Enhancing Community Resilience During COVID-19

BY JEREMY RICH, DPM, PAUL FRY, PA-C, AND RANDALL MICHEL, MD

Dubbed the City of Arts and Flowers, Lompoc is a semi-rural community nestled in the Santa Rita Hills on the central coast of California. Outpatient healthcare is provided by Lompoc Health, two federally qualified health centers (FQHCs)—a Santa Barbara County clinic and Community Health Centers-Lompoc—and other clinics and private practices.

“The primary concern was balancing access with resource protection. We had no intention of closing our doors.

All these organizations deliver primary and specialty care and refer to larger medical resource facilities in the area. There is no typical Lompoc patient; individuals represent various ages, ethnicities, and socioeconomic levels. had no intention The region has had a shortage of primary care doctors for several years, leaving many individuals behind in their preventive care.

Lompoc Health is dedicated to developing and enhancing wellness throughout Lompoc Valley. So how does the organization envision productive operational changes in the era of COVID-19 and beyond? Jeremy Rich, DPM, Director of the HealthCare Partners Institute for Applied Research and Education, recently interviewed two Lompoc Health officials—Randall Michel, MD, Chief Medical Officer, and Paul Fry, PA-C, Director of Ambulatory Services—to get their thoughts on how they are eliciting and sustaining impactful care delivery refinements.

COVID-19 aside, U.S. health delivery can be a landscape filled with anxiety and ignorance. How do you allay fears and promote access?

We give individuals authentic reasons to access care locally by adhering to our “three pillars of care”:

1. Culture of respect. Staff and providers are expected to treat patients, family members, and each other with respect as fellow community members.

2. Patient access. To address the need for more urgent, primary, and specialty care services, we recruit highly qualified physicians and advanced practice providers who share our commitment to preventing delays in care access.

3. Provide value. Healthcare value is not always clear; a test may not get a patient closer to a meaningful encounter. In an era of operating margin challenges and focus on volume metrics, we want our providers to obtain a detailed history via active listening. This can help drive person-centered care that promotes greater health literacy.

We focus on care access and inclusion for all socioeconomic levels and demographics. Access to local FQHCs can be challenging—it can take weeks to months to get an appointment as a new patient at those centers. Lompoc Health provides a secondary service to those clinics and to lower-income Californians, increasing their access to timely care.

Given initial limited COVID-19 testing, how did you determine testing parameters? Did protocols change with increased testing availability?

We began testing in February, when travel to China was a primary criterion. We were expected to call the county public health officer and only test if a patient under investigation (PUI) number was issued. The travel history was then expanded to Japan, Italy, Korea, and Iran because there were outbreaks in those countries.

When it was clear that community transmission was prevalent, travel criteria were removed as a requirement for obtaining a PUI number. Initially, we swabbed both nasopharynx and oropharynx. Later, nasopharyngeal swab sensitivities were superior to oropharyngeal. Because the two-swab method appeared confusing, we changed to single nasopharyngeal swabs. Serology tests were of no benefit acutely, yet had limited benefit for certain populations.

Was it a challenge to obtain personal protective equipment (PPE), such as N95 masks, and fittest personnel?

An interruption in PPE supplies can halt care delivery. The early heroes of the emerging pandemic were the materials management team members, who ensured adequate supplies were available and fitted properly. That included N95 masks, gowns, gloves, and face protection. COVID status was discussed at daily meetings in the hospital and clinics to proactively address supply needs. PPE “burn rates” were calculated and followed by daily updates on supply levels. Levels were reported in number of days of availability so unit managers could plan accordingly.

How did you manage some public policy recommendations that were aspirational “we need to’s” and “we should’s”?

We needed to balance recommendations with practicality to achieve community protection. While door screening was implemented to route symptomatic people outside and protect folks inside the clinic, the ever-expanding question list led to screening fatigue. Also, screening processes inevitably resulted in long lines, which presented physical distancing challenges.

Our infection control team contributed to pragmatic county policy changes. For example, before widespread testing was available, there was strict COVID screening criteria. Although fever is typically seen in those with a robust immune system, we recognized that some immunocompromised patients went undetected because of their inability to mount a fever. Based on team input, immunocompromised patients were COVID-screened even though they were afebrile.

What operational changes enhanced pandemic responsiveness?

Telewellness such as Doxy.me is the primary expansion that was most impactful for at-risk individuals. When community transmission was recognized, the primary concern was balancing access with resource protection. We had no intention of closing our doors and sending symptomatic patients to the ER.

Fortunately, our county has a proactive public health team. Although recommendations changed frequently, most principles remained constant, such as ventilation and airflow. We focused on workflows that enhanced patient access, yet delivered it outside.

We used a disaster tent with open walls and cots with wipeable surfaces. We used screening tables to identify individuals with COVID symptoms and then routed them to urgent care. Without entering our facility, they were given telephone access for registration and triage, and they were evaluated with appropriate PPE. Staffing levels in the urgent care were expanded to accommodate the anticipated increased volume.

