Delivery of Care

Connecting primary care to emergency care in a pandemic

Community health centers are playing a critical role in protecting Rhode Islanders

Image courtesy of The Providence Community Health Centers

The Providence Community Health Centers are serving in an integral role in helping to protect Rhode Islanders in a time of pandemic.

By Richard Asinof
Posted 4/13/20
Community health centers such as The Providence Community Health Centers are playing an integral role in containing and mitigating the spread of the coronavirus in Rhode Island.
When will the state deploy culturally appropriate testing sites in coordination with community health centers and health clinics? In the post-pandemic coronavirus world, how much of the day-to-day contact with health providers will become virtual, with televideo and texting replacing in-person visits? Have home health nurses received permission to bill for reimbursements through telehealth visits? Is there interoperability between the numerous telehealth texting platforms to help better coordinate care?
What is the algorithm to measure empathetic care delivery in a world consumed by pandemic? How does that track in outcomes measured by accountable entities and insurance health plans for increased payments?
For years, the corporate models for health care have looked to consolidations in the hospital, insurance and pharmacy industries as providing a cost-effective model to reduce the ever-escalating costs of health care. The plaintive messaging must sound familiar: if only we can reduce waste and redundancy in the system, we can reduce costs by choosing more wisely about which procedures are needed. We can deploy lean management systems.
Such business axioms provide little comfort or practical savings during a pandemic. What works best to control and mitigate and contain the spreading virus are tried-and-true public health interventions: testing, contact tracing, testing, social quarantine, testing, mitigation.
Unfortunately, our public health infrastructure has been gutted for the last 40 years by a failure to make the necessary investments – at the state and the national level.
The work being done by community health centers in Rhode Island is unheralded and underappreciated often left out of the story at news briefings.

PROVIDENCE – In a time of crisis, the lens through which we see the world often becomes constricted, suffering from a pernicious kind of progressive myopia – that’s nearsightedness – that afflicts our conscious ability to see the world around us when so much is happening in our own personal lives.

It is more than the condition of not being able to see the water you are swimming in. It is more than the problem that our visual spectrum as humans is limited.

Our nearsightedness is both narrowed and magnified when we are sheltering in place, staying at home, our interactions restricted with the outside world, and our sources of news limited to what can be found on TV or radio and online. Without the daily dose of sports and reality TV, our realities revolve around interactions in cramped living spaces, and our lack of connectedness narrows what we can take in. We are learning how to live with ourselves and with our families, in relative harmony, without being able to call on the usual distractions to avoid “collisions.”

The news is dominated by news briefings by our elected officials, providing us with daily updates, which is an effective way of managing and controlling the news flow. There are conflicting styles:

• President Trump treats his daily briefings as a new kind of campaign rally, repeating lies, distortions and shibboleths, blaming others for his own failed leadership on the coronavirus, berating reporters who dare to ask  questions he doesn’t like, calling it fake news, or admonishing the reporters if the question doesn’t begin with enough adulation for the great job he claims he is doing.

• In contrast, New York Gov. Andrew Cuomo, in a no-nonsense tone, seeks to highlight the data each day, for better or for worse, admitting when he doesn’t know the answers, talking about the realities being faced on the ground regarding the number of deaths, the number of intubations, the number of ICU beds, the difficulty in obtaining personal protection gear.

• Here in Rhode Island, Gov. Gina Raimondo has chosen a third approach, attempting to provide daily updates in a kind of matronly tone, warning the population to behave, to “knock it off” when it comes to gathering in large groups. She has shared the stage with Dr. Nicole-Alexander-Scott, the director of the R.I. Department of Health, which has led to a belated number of news feature stories shining the spotlight on the extraordinary work of Alexander-Scott.

There are still numerous stories that go unreported, unmentioned and uncovered that fall outside the spectrum of news briefings. As the old intro to the TV noir series, “The Naked City,” used to begin, “There are a million stories in the naked city, and this is one of them.”

True blues ain’t no news
One of the emerging data points has been the high number of people of color who have been afflicted and died as a result of the coronavirus, with questions now being asked about why that is so.

The data should surprise no one who has been involved with public health and with the struggle to achieve health equity. Or, for that matter, anyone who has trumpeted during the last week about the effectiveness of the latest Rhode Island Kids Count Factbook in compiling data that reveal the widening inequities when it comes to children and families in health, education, well being, poverty and economic opportunity.

Indeed, the president of Brown University, Christina Paxson, in a talk delivered on Nov. 16, 2015, “Unpacking racial health disparities,” had documented the pervasive health disparities between blacks and whites in America, during which she invited Dr. Alexander-Scott to share the podium with here. [See link below to ConvergenceRI story, “Unpacking racial disparities in health.”]

As ConvergenceRI reported: Paxson examined the morbidity for specific conditions – arthritis, heart conditions, stroke, high blood pressure, diabetes and breathing disorders – and detailed the large gaps between blacks and whites, not just in incidence, but when the onset of these conditions occurred, and the way in which they limited opportunities for work and wealth.

