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EMPLOYMENT LAW: EMERGENCY TEMPORARY STANDARDS
ABOUT THE AUTHOR
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Mark Kruthers is an attorney in Fennemore Dowling Aaron’s employment law practice group. He provides advice and counseling to employers and management regarding federal and state employment laws, assists in the development and implementation of legally compliant employment policies and procedures, drafts employment related documentation (employee handbooks, employment agreements, compensation/ benefit plans, disciplinary documents, etc.), conducts employee training, and assists employers with numerous other employment related business tasks. Mark also represents employers and management in legal actions venued in both state and federal court. Mark can be reached at (559) 432-4500 or mkruthers@fennemorelaw.com While it seems as if the COVID-19 pandemic is starting to slow, employers still have questions about how to deal with COVID-19 in the workplace. At the end of 2020, California enacted a set of emergency temporary standards intended to help prevent the spread of COVID-19. The temporary standards remain applicable to all employers except those that have employees covered by California’s Aerosol Transmissible Diseases regulation. Even then, for employees not identified in the employer’s Aerosol Transmissible Diseases Exposure Control Plan, the employer must comply with California’s emergency temporary standards.
It is important to note that California’s COVID-19 emergency temporary standards (the “ETS”) apply to workplace exposures and are not intended to address exposures outside of the workplace. When dealing with an employee who reports an exposure outside of work or an employee who otherwise needs to quarantine but has not been in the workplace so as to potentially expose other employees, different federal/state/county regulations would apply. However, the ETS still provides employers with procedures to use to address COVID-19 exposures regardless of where they might occur.
Pursuant to the ETS, employers must develop and implement a written COVID-19 Prevention Program. Cal-OSHA is charged with enforcing the ETS and will expect to see the COVID-19 Prevention Program as part of the employer’s existing Injury Illness Prevention Program (“IIPP”). Starting February 1, 2021, Cal-OSHA was authorized to impose monetary penalties on employers who fail to have a proper COVID-19 Prevention Program in place.
While a large portion of the ETS is dedicated to outlining what must be included in the mandatory COVID-19 Prevention Program and describing the various training, masking, social distancing, and ventilation requirements, the portion of the ETS that employers struggle with the most is the mandatory investigation and quarantining requirements. Specifically, when an employer learns of the presence of COVID-19 in the workplace, an immediate investigation must take place. Of course, the infected individual must be excluded from the premises until he/she has recovered. However, the employer must also determine which employees were within 6 feet of
the COVID-19 case for a cumulative total of 15 minutes but is unable to work due to COVID-19 related symptoms, within a 24-hour period while the infected individual was the employer’s obligation to continue the employee’s pay in the “high risk exposure period.” For an individual with may be offset by workers’ compensation or temporary symptoms, the “high risk exposure period” begins 2 days disability benefits received by the employee. before the onset of the symptoms and continues until 10 In situations where an employer experiences an days after the symptoms first appeared, and 24 hours have outbreak (3 or more COVID-19 cases in an “exposed passed with no fever and an improvement in the symptoms. workplace” within a 14-day period), the employer’s For a person who tested positive for COVID-19 but has no obligations under the ETS increase dramatically. The symptoms, the “high risk exposure period” starts 2 days employer must immediately provide testing to all before the sample that led to the positive test result was employees in the “exposed workplace” (even those that collected until ten days after the collection of the sample. might not have come into close contact with one of the
An employer must notify all employees who may infected individuals) and continue testing on a weekly have had a COVID-19 exposure in the workplace of the basis until the workplace no longer qualifies as an outbreak. possible exposure within 1 business day in a manner If an outbreak turns into a major outbreak (20 or more that does not reveal the infected individual’s personal COVID-19 cases in an “exposed workplace” within a 30identifying information. day period), the testing The employer also must requirement increases to offer those employees free twice weekly and the ETS COVID-19 testing and pay Pursuant to the ETS, employers must requires the employer the employees for any time develop and implement a written to consider halting all they spend getting tested. Finally, the employer must COVID-19 Prevention Program or part of the operations to control the spread of exclude employees who the virus. In an outbreak have had a COVID-19 situation, the employer exposure at work from the workplace. Those employees are will need to be communicating with the local health not allowed to return to work until at least 10 days after the department to make sure all appropriate precautions are date of the last known exposure, assuming the employees being taken. are not experiencing any COVID-19 related symptoms. The notification obligations discussed above are (However, a 14-day quarantine period is recommended.) based off the requirements in the ETS. Effective January 1, If an exposed employee subsequently tests positive for 2021, AB 685 imposed additional reporting requirements COVID-19 and/or develops symptoms, their time table upon employers including, among other things, notifying for returning to work will be determined as described the local health department and all employees present in above with respect ascertaining an individual’s “high risk the same work area as the infected individual of potential exposure period.” As to any employees excluded from the exposure and providing potentially exposed employees workplace, the ETS does not require a negative test result with a summary of the COVID-19 related benefits available to return to work and securing a negative test result will not to them. Accordingly, an employer’s obligations under shorten the quarantining period(s) mandated by the ETS. the ETS and AB 685 must be considered together when
