Delivery of Care

Meeting the unmet needs for testing

New testing site for coronavirus in Providence managed by Open Door Health offers some lessons in successful community outreach

Photograph by Amy Nunn

Rosa de Castillo, an outreach coordinator with Lt. Gov. Dan McKee's office, at the new Open Door Health testing site in Providence.

Photo courtesy of Amy Nunn

Rosa de Castillo, a member of Lt. Gov. Dan McKee's staff, gets tested at the new facility managed by the Open Door Health Clinic at the Southside Cultural Center in Providence.

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By Richard Asinof
Posted 6/15/20
A newly opened coronavirus testing site in Providence, managed by the Open Door Health clinic at the Southside Cultural Center, has seen a heavy demand for services in its first week.
How can we measure the quantity of the unmet needs for coronavirus testing in Rhode Island? Why is there still a problem in the supply chain for personal protection equipment for health care workers in Rhode Island? How many of the Abbott testing devices still remain in service in Rhode Island? Who will pay for testing for employees when their employers demand testing and proof of negative results in order to keep their jobs? Will the R.I. General Assembly prioritize enacting permanent waivers for reimbursements for telehealth visits? How many reporters have been tested for coronavirus and how many would be willing to share their results?
Given all the confusing messages around testing for the coronavirus and what conclusions can be drawn, I recall how a phys ed instructor in high school once ordered my class: “Line up alphabetically by height. Move!” When the class, puzzled, did not respond, the instructor shouted again: “Line up alphabetically by height. Move!”
The problem, clearly, was in the puzzling messaging.
The contradictory messaging coming out of the White House around the coronavirus continues to be confounding. In numerous states, including Florida, Arizona, Arkansas, Alabama, Oklahoma, South Carolina, Mississippi, Texas and Alaska, among others, there has been a precipitous rise in new cases. The move of the Republican National Convention to Jacksonville from Charlotte, because of a lack of restrictions of large gatherings, seems to go against common sense wisdom about protections from the coronavirus.

PROVIDENCE – Testing for the coronavirus has emerged as the data fulcrum, the crucible, upon which the reopening of the economy in the post-pandemic world now depends.

What current testing results provide us with is an individualized digital snapshot, positive or negative, for the virus, an illuminating moment, for sure, much like a sudden flash of lightning that transforms darkness into a brief glimmer of a brighter world.

But, testing alone, deployed as a surveillance technique, will not stop the spread of the COVID-19 virus, which has not gone away, despite the wishful thinking by some, including President Trump.

Personal habits – the wearing of masks, the frequent washing of hands, and maintaining social distancing – remain the most effective tools to limit the spread, in advance of being able to administer an effective, safe vaccine.

The challenge of testing is attempting to map the spread of the virus by charting the longitudinal metrics of data trends – the number of deaths, the number of cases identified, the number of hospitalizations, the number of intubations, the demographics of who has been infected by the virus, and the correlation between high-density living and working environments. The ratio of disease spread – how many people someone with the virus infects – becomes a key metric.

In response, many elected officials, business CEOs and the news media have become amateur epidemiologists, trying to read the “tea leaves” to interpret the data trends and translate them into projection models about what may or may not happen.

Translated, the long-term meaning of testing results remains open to interpretation. Is it safe to go back into the water? It often depends upon whom you ask – and who has not yet been tested.

It can be confusing, with lots of conflicting messages around testing, particularly when some states, such as Florida, intentionally attempted to cloud the data results to promote an early reopening. Former Florida state public health official Rebekah Jones, who said she was fired for refusing to fudge the public health data, has responded by setting up her own public health dashboard. Jones had alleged that the health department under Florida Republican Gov. Ron DeSantis had been manipulating statistics to support his desire to reopen. [See link below to The Washington Post story, “Florida fired its coronavirus data scientist. Now she’s publishing the statistics on her own.”]

Here in Rhode Island, Gov. Gina Raimondo has proudly proclaimed that the state has been a national leader in testing, with a high rate of testing per capita, with some 17 percent of the population having been tested. The problem is that there have been some “significant gaps” in the screening process around who has been tested, and whether or not the test results were “accurate,” given the high number of false negatives reported with the Abbott device.

