The COVID-19 pandemic is a monumental public health crisis that is straining Nebraska’s health care infrastructure in a myriad of ways. From overwhelmed emergency rooms and community health centers in some parts of the state to financial worries at other health care facilities where there are no COVID-19 patients but also few other patients due to public health directives halting elective surgeries and other procedures, the virus presents unprecedented challenges to our health care system.
To get a better picture of the real-world impact of the virus on Nebraska’s health care infrastructure, we posed several questions to four health care administrators from organizations throughout Nebraska. Below is a sampling of their responses.
Can you tell us a bit about what it is like for health professionals on the front lines in Nebraska right now?
Administrator 1, who works at a rural hospital: Currently we are seeing no COVID-19 patients and very few suspected patients. The volume of work in the hospital has declined by 75% so the staff has very little to do. … With a limited number of staff and limited supplies, a small rural hospital can become overwhelmed in a short period of time. Many of the rural hospitals in Nebraska are under tremendous financial stress right now. They were suffering financially before the pandemic and this is causing them to stress to the breaking point. Volumes are down and costs are up. Many will need help to survive.
Administrator 2, who works with community health centers around the state: For community health centers, the pandemic has required them to completely redesign how care is provided. Dental providers and staff have been redeployed to other areas in the clinic to staff phone lines, triage patients, or help with medical care since nearly all dental services have stopped. Nearly 80% of all health care in the health centers is conducted via telehealth. Overall, patient visits are down anywhere from 40% to 60% in health centers due to postponing routine care, patient fear, and the closure of services pursuant to state guidelines. Health center staff spend a significant amount of time on the phone with patients, educating them about staying safe, answering questions and calming fears.
Administrator 3, who works at a hospital in an area that has been hit hard by COVID-19: It has been a very challenging, stressful and emotional situation for many of our front-line doctors, non-physician providers, nursing staff and the hospital team as a whole. … Over the past week we experienced a county laboratory confirmed positive rate of one that quickly moved to 21. The COVID triage for testing and associated paperwork, like patient work notes and isolation orders, became unmanageable at over 100 calls a day. Roughly half of those resulted in isolation and about 10% required emergent assessment. … Managing PPE and testing supplies through existing distribution channels is not working, calculating burn rates underscores the shortage of supplies. Some risk mitigation has involved adding increased engineering controls, and as supply chain interruptions have increased, using more innovative ways to reduce the risk of exposure. Still, the idea that they may have to care for people while putting themselves and more importantly their families in harm’s way, has created real stress and fear for (health-care workers) on the front line. … The (emergency department) is experiencing unsustainable workloads, given the current staffing patterns. Recently, over a four-hour period, all ER rooms were full with presumptive positive patients requiring either admission, transfer or ER management. Ruling out strokes and/or heart attacks and managing traumas are still part of the normal ER activity. It is this activity, coupled with care of positive and presumptive positive patients, that led to a burn rate of 50 isolation gowns over a four-hour time period. Being fully garbed and mentally prepared for COVID-19 care requires deliberation, critical thinking and situational awareness. It also means people have to withstand the actual heat associated with all the PPE and a three-hour visit; all of this is new to our team. They are exhausted but amazing, all at once.
Administrator 4, who works with public health departments around the state: Public health personnel are working essentially non-stop right now to try and keep each of their local communities safe. That has been emotionally draining for many and especially with no specific end-date in sight. Each local health department currently has incident commands setup that bring in a cross-section of public personnel to plan for each step of COVID-19. They meet on a daily basis to analyze community needs and determine the spread of COVID-19 and prioritizing the needs in each community. It is obviously incredibly taxing for the frontline workers and first responders as well as they respond to the crisis and are put in direct contact with the virus.
What resources have frontline public health workers received thus far?
Administrator 1: Most of what we have received so far has been in the form of personal protective equipment. We have received some test collection supplies, but not very many.
Administrator 2: Health centers have received some testing kits and supplies, but the amounts are not significant. Health centers continue to face significant shortfalls in PPE and supplies.
Administrator 3: We have not received much yet, some long-expired N-95 masks that are not suitable for use without repair and definitely not allowed for use pre-COVID, and some additional tie-on masks, which were also expired. We are working through the Nebraska Hospital Association and the Department of Health and Human Services to access funding and PPE in a more meaningful way.
Administrator 4: PPE Equipment like N95 masks, gowns and tie-on masks. Local public health departments distributed as much as they had on hand when the pandemic started to hit. As soon as equipment is being received by the state it is being distributed to the community as quickly as possible.
What resources do public health workers still need?
Administrator 1: We have everything that we need right now. That will change quickly if we should experience a surge in positive patients.
Administrator 2: Health center staff are in desperate need of gowns, N95 masks, gloves, face shields and testing supplies (swabs, test kits, etc.).
Administrator 3: I think their teams have been stretched thin as contact tracing and testing has increased. They have also been working to create county- and district-level incident command meetings, prepared and released, at least daily, notifications and conducted meetings with community stakeholder groups to assess and manage responses to this crisis.
Administrator 4: PPE needs will likely increase again once elective surgeries begin again on May 4. There are certain requirements in place for amounts that hospitals must have on-hand before surgeries begin, but the reality is that there may be spikes in communities and the PPE can become more in-demand with any spike in cases.
Will more funding be needed for testing and contact tracing once businesses in the state re-open? Or is current funding sufficient?
Administrator 1: More of everything will be needed if the state reopens for business.