If an employee is excluded from the workplace determining how best to respond to COVID-19 in the due to being exposed to COVID-19 at work, but is workplace. otherwise able and available to work, the ETS requires The above is only intended to be a brief discussion the employer to continue to provide the employee with of the ETS and how it impacts California employers. pay and benefits. This is true even if the employee has no For more specific information, employers can review accrued or otherwise available paid time off. (Certainly, the California Department of Industrial Relations’ ETS if the employee is able to work remotely, the employer “questions and answers” webpage at www.dir.ca.gov/dosh/ may require him/her to so during the quarantine period.) coronavirus/COVID19FAQs.html. However, in the event the employee is excluded from work
First Year Medical Students Thrive Despite Pandemic Challenges
Deans, Faculty, Preceptors and First Year Medical Students from the CHSU College of Osteopathic Medicine Volunteer as Vaccinators at the Fresno Fairgrounds. From left to right: Dr. Lisa Chun, Associate Dean; Dr. Jonathan Terry, Preceptor; Dr. Pamela Kammen, Faculty; Christine King, Student; Jake Dertinger, Student; Dr. John Graneto, Dean; Seaverson Stoll, Student; Joshua Garcia, Student; Tyler Laws-Mahe, Student; Mia Nurit Hirsh, Student. Photo courtesy of California Health Sciences University.
The COVID-19 pandemic brought an onset of challenges to medical education across the country. For the new California Health Sciences University College of Osteopathic Medicine (CHSU-COM) in Clovis, this meant asking their experienced leadership and educators to adapt their innovative curriculum delivery to introduce creative methods for teaching their inaugural cohort of 79 medical students.
The CHSU-COM rapidly converted to virtual education for their first-year medical students who started classes last July. John Graneto, DO, MEd, Dean of the CHSU-COM, is especially proud of how quickly both the faculty and students adapted to online courses.
Attending medical school during a global pandemic is certainly an unprecedented challenge that no one expected would arise. But these extraordinary medical students are flexible and resilient. The leadership and faculty creatively utilized the state-of-the-art technology built into the new medical school to deliver curriculum for their first-year students. For example, the nutrition and wellness faculty offered online cooking classes, the simulation center staff developed virtual simulation cases and the holographic anatomy curriculum easily transitioned to remote instruction. The students are eager to return to in-person
courses, but they understand the importance of prioritizing the health and safety of the campus and community at large.
Dr. Graneto says, “Balancing the desire of the students wanting to come back on campus, while ensuring we are keeping within the safety and compliance guidelines of federal, state and local public health officials has been challenging at times.”
CHSU-COM has found a healthy balance between teaching classes virtually and holding small group, hands-on laboratory and specialized sessions within the public health and higher education guidelines and with proper safety protocols in place.
“The hands-on experiences are crucial for learning in the first year of medical school,” remarks Dr. Graneto.
Another challenge that the CHSU-COM faced was providing their students an opportunity to bond with each other as an inaugural cohort while being remote. Forming relationships with classmates is important for wellness and gives students an additional support system.
The CHSU-COM Office of Student Affairs has been working with students to host virtual study groups and social nights, and provided the opportunity for
students to form special interest clubs and professional organizations to help students feel connected to each other. The faculty and staff have also been supportive by assisting each other in Zoom classroom logistics and meeting with each other in virtual sessions.
ANSWERING THE CALL TO VACCINATE OUR COMMUNITY
As COVID-19 vaccination efforts continue across the San Joaquin Valley, California Health Sciences University (CHSU) has found ways to assist in the administration of the vaccine and provide support for these important efforts, all in the spirit of furthering its mission to help improve health care outcomes for the people in the Valley.
Led by the CHSU President, Florence Dunn, their College Deans and the President’s Executive Council, the University quickly mobilized and determined ways that CHSU can help with vaccination efforts.
Both student and faculty volunteers from the CHSU College of Osteopathic Medicine and College of Pharmacy have been actively helping local public health departments and health care clinics to administer the vaccines to the community.
While CHSU pharmacy students become intern pharmacists in their first year of pharmacy school and are trained to administer vaccinations, CHSU-COM accelerated the first-year medical students’ vaccination training so they could also become volunteer vaccinators.
