COVID-19 offers lessons on preparing for public health disaster
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March 13, 2021 01:00 AM

COVID-19 offers lessons on how to prepare for the next public health disaster

Erica Hensley
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    A provider wearing a gown, face mask and face shield walks down a hospital hallway.
    UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

    Some University of Mississippi Medical Center clinicians devised their own COVID-19 safety messaging to try to get ahead of the fast-spreading coronavirus.

    As community transmission of COVID-19 took hold last March, state health departments launched messaging blasts that some experts say missed the mark with an overly vague suggested response, essentially giving up an opportunity to get ahead of the novel coronavirus.

    Dr. Leandro Mena, a clinician-researcher and chair of the Department of Population Health Science at the University of Mississippi Medical Center, said the health departments’ instructions to the public often centered on just calling a doctor if worried or they had signs and symptoms of infection. “For me there was a little bit of a problem with the messaging and lack of awareness,” Mena said.

    That early mixed messaging caused irreversible damage in some communities, including Mena’s, where uninsured rates are high, chronic diseases prevalent, and low-wage public-facing jobs dominate the employment landscape.

    Those conditions formed a perfect storm for virus spread among vulnerable populations that were already harder to reach before the pandemic.

    By summer, Mississippi would have the highest new case rate in the nation. “On one side the people who you saw being initially most infected by COVID … were disproportionately Black and Latino, people who are disproportionately uninsured,” Mena said. “So people who you knew probably did not have a primary-care provider, but a choice was not given to them.”

    Public health leaders across the country faced similar challenges, forcing them to innovate and improvise ways to get patients the tests and treatment they needed.

    Tracking COVID-19 with tech

    The Public Health Institute helped roll out a COVID-19 vulnerability indexing tool that uses preexisting health disparity mapping technology to understand disparities and community COVID-19 demographics.

    PHI-member Public Health Alliance of Southern California launched the Healthy Places Index in 2018, which has been used by more than 100 government, community and independent agencies to tap into factors that influence health across the state—and importantly, to understand local disparities, all at the Census tract level.

    The new COVID-19 adaptation maps out case and death counts, vulnerable populations, associated health risk factors, healthcare infrastructure, socioeconomic and community conditions, and race demographics.

    Mary Pittman, the institute’s CEO, said the tool has helped the state identify Census tracts to prioritize for vaccination distribution, which can soon be sped up and further leveraged for harder-to-reach populations because of Johnson & Johnson’s single-shot vaccination.

    But even before the vaccination distribution chain started to bulk up, PHI used the tool to target early vaccination campaigns in the Coachella Valley farming communities.

    “They’re essential workers and they rank high in the vaccine priority, but they were not being reached. In part because they couldn’t take off work or they didn’t have transportation to go to the sites where the vaccine was being offered or they don’t trust government,” Pittman said. “Or if they didn’t have a computer, they couldn’t sign up, so they couldn’t get in.”

    In an initiative dubbed Together Toward Health, PHI worked with the Desert Healthcare District-led Coachella Valley Equity Collaborative and farmworker groups to set up on-location vaccination events, going to where the farmworkers were. They vaccinated more than 1,700 in just one week.

    Rallying round vaccination

    Mena, with colleague Rodney Washington, an associate professor of population health, formed a task force in early September to embed in majority Black, rural Mississippi Delta counties where COVID-19 case rates were staying high, and interventions were minimal.

    Moreover, the department wanted to get in front of vaccination hesitancy before distribution plans materialized from the state. Washington held community listening sessions to identify “community brokers” who could introduce COVID-19 safety and vaccination messaging directly into the community through trusted voices, such as faith leaders.

    Both Washington and Mena saw views on vaccination acceptance shift in targeted Delta counties after months of bi-directional community engagement. But once it did, just in time for early Pfizer and Moderna vaccination approval, the question moved to equitable distribution. “The conversation about vaccination has gone from, ‘We don’t want it, we are afraid of it,’ to now a matter of equity,” Mena said. “It’s now, ‘Why are we not getting it?’ ”

    As states scrambled to create vaccination distribution plans, only nine would formally prioritize vaccinations for communities of color in their plans. A January 2021 Kaiser Family Foundation report shows decreasing vaccination hesitancy across races, but persisting disparities in states’ patchwork efforts to reach hard-hit communities of color. By early March, 13% of whites had been vaccinated while just 7% of Blacks had been, according to Kaiser’s website.

    System-wide innovation

    In Utah, which kept a relatively tight lid on new cases until a late-2020 surge that rivaled most states, Mikelle Moore, senior vice president and chief community health officer at Salt Lake City-based Intermountain Healthcare, said listening to not only the community’s, but also healthcare workers’ needs drove early innovation.

    Before the pandemic, Intermountain had launched a clinical intervention in behavioral health, aiming to reduce alarmingly high and growing suicide rates in the health system’s service area. When COVID-19 threw healthcare workers’ shifts and lives into chaos last year, system leaders pivoted that mental health work to their own staff. Intermountain set up a mental health hotline for staff and is transitioning it community-wide by the summer.