Administrator 2: Yes, absolutely. Between the lack of sufficient supplies, the significant drop in patient visits and the high number of uninsured patients traditionally served at health centers, health centers are relying heavily on emergency funding received through the federal stimulus packages. One of our national partners has estimated that the federal funding received will be enough to support health center operations in Nebraska through the end of June, absent additional funding.
Administrator 3: Our experience would indicate that much more funding is needed to provide adequate and reliable testing materials and kits, PPE, testing sites that adhere with infection control guidelines, and contact tracing. The current funding has seemed inadequate as new cases and clusters emerge.
Administrator 4: Yes, more funding will be needed. We will be interested to see how testnebraska.com assists with the testing. That will certainly be a benefit for the numbers that will be tested. However, each community has separate testing needs and funding is necessary to test in mass, process those tests and to trace the positive tests.
What public health issues should legislators be aware of, and what should they be thinking about when they come back into session?
Administrator 1: We will need more testing before the state can be opened up for business again.
Administrator 2: Making some of the telehealth changes permanent beyond the pandemic will be vitally important. We believe that the increased reliance on telehealth now will fundamentally change how health care is provided going forward. Because the majority of health center patients are low income and face numerous barriers to care, sustaining the ability to provide care remotely — via both audio-visual and audio-only — will be important to ensuring access to vulnerable populations. In reviewing the state’s emergency response, ensuring that health centers are included in planning will also be important. Health centers are serving the populations that are disproportionately impacted by COVID-19, but have been largely left out of the conversation around solutions in many parts of the state. This emergency has highlighted the disparities certain communities face every day. It is important to have a plan to address social determinants of health and look for unique ways to provide those services. Finally, the economic impact of COVID-19 will have a significant impact on public benefit programs, including Medicaid and SNAP. The Unicameral will need to be prepared to review eligibility for these programs as well as the increased funding that will be needed to support increased utilization.
Administrator 3: Constraints must be recognized – simply stating widespread testing should occur, without recognizing the limitations, does little to help and much more to harm community trust in health systems. Communication should be consistent and follow CDC recommendations, which do recognize priorities and constraints. Uniform planning around risk mitigation, replenishment of supplies that have been completely exhausted by the outbreak and meaningful support of health care providers and all stakeholders must be a priority as we all try to find our way back to a new normal. Most of the burden of the additional costs and loss of revenue has impacted health care providers and it will take time to recover. Rural health care providers were already experiencing serious financial stressors and closures. It should be glaringly obvious that rural health care access and economic vitality is critical to all constituents. Legislators should be mindful of the need for critical infrastructure. Finally, predatory payer practices must be controlled. Even now, in the midst of a national crisis, when people are volunteering time, money and potentially their lives, commercial payers are exerting some of the same devastating practices that placed rural communities at such financial risk over the past decade.
Administrator 4: COVID-19 has raised public health and the need for public health measures and personnel to the forefront of most conversations now. In reality, the work by public health personnel has been happening around the state, mostly in the background and it has been underfunded. Local public health departments do so much to prevent health crises in communities and prevent spread of other diseases. Sometimes certain public health measures are not taken seriously or are considered to be overly burdensome, but these measures are to prevent outbreaks in our community and keep the public safe. Public health relies on data to make these policy decisions and not politics or emotion. There is much planning that goes into pandemic planning and response and that planning takes time and money. The local public health departments are the hubs of their region and they want to play that role.
There have been national reports that COVID-19 is disproportionately impacting communities of color. Are we seeing that here in Nebraska as well?
Administrator 2: Yes, absolutely. The recent uptick in cases at meat packing plants is a clear example of the disparities. Health centers are seeing a tremendous need for educational resources in multiple languages to support the immigrant and refugee populations they serve. Social factors that impact access to health care and healthy behaviors are also magnified during an emergency. Individuals may not have the option to stay home from work or socially distance from family members. They may not seek medical care out of concerns over paying for services or have access to adequate food.
Administrator 4: Yes. Particularly as it relates to areas with meat packing plants. Communication has been a challenge in those areas and communication to those populations is something the public health community is trying to address.
Have there been discussions about targeting resources toward outbreaks in businesses like meat-packing plants, where the essential workers are disproportionately non-white, or to hotspots like Grand Island, which has now surpassed Omaha in number of cases despite being significantly smaller in size?
Administrator 3: There have been efforts, most notably through increased focused testing by the National Guard. … One area that must be more effectively addressed, is understanding how the messaging around the importance of social distancing could be better deployed. Areas across the nation that have large diverse populations might provide some evidence-based strategies to implement as we continue to look for ways to contain spread.
Administrator 4: The local public health departments in these areas are stretched very thin right now and the departments are requesting additional resources from the state. In our mind, it’s up to the state in terms of how that funding is prioritized and how quickly funding gets to the areas with hotspots.
What steps can we take to better protect the health and safety of non-white communities in regard to COVID-19?
Administrator 2: Testing! Focusing testing on areas where there are hot spots such as meat packing plants or larger minority communities. We also need to make sure there are adequate educational resources that are culturally competent and produced in multiple languages. We need to look at the programs that address the social factors that influence health – housing, food, etc. – and ensure those are adequately funded. Finally, working with the providers and community organizations who serve minority communities to deliver educational messages, testing and health care. These organizations are trusted by the communities they serve and should be utilized when developing a plan to address disparities.
Administrator 4: Communicating to these groups effectively is vitally important. Obviously testing and resources also are critical in these areas. Furthermore, businesses in these areas need to take proactive steps to stop the spread of COVID-19.