Initial testing was restricted to those who had “symptoms” of the virus, with appointments made through primary care physicians. One problem was that many of those “infected” by the virus were asymptomatic. A second problem was that access to the initial testing sites was limited to those who could drive to a testing site. A third problem was that the testing sites often presented significant language and cultural barriers, particularly for immigrant populations.

What the demographics of case counts and deaths have revealed, along with the testing results, were Rhode Island’s profound racial and ethnic health disparities.

For instance, a recent effort to test for the presence of antibodies by the state found that the “seroprevalence” – the presence of antibodies in those who had been exposed to COVID-19 – was approximately 2.2 percent. However, the antibody testing revealed wide variations between different races and ethnicities – 8.2 percent among Hispanic Rhode Islanders, 5.2 percent among African American Rhode Islanders, and .9 percent as white Caucasians.

Expanding the testing
Last week, the state moved to expand testing for people without symptoms, including restaurant workers, childcare workers, bus drivers, gym employees and personal workers, who can now schedule a free test at National Guard testing sites.

One of the new testing sites established is being managed by the Open Door Health Clinic in Providence, the state’s first dedicated LGBTQ health clinic, which officially opened its doors on March 2. [See link below to ConvergenceRI story, “We help you to be you.”

The new testing facility, located in the parking lot of the Southside Cultural Center of Rhode Island on Broad Street, officially opened on Monday, June 8, and the demand has been very high, according to Amy Nunn, Sc.D.,the executive director of the Open Door Health Clinic and the executive director of the Rhode Island Public Health Institute.

“Richard, my site is booked,” Nunn told ConvergenceRI in an interview last week, talking about the high demand, having already tested some 80 patients. “We are full until Tuesday.”

Nunn praised the coordination efforts by Commerce RI, which facilitated the construction of the site, provided access to the personal protection equipment, and the collaboration with the National Guard.

“Their response was immediate, organized and fantastic,” Nunn said. “They sent in the National Guard, who trained us on how to don and doff the PPE, which sounds basic, but it is really complicated, to get dressed without touching anything. The most complicated part is getting undressed so as not to contaminate anyone.”

The National Guard, Nunn continued, “They measured the site; they set up all the tents, and then facilitated us getting the tests, the PPE, everything. I cannot say one negative thing about the whole experience.”

Nunn also praised the efforts of community leaders in the Latinx community, including Rosa de Castillo, a community outreach specialist who works in Lt. Gov. Dan McKee’s office, and Dr. Pablo Rodriguez, for helping to get the word out on radio about the new testing site. Last Thursday, de Castillo herself got tested at the new facility.

“The Latinx patients are literally lined up around the block,” Nunn said. “I don’t think this is rocket science. I just think we need a more culturally congruent and deliberate approach to reaching out to the Latinx community leaders. I think that people want to get screened.”

Here is the ConvergenceRI interview with Amy Nunn, the executive director of the R.I. Public Health Institute and the executive director of Open Door Health clinic, talking about the launch of a new testing site in Providence, facilitated by the R.I. National Guard, which has focused on serving the unmet needs in the community.

ConvergenceRI: What kinds of tests are you using?
NUNN:
The PCR test, nasal swab.

ConvergenceRI: You are not working with the Abbott testing machines?
NUNN:
No.

ConvergenceRI: You opened on Monday. What has been the response so far?
NUNN:
We are delighted that we have patient volume, because I thought that it would be slow. And, it’s busy.

ConvergenceRI: How important is the new testing site in terms of increasing surveillance?
NUNN:
Looking at the big picture, I believe we’ve made several missteps. The first was the challenge with the federal response and not having enough test kits to keep up with demand.

That wasn’t anyone here’s fault, but now that we’re over the hump, I think that we should be moving toward universal screening, for a number of reasons.

One, it normalizes a test. Two, it’s not expensive. And three, we’re living in a hot spot. Rhode Island is a hot spot. And there are hot spots within the hot spots.

This test is not very expensive, and I believe we should be screening everyone.

That is particularly important in minority communities, where there is a lot of fear and stigma [around testing].

Normalizing testing by encouraging everyone to get screened is really important, because so many people may be asymptomatic.

ConvergenceRI: Is one of the issues that we need to keep testing?
NUNN
: Yes. I think we should.