    “We’re learning that we need those types of resources for healthcare workers to be very accessible,” Moore said. “And we, as leaders, need to be much more transparent and talking to people about how they’re really doing.” Since April 2020, the hotline has connected about 5,800 callers with mental health resources.

    In Wisconsin, Marshfield Clinic Health System intensified the level of care provided in the home as a result of the pandemic. Marshfield CEO Dr. Susan Turney said that by expanding telehealth, an essential piece of the pandemic response, the health system completed about 110,000 more telehealth encounters in 2020 than 2019.

    Marshfield used that surge to stand up a new convalescent program to provide hospital-level care in patients’ homes. The system’s Home Recovery Care Model reduced costs up to 30% compared with a typical hospital admission, cut readmissions by more than half, and reduced average length of stay by 38%. And patients seem to like it—satisfaction with the program stands at 98%.

    To help tech-shy patients, Marshfield launched a community telehealth training program to acclimate its service area to the idea and importance of telehealth.

    Policy recommendations

    A new report from the Duke Margolis Center for Health Policy and National Dialogue for Health Innovation highlights lessons learned from the response to the COVID-19 crisis and looks at innovations that can be maintained or strengthened to prepare for the next emergency.

    “One of the big focuses of this report was the recognition that the next crisis may not be a pandemic. … So there’s a lot of lessons we can learn from COVID-19, but we’ll also need to be ready for a natural disaster or for other types of disasters that could come down the pike,” said Rob Saunders, research director on payment and delivery reform at Duke-Margolis, who contributed to the report. The Disaster Preparedness and Response Initiative surveyed over 100 health systems and organizations, and narrowed key recommendations around:

    Improving data and evidence generation, such as:
    HHS and coordinating agencies should work with private sector stakeholders to develop an improved process for standardized data collection and reporting across the public health and healthcare ecosystem, including among providers/clinicians and federal, state, tribal, territorial and local health authorities.

    Strengthening innovation and supply chain readiness, such as:
    Clearly define the roles and responsibilities of federal and state regulatory agencies regarding the supply chain, including critical inputs and delivery of countermeasures or medical products.

    Innovating care delivery approaches, such as:
    Federal and state regulations should be streamlined based on what has been learned during the pandemic, especially on capacity challenges, virtual care expansions, and licensure and scope of practice for workforce mobility across states.

    Source: Duke Margolis Center for Health Policy and National Dialogue for Health Innovation

    Expanding primary care’s role

    Physicians groups would like to do more with the vaccination effort, but feel hamstrung. Primary care has largely been an afterthought in the federal, and most state vaccination plans, said Dr. Emily Maxson, chief medical officer for Aledade, a company that helps medical groups form accountable care organizations. It works with more than 7,300 independent providers across 27 states.

    While she’s encouraged that President Joe Biden added primary-care vaccine distribution to his COVID-19 response plan, she hasn’t seen any concrete efforts yet. The tools are there, it’s just a matter of utilizing them, Maxson said. She points to the Centers for Disease Control and Prevention vaccine tracking system, which was already leveraged to route and track new vaccines to pharmacies. Looping in primary care is an obvious extension, said Maxson, adding that the increasing Moderna and Johnson & Johnson supply, which can be stored more easily, are perfect opportunities to deputize the nation’s primary-care workforce.

    “We’re going to be behind until we fully leverage the primary-care workforce out there,” Maxson said.

    Despite delivering more than half of all U.S. vaccinations year-round, only about 15% of the 500,000 primary-care providers across the nation report having access to vaccination deliveries through states’ initial rollouts, according to American Academy of Family Physicians research.

    “Primary care across the country has intrinsic value because of the trusting relationships they’re building with their patients. They’re the first line of defense in a pandemic and for any health system or healthcare issue, because they’re the ones who are going to reach that last mile in rural healthcare and make sure to serve vulnerable patients,” she said. “We can’t leave them out of the conversation again, or we risk delays and additional deaths that didn’t need to happen.”

    How we got here

    Mary Pittman, CEO of the National Public Health Institute, based in California, said that widespread undervaluing of public health impeded the nation’s ability to get in front of the pandemic early on.

    “We’re paying the price for ignoring all the research that has been out on the social determinants of health. And what we’ve also seen is that the lack of investment in our public health systems left us unprepared to be able to respond to the virus,” Pittman said.

    She said ongoing vaccination disparities are a result of not only underinvestment in public health, but they’re also exacerbated by a lack of data. The National Association of County and City Health Officials, which represents the nation’s nearly 3,000 local health departments, estimates average local health department expenditures per capita decreased 30%, from $80 in 2008 to $56 in 2019.

    Pittman said the industry must get back to the basics: fully funding science-driven public health departments and leveraging community-based mobile teams that can quickly adapt to local emergencies.
    “I think this pandemic has shown that there are a lot of people who have not been reached by either our public health or healthcare systems.”

    Erica Hensley is a freelance writer based in Jackson, Miss.

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