they are considering smaller facilities where physicians rotate throughout the week to take video and phone calls.

In addition, Providence recently launched its first virtual medical group, comprising specialists and primary-care physicians in Orange County, Calif. The medical group can connect patients to doctors across the county who can offer a wide range of services rather than just treating an earache or rash, said Dr. David Kim, chief executive of physician enterprises at Providence.

“It really is a medical group without walls. That was unthinkable a year ago,” he said.

More patients and physicians are getting comfortable with the medium. To ease the transition, Providence established a team prior to the pandemic that helped train and field questions from clinicians. Those same coding, engineering and nursing staff were instrumental in helping clinicians navigate billing, technology and workflow issues during the pandemic, executives said.

A lot of the providers’ concerns were assuaged during the pandemic: Will the patients find it valuable? Will they be able to establish a connection? Could they address chronic or acute conditions? Will they get paid similar rates?

“Many of the hesitations that doctors had were proven to be false,” said Kim, noting that quality scores were similar between virtual and in-person care. But doctors said patients were eager to get back into the clinic, according to Kim.

As for payment parity, the jury is still out, Schaab said. Some states have leveled reimbursement for in-person and telehealth visits, similar to the waivers implemented during the pandemic.

If telehealth ends up being reimbursed at 70% to 80% of the in-person rate, Providence has crunched the numbers and secured physician buy-in on a volume boost that would offset the payment disparity, she said. Providence is also lobbying for easing federal site-of-service regulations that limit where clinicians and patients are located during telehealth visits.

Telehealth has been a lifeline for behavioral healthcare, Schaab said, noting Providence’s growing behavioral health team that serves Alaskans. “We are building a nationwide behavioral health group with a focus on the pediatric and young adult population,” she said. “We will be able to get to a population that we couldn’t get to before.”

It also increases access to providers, Kim said. The flexible hours and locations that telehealth offers attract more clinicians.

“It is a difference-maker for physicians and other providers,” he said. “I couldn’t find a psychiatrist that I trusted to send my patient to. Now, so much of the access barrier is eased by taking away the geographic limitations. That has had an enormous impact.”

One of Dr. Elizabeth Lowe’s nursing home patients was considering going to the hospital as he battled COVID-19.

It was last April, the height of the first wave that slammed many nursing home residents and staff. The patient was in the second week of the illness, and Lowe knew that his family wasn’t going to see him again if he went to the hospital. Lowe told the patient’s daughter to give her two hours—enough time to convince an oxygen company to bring a tank and write a morphine order.

“We dressed them up in PPE and she got to be with her dad as he passed away,” Lowe, an internist at MarinHealth, said. “Being able to provide those moments made me feel like I was helping make a bleak scenario slightly less dark. I might not have been able to change the outcome, but I could help change the experience—that mattered.”

Lowe and Kaiser Permanente caregivers, in collaboration with the Marin County Department of Public Health, have traveled to long-term care facilities throughout the California Bay Area to try to curb the spread of COVID-19. While skilled-nursing facility residents and staff make up less than 1% of the population, they account for around a third of COVID deaths, according to Kaiser Family Foundation data.

The daily calls have slowed to twice a week as vaccination efforts reduced COVID cases across long-term care facilities.  
While COVID grants fueled their mobile van, long-term funding has been hard to come by.

Lowe has reached out to University of California at San Francisco, which helped the providers set up an acute-care clinic with drive-through testing last year. The goal is to expand the mobile outreach for the immobile.

But it’s hard to measure the impact. Preventing hospital visits and acute care doesn’t translate well to dollars and cents, Lowe said.

“My eyes can’t unsee what I have seen this past year,” she said, adding that she cried herself to sleep on Christmas Eve because the facilities didn’t have enough staff, which meant some COVID-positive patients had to lie in their own waste. “Our elderly are very vulnerable. It’s nothing against these facilities, it’s just hard work that is not reimbursed or compensated well. It opened my eyes to how we treat our elders and our communities.”

Even without funding for mobile outreach, providers expect the partnership to last.

“It’s been one of the silver linings of the pandemic,” said Dr. Karin Shavelson, chief medical officer at MarinHealth Medical Center & Network.

Lowe has restarted her primary-care practice, splitting time with the mobile outreach. But she and her peers have not been able to breathe a sigh of relief as variant strains of the virus threaten the progress they’ve made.

While there isn’t a silver-bullet solution, long-term care workers need to be rewarded with the respect and compensation they deserve, Lowe said.

“I don’t know what the greater fix is. But people who work in long-term care are definitely heroes, because I think a lot of CEOs wouldn’t do that job,” she said. “It’s hard to bear witness to that and not be changed.”