ConvergenceRI: Why are you so busy? Where is the demand coming from? How many positive tests have you had, to date?
NUNN:
I don’t know [the number of positive tests]. We just started on Monday.

So far, we have had a grab bag of totally different people.

One group is the LGBTQ folks. A second group is protesters. A third group [seeking tests] is Latinx folks.

We have deliberately focused on all these people because there is an unmet need in these categories, and also, because they are our core competencies.

ConvergenceRI: Will you get the first test results back at the beginning of next week?
NUNN:
Yes.

ConvergenceRI: How many people, roughly, have you tested, to date?
NUNN:
I think around 80.

ConvergenceRI: Are you coordinating with the Providence Community Health Centers?
NUNN:
One of their administrators has asked if they could come by. We definitely told them that we were doing it. But we haven’t made a strategic decision to work on [testing] together. Everyone agrees that there is unmet need.

ConvergenceRI: From what I have been told, a number of community health centers, including Thundermist, Providence Community Health Centers, and Blackstone Valley Community Health Centers are all doing expanded testing.
NUNN:
Yes.

ConvergenceRI: Is there a demand for antibody testing?
NUNN:
I want to do it, but there is not a good test on the commercial marketplace.

ConvergenceRI: Have you been working in close collaboration with the R.I. Department of Health, with their new guidelines, released this week, for expanded testing for people without symptoms, where you do not need physician’s request?
NUNN:
Yes.

ConvergenceRI: What have you learned, as result of opening Open Door Health earlier this spring?
NUNN:
We opened on March 2; the first diagnosis in Rhode Island was on March 1. We moved to telemedicine three weeks later, and we’re still doing a lot of telemedicine, but not exclusively.

Patients love telemedicine, and the providers also like it. It’s a great option. We have been able to do most things on the telemedicine platform. But there are things that are difficult to do on telemedicine, like labs, for example.

I would love it if there were telemedicine parity after July 30, which is when Blue Cross has committed to so far.

What else have I learned? I miss seeing people in person; I miss my team.

People are starting to come back in for STD visits, which is good. There were some patients who faded away during COVID-19.

Patients that were the most persistent about their health were our transgender patients. And, I think that’s because there has been so much unmet need and pent-up demand. All of them kept their appointments; there were zero no shows. They were willing to come in, even during the peak of the pandemic.

ConvergenceRI: It seems you have created a trustworthy source of health care, which, in this environment, is really important.
NUNN:
I would love to have more patients, but things are slow, they are picking up pretty quickly. That’s good.

ConvergenceRI: What part of the story about what you’re doing hasn’t been covered and needs to be covered better?
NUNN:
I think there is hope for offering better screening for the Latinx community.

ConvergenceRI: Is the neighborhood protective of the clinic?
NUNN:
we’re working with the Southside Cultural Center. They’ve been wonderful. I mean, a lot of the other businesses have been closed. But we have felt a warm embrace from them.

I wanted to do this testing site at the clinic, but my landlord told me no. I’m still mad about it. They wouldn’t let me do it on their property. So, we’re doing it at the Southside Cultural Center. It ended up being a better fit, anyway.

We have way more space there, and it has been just a great partnership.

ConvergenceRI: In terms of other partnerships, in terms of outreach, have there been other collaborations in getting the news out about the new testing site?
NUNN:
RI PRIDE has been awesome. They have been wonderful partners. We also work with the Providence Housing Authority; their executive director is on my board.

ConvergenceRI: Is your approach something that can be replicated?
NUNN:
My hope is that I can prove that you do this kind of screening, in the middle of the ‘hood, and that this will become a model.

I’d love for us to open a respiratory clinic, if we can. That’s the next step. I’d love to figure out sustainable funding.

ConvegenceRI: What are the takeaways for Rhode Island?
NUNN:
I think we can get people to come out [for testing] if we do community outreach. But we can’t wait for people to come to us. We have to really do outreach into the community.

I think we should be moving toward universal screening.

If you look at the data from countries that are trying to do better, in Europe and South Korea and in China, it is pretty compelling. Wuhan screened everybody; in 10 days they screen 2 million people. That is remarkable by any measure.

We are the most affluent country n the world. If we want to do this, we can do this. We just need political will to get it done – and to using all of our talent as a country and as a state. I am committed to trying to do our part.

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