Almost every week since inception, CHSUCOM students and faculty have been volunteering to administer COVID vaccines at the Fresno Fairgrounds mass vaccination site. Dr. Graneto collaborated with W. Timothy Brox, MD, and the Fresno County Department of Public Health to ensure that CHSU faculty, staff, and students can contribute to the mass vaccination efforts.
CHSU vaccinators have been logging hundreds of hours at the Fresno Fairgrounds and can help to vaccinate approximately 1,500 - 2,000 people per day.
Outside of the Fairgrounds, Anne VanGarsse, MD, Associate Dean of Clinical Affairs, Community Engagement and Population Health and CHSU’s visiting third and fourth year students from Kansas City University (KCU-COM) and A.T. Still University (ATSU-KCOM), as well as first year students have also been on the frontlines administering vaccines. Several students are assisting Golden Valley Health Centers in Atwater and Los Banos administer vaccines. The visiting medical students also joined forces with the CHSU College of Pharmacy students to administer vaccines to educators with Adventist Health in Reedley.
College of Pharmacy students are continuing to help aid in the vaccination efforts through their experiential education rotations, particularly at Saint Agnes Medical Center, in addition to volunteering on their own time.
With the vaccination efforts rapidly increasing, Dr. Graneto maintains a positive outlook about the COVID-19 pandemic and hopes things will progressively improve over the next few months.
“Providing education and encouragement to our faculty, staff and students to receive their COVID vaccine is now our highest priority so we can safely return to more in-person education and training activities,” said Dr. Graneto.
CHSU encourages widespread and early COVID-19 vaccination of all eligible individuals to help ensure the health of the community and restore the activities of daily lives that have been missed for the past year. Many eligible
members of the CHSU campus community have already received their COVID-19 vaccinations.
ADDRESSING THE HEALTH INEQUITIES OF THE VALLEY
The pandemic truly has informed community awareness of the health inequities that exist within the San Joaquin Valley, rural and inner-city areas. The health care access barriers and lack of health care providers has become even more evident. This has fueled the passion of CHSU medical students and reinforced their career pursuits even more. Volunteering at COVID vaccination sites gives them valuable insight into patient care and public health that may not exist under normal circumstances.
“I had never imagined how rewarding it is to participate in a vaccination campaign, especially as a provider,” said Andrea Torres, first year medical student. “The experience was definitely a great reminder of why I wanted to study medicine in the first place.”
Pre-medical students have also been inspired by the global pandemic. Known as the “Fauci Effect,” medical schools across the nation have seen an 18% increase in applications according to the Association of American Medical Colleges (AAMC). The CHSUCOM admissions team has developed creative ways to host virtual information sessions and interview days and is currently in the process of recruiting the second cohort of medical students to begin classes July 2021, which will include 121 students.
For more information about CHSU-COM visit osteopathic.chsu.edu.
Study, New Outcomes, New Memories New
By: Kellie Hustedde, CCFMG
When Leigh Ann O’Banion, MD, was completing her fellowship at the UCSF School of Medicine, she found that patients with a lower extremity amputation were spending almost a week in the hospital and taking six to eight months to begin walking independently again. When she became a physician at Valley Vascular Surgery Associates and UCSF faculty teaching at UCSF Fresno, she found a similar situation.
Convinced there was a way to improve patient outcomes, Dr. O’Banion created a multidisciplinary team that included all the resources a patient would need on their road to recovery. The team included health care professionals from Leon S. Peters Rehabilitation, San Joaquin Valley Rehabilitation, Community Regional Medical Center (CRMC), Hanger Prosthetics, peer counselors, social workers, and case managers.
A team approach is critical in providing information to patients before their operation and helps the patient understand and process what is happening and what to expect in terms of pain after their amputation. Including patients in the process from the very beginning produces better patient outcomes according to Dr. O’Banion.
With the team assembled, she began enrolling patients in the Lower Extremity Amputation Pathway (LEAP) study in March of 2019.
When Hanford resident Raymond Whaley accidentally stepped into a pothole and fractured his ankle on a chilly December night in 2019, he had no idea that he would become one of Dr. O’Banion’s LEAP study patients.
Amputation Patient Walks Seven Weeks After Surgery
Through December and into January 2020, Raymond sought treatment for his ankle. When issues with his ankle worsened, he went to his podiatrist. His foot was swollen, discolored, and extremely painful. As a diabetes patient, Raymond was concerned that doctors would have to amputate part of his leg. While he was somewhat mentally prepared to hear that news, his wife was not. Their youngest daughter was getting married in a few weeks, and, as many fathers dream of doing, Raymond was going to walk her down the aisle.