Paxson presented the stark differences between the total wealth for an average black household and the average white household in 2013: $11,000 compared to $190,000.

Most striking were her conclusions: that we cannot “educate our way” out of the disparities, nor will improved access to health insurance under the Affordable Care Act solve the persistent, structural racial disparities.

It should surprise no one, then, that the racial disparities in health should emerge and become painfully visible with the coronavirus pandemic.

Treating the “invisible” people in our midst
In this time of pandemic, when the issues of health care dominate the conversation, the tendency has been to focus on the big hospital systems, which are seen as the front lines in the battle where coronavirus patients end up, in serious condition – and on the heroic nurses and doctors battling to save their lives.

But there is another level of care that often tends to get glossed over and unreported: the network of community health centers in Rhode Island that serve as the deliverers of primary care to more than one-third of all residents, including many who receive Medicaid.

The critical role that community health centers in Rhode Island is well understood by the state’s Congressional delegation. On Wednesday, April 8, Sens. Jack Reed and Sheldon Whitehouse, along with Congressmen Jim Langevin and David Cicilline, announced $7.25 million in federal grant funding to help eight Rhode Island community health centers in the fight against the COVID-19 pandemic, including to expand coronavirus testing, prevent and treat COVID-19, and increase staffing and treatment capacity to address the public health emergency.

“Our community health centers are doing critical work under tremendous financial strain. This is like a booster shot to help them continue to serve patients and communities and offset some of their coronavirus-related expenses,” said Sen. Reed, in the news release accompanying the announcement.

The health centers receiving money included: Blackstone Valley Community Health Care, Pawtucket – $878,510; Comprehensive Community Action, Cranston – $796,160; East Bay Community Action Program, Newport – $688,715; Northwest Community Health Care, Pascoag – $781,850; The Providence Community Health Centers, Providence – $1,464,095; Thundermist Health Center, Woonsocket – $1,403,510; Tri-County Community Action Agency, Johnston – $624,680; and Wood River Health Services, Hope Valley – $615,185.

ConvergenceRI reached out to The Providence Community Health Centers to get a better understanding of how the $1.64 million in new federal resources were going to be spent as well as to better understand the role that community health centers were playing in combating the coronavirus pandemic in Rhode Island.

Here are the responses from CEO Merrill Thomas, MBA, and Chief Medical Officer Dr. Andrew Saal, at The Providence Community Health Centers.

ConvergenceRI: What will the new federal grant money be used for?
PCHC:
We will use the federal stimulus dollars for several things including:

• Safety. The safety of our staff and patients is paramount. Purchasing additional personal protective equipment, additional facility cleanings and associated supplies, redesign of clinic space for adherence to social distancing, and additional clinic security are all necessary to maintaining the safety of our team and our patients.

•  Supporting our staff. PCHC is committed to keeping our staff employed in order to support their families as well as the local economy. Like other primary care clinics, PCHC has had to decrease its routine clinical services to maintain a safe environment for all patients. Though we continue to provide emergency dental, optometry and podiatry services, we are looking for ways to train and redeploy staff into new roles for the duration of the pandemic.

• Technology. With the rapid transition to telehealth, our network infrastructure required immediate upgrades to achieve the necessary capacity. Half of PCHC’s 500+ employees are now working remotely and require additional hardware, secure laptops and cybersecurity measures.

Testing. The health center is working with RIDOH and other community partners to develop neighborhood-based testing options for the Covid-19 virus.

ConvergenceRI: What have been the most dramatic impacts on the delivery of care at PCHC?
PCHC:
The pandemic has had obvious short-term impacts that most people see now. But the long-term impact is important to recognize because it is rapidly transforming health care in the United States. Some of these changes will likely persist following the pandemic.

The immediate impact, of course, has been a devastating shock to the entire community – patients and health care teams alike. There’s no easy way to describe just how profoundly this virus has up-ended the health care system.

Yet despite the chaos, there are moments of hope and genuine innovation. Despite our inability to provide a face-to-face visit with a worried patient, we call our patients and are humbled to hear, “Thanks for calling, doc. It’s good to know I’m not alone in all of this and that I can still get help.”

Right now, most of the primary care system is reeling from the abrupt inability to provide traditional office visits. PCHC has had to significantly limit office visits for most, while preserving direct care for special populations such as pregnant women and infants.

Preventative services for healthy adults have been significantly restricted in order to see our patients safely. The health center’s large dental program is now limited to only a handful of emergencies per day. Likewise the optometry and podiatry programs have been greatly restricted.

The immediate impact of these shutdowns [in care] is a financial shortfall of about $1 million per month. The health center leadership has chosen to not lay anyone off for the time being, and has been carrying all of the salaries for the past month.

The most dramatic and possibly enduring impact of the pandemic has been the rapid introduction of telehealth services. Though PCHC had been piloting telemedicine video capacity, we abruptly had to mobilize and scale up the technology to serve 70 care teams and 60,000 patients.

In order to provide high-quality health care to our existing patients as well as the new patients seeking care, our stellar staff had to quickly re-design clinic workflows and safety protocols.