There was guarded optimism that these strategies would serve the population without compromising staff safety. Guarded optimism was replaced with more robust confidence when it was reported that, while almost 30 healthcare workers in the county had contracted COVID-19, none of our staff were infected—despite treating hundreds of COVID patients.

Another challenge was emerging virus fear. From a leadership perspective, managing care team and patient anxiety was more difficult than keeping abreast of changing protocols. Whether rational or irrational, fear and uncertainty were expressed as distrust and anger. Our primary strategy, similar to the virus itself, was to let it “ventilate.” Open-air meetings provided current information and countered misinformation. We set standards for new recommendations because we were overwhelmed with information from unverified or nonpeer-reviewed sources.

We filtered guidance with a reliability hierarchy. Recommendations from the Centers for Disease Control and Prevention (CDC) and the county department of public health were considered the standard. Peerreviewed publications were highly regarded. Non-peerreviewed articles were considered, unless they were refuted by a higher standard. In time, our operational strategies were effective, which had a profound impact on patient and personnel trust.

Did your organization examine patient and staff knowledge, attitudes, and beliefs prior to refining telehealth?

Our team had discussed using telehealth before COVID, and we had met with vendors to evaluate it. Consensus was favorable, yet there was some uncertainty about whether patients would be high- or low-service users. Our group suspected that the risk may be higher than the reward if we used an established vendor. We were starting telehealth using our electronic medical record (EMR) capabilities and a few providers when the pandemic struck.

The EMR telehealth function appeared too cumbersome for many patients, and it was changed to the more intuitive Doxy. me platform during the pandemic and for longer-term use.

How did provider schedules change? Was there a protocol in place to change appointments to telehealth for at-risk patients, or was this providerdriven?

We made telehealth adoption mandatory. All providers were given telehealth accoutrements and obtained a Doxy.me login. We also informed the public that telehealth was available. The frequency of telehealth was driven by provider and patient demand. Some early adopters saw patients completely through virtual modalities. Many patients were unable to connect due to bandwidth problems, lack of technical knowledge, or lack of computer access. In these cases, providers pivoted to clinic visits or telephone visits for those at highest risk.

Screening process confidence and PPE use prevailed, and in-person visits began to rise. Televisits remained at 35% of all visits in oncology but averaged 20% of all visits in the remainder of the clinics. Total clinic volumes (in-person and virtual) dropped to approximately 65% of pre-COVID levels, while in-person volume in the urgent care dropped to 45% of pre-COVID levels.

Were there any barriers to accessing telehealth for linguistically isolated and socioeconomically challenged individuals?

For the linguistically isolated, challenges were overcome using the language line. This is amenable to in-person exams, telephone encounters, and telehealth visits. A telehealth barrier is lack of internet access or computers. Smartphones are practically ubiquitous, but not for those most economically challenged.

Less than ideal, telephone visits are a backup when interactive audio and video are unavailable. Also, an individual may not have the technical knowledge to access a televisit. We learned that key staff members, such as medical assistants and registration personnel, have the skills to bridge that knowledge gap.

Do you have protocols for COVID-19 surges and the next public health emergency? Where will you be seeking guidance post-pandemic?

We continue to have small surges that are managed by current protocols. For the next pandemic, we will apply lessons learned, and we will not forget history. It isn’t clear how well we can maintain staffing during flu season. Never before has a new minor sore throat or slight cough been the cause of such staffing challenges.

For example, an employee with an ill child at home presents the dilemma of a potentially pre-symptomatic staff member. Our policy is if an employee’s family member tests positive, that worker must stay home for 14 days. These unprecedented staffing challenges can likely be met by increased staffing beyond what is needed for regular operations in anticipation of symptom or community exposure absenteeism.

Any operational pearls for reducing staff burnout while cultivating stakeholder engagement?

Research by Maslach et al. states that burnout is identified by emotional exhaustion, depersonalization, and lack of personal efficacy.1 Staff can burn out due to rapidly changing pandemic policies and potential exposure risks, resulting in personal inefficacy.

A culture of respect and inclusion may result in better interpersonal engagement between provider and patient. This may reduce feelings of emotional exhaustion and increase personalization. Patient access improves personal efficacy; an appreciative patient can help alleviate emotional exhaustion.

Providing this value may cultivate a meaningful work environment and enhance care team members’ wellness as they, too, navigate the U.S. health delivery landscape—during COVID-19 and beyond. o

Jeremy Rich, DPM, is Director of the nonprofit HealthCare Partners Institute for Applied Research and Education. He can be reached at hcpinstitute@ gmail.com. Randall Michel, MD, is Chief Medical Officer at Lompoc Health, and Paul Fry, PA-C, is Director of Ambulatory Services at Lompoc Health.

Reference:

1The Maslach Burnout Inventory Manual. 1997. Christina Maslach, Susan E. Jackson, Michael P. Leiter. The ScareCrow Press. Editors: C.P. Zalagutt and R.J. Wood.

Jeremy Rich, DPM

Paul Fry, PA-C

Randall Michel, MD