With telehealth services now becoming widely accepted by patients and staff, we are witnessing a rapid evolution of primary care.

For years, the vision of health reform has included patient-centered care delivered by many alternative types of visits such as cell phone video chatting, texting, and electronic means, as well as traditional face-to-face visits. Instead of a gradual evolution, we are experiencing a tectonic shift to the new technologies in the space of weeks instead of years.

ConvergenceRI: Is testing happening at any of your offices, or is it being referred to other testing sites?
PCHC:
We are in the process of launching several testing sites for our inner-city patients. Our regional public testing system now requires that an ill person be tested from within a vehicle at a site that may be several miles from their home.

Not all of our patients own cars or have reliable transportation. Over half of our patients are best served in a language other than English. PCHC has culturally appropriate staff, locations, and security to launch a testing site for our inner-city patients.

But like other clinical facilities, we are having difficulties obtaining enough personal protective equipment to keep our staff and patients safe. Securing enough COVID-19 test kits to provide the necessary volume of testing continues to be a challenge across the state.

Families, unable to access prompt local testing, have limited capacity to recognize viral infections, self-quarantine, and warn possibly exposed friends.

Local testing sites within neighborhoods will be crucial to address the immediate pandemic as well as subsequent flare-ups in the months ahead. Urban testing sites would help address the racial and economic disparities that currently confound our state’s response to the pandemic.

Working families living near the poverty line need more than just a drive-up tent. They need testing sites that can be accessed on foot or by public transportation. They need culturally appropriate care and patient education in their preferred language. Perhaps more importantly, testing must occur in an environment that is safe from immigration concerns.

Public anxiety from the virus is already significant. But being afraid to seek testing because of worry about a family member’s legal status is a recipe for an ongoing public health emergency that smolders among under-served populations.

ConvergenceRI: Are you using the new text messaging service developed by Healthcentric Advisors?
PCHC:
We launched a secure interactive texting platform last year. CareMessage allows our clinical teams to communicate with patients via text message. We are currently using the CareMessage to send health messages regarding COVID-19, the importance of social distancing, and how to access services at the health center if one were to have significant symptoms. Our clinical teams also use BlueStream, ComputerTalk, and other software platforms to communicate with patients.

ConvergenceRI: Are your health care workers in need of Personal Protection Equipment?
PCHC:
Yes. Like many other providers in the state, we are in need of small N-95 masks, standard gowns, surgical masks and gloves of all sizes. We currently have enough PPE to keep our staff and patients safe for a few weeks. However, as one of the few primary care providers in the state that is accepting new patients while also launching COVID-19 testing sites, we will need additional supplies.

ConvergenceRI: Are you keeping records on the data regarding demographics of those in need of testing?
PCHC:
We are focusing on the demographic data of those we serve in order to adapt and to better care for them. Our clinicians and public health teams are acutely aware of the health care disparities prevalent in our communities – especially now that we are facing limitations in testing for the virus.

ConvergenceRI: What haven't I asked that I should have asked?
PCHC:
A vaccine against COVID-19 is a year or more away. If we are ever going to get ahead of this virus we will need to use a strategy that relies on mass-testing, patient education, and self-quarantine.

As mentioned earlier, if mass testing can only be done from a car, then only those with access to a vehicle will have access to being tested. But the choice of test also matters.

RNA-amplification tests can take two-three days for the results to return. Rapid testing technology exists, but is only now becoming available. Knowing whether or not the virus is present is essential for a public health strategy based upon recognition and self-isolation.

Rapid testing allows prompt patient education and contact tracing of those possibly infected. For under-served populations, rapid testing at the point of care is the strategy of choice to contain the spread of the virus.

Our ability to stand up telehealth has been a paradigm shift in health reform. We couldn’t be more proud of all of our staff members who have made a swift and successful change. In the months beyond this pandemic, we hope to take what we’ve learned and build upon it.

PCHC has committed to our patients and our community to remain open. Our clinical staff is on the front lines every day, and will be for the duration. We can’t thank them enough for their bravery and commitment to the mission.

Our role in this pandemic is to continue providing high quality primary care in order to prevent people with chronic diseases from decompensating and having to go to the emergency room or hospital.

Our role is to provide a safe clinical environment for pregnant women to receive prenatal care.

Our role is to continue providing childhood immunizations to protect the next generation of Rhode Islanders.

Our prayers and thoughts go out to our hospital colleagues who face the brunt of the impact of COVID-19. If health centers are able to do our job well, then we can keep more patients from ever needing that level of care.

Editor's Note: Clinica Esperanza, a free health clinic in Olneyville, is now offering tests to its clients, many of whom are immigrants and uninsuired. "No one should die just because they are poor [and undcoumented], or because people who 'have' don't care," said Dr. Annie De Groot, volunteer medical director at the clinic, in a tweet.

Also, mobile testing sites around Rhode Island are scheduled to be closed on Monday.

Later this week, according to sources, Providence Mayor Jorge Elorza may be announcing a collaboration around "testing" with The Providence Community Health Centers.

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