After examining his ankle, Raymond’s podiatrist, Emmy Oji, DPM, of Valley Foot & Ankle Specialty Providers, called Dr. O’Banion. They found that Raymond had adequate blood flow in the big arteries of his leg and thought Raymond would heal very well with a below-theknee amputation. Dr. Oji then sent Raymond directly to the Emergency Department at CRMC. With the goal of walking his daughter down the aisle, his diabetes, and the type of amputation needed, Raymond was an ideal candidate for the LEAP study.
Members of the LEAP team met Raymond and his wife at CRMC. “I was in such pain that I was out of it, but I do remember that when I went in there … they got the team together, and … they were telling me about everything and how it was going to go, they were going to do the surgery in the morning, and I said ‘Ok, I’m ready for it,’” Raymond said.
Raymond had the lower part of his leg amputated the morning after arriving at CRMC. The weeks that followed were the whirl-wind of hard work, dedication, and determination Raymond had prepared for with the LEAP team.
The day after his amputation, Raymond met with the physical therapy team to start learning how to sit up, move from the bed to the wheelchair, and discuss further physical therapy.
Two days after the operation, Raymond headed to Leon S. Peters Rehabilitation Hospital where he underwent two weeks of intense physical therapy. He then headed home determined to continue relearning how to walk.
Knowing how important it was for Raymond to be prepared for his daughter’s wedding, Joe Beall with Hanger Prosthetics met frequently with Raymond to ensure he received his prosthetic in time. One week before the wedding, Raymond received a prosthetic leg that would allow him to begin the next phase of physical therapy and start learning how to use a prosthetic leg.
At a follow-up appointment after his surgery, Dr. O’Banion was amazed at Raymond’s progress. Raymond told her, “I’m just trying so hard because everything within me wants to walk my daughter down the aisle, and I promised her, and I can’t back down.”
On March 5, just two days before his daughter’s wedding, Raymond received his custom-fit prosthetic. That day, in his Hanford home, Raymond was able to walk independently with a prosthetic for the first time.
The next day, the Whaley family headed to Cambria, California for the rehearsal dinner. As Raymond’s son rolled him down the aisle while he was wearing a shirt that said “This wedding cost me an arm and a leg,” no one but Raymond and his wife knew that he would be able to walk his daughter down the aisle the following afternoon.
On March 7, 2020, as Raymond’s son began rolling him down the aisle in his wheelchair, Raymond stopped him. “I’m going to walk my baby down the aisle,” he said.
Stunned, everyone, including his daughter, watched as Raymond stood, placed his daughter’s arm in his, and walked her down the aisle, just seven weeks after his amputation.
“When you go through a tragic thing like I went through and they pick a surgeon and they come and are introduced to you, really listen to what they’re telling you. What they’re telling you is going to help you. And you just have to be positive,” Raymond said.
While Raymond’s case was exceptional, the preliminary findings of the LEAP study are just as astounding. On average, patients enrolled in the LEAP study leave the hospital three days earlier, begin physical therapy two days sooner, and receive a prosthetic 56 days earlier than patients not enrolled in the study. Study participants also begin walking independently with their prosthetic on average two months earlier.
“The ultimate goal would be to implement this protocol in all hospitals across the country as the members of this team exist in all hospitals. It’s just a matter of getting people working together toward a common goal,” said Dr. O’Banion.
Dr. O’Banion is one step closer to that goal. Due to the significance of the preliminary findings, all three of Community Medical Centers’ hospitals will now be adopting the LEAP study protocols as a standard of care for lower extremity amputees.
The Ripple Effects of ACEs
By Keenia Tappin, MD
– Dr. Robert Block, former President of the American College of Pediatrics.
From 1995-1997, Dr. Felitti from Southern California Kaiser and Dr. Anda from the CDC conducted the landmark Adverse Childhood Experiences (ACE) Study. The study included ~17,000 Southern California Kaiser members who were 54% female, 46% male, 75% Caucasian, and 39% college educated. The study was designed to look for a correlation between exposure to abuse or family dysfunction during childhood and development of common deadly medical and public health problems in adulthood. The 10 ACEs included in the study were psychological, physical, and sexual abuse, emotional neglect, physical neglect, household substance abuse (alcohol or illicit drug use), mother treated violently, mental illness, depression in the household, parental separation or divorce, and having an incarcerated household member. The negative adult health outcomes assessed included: severe obesity, being a smoker, being an alcoholic, lack of physical activity, 2 or more weeks of depressed mood in a year, lifetime attempt at suicide, illicit drug use, ≥50 sexual intercourse partners, and history of sexually transmitted disease. Adult chronic diseases assessed included: ischemic heart disease, cancer, stroke, chronic bronchitis/ emphysema, diabetes, hepatitis, fair or poor self-rated health.
This landmark study revealed two unexpected and pivotal facts about trauma during childhood. Firstly, ACEs are common. 36% of the participants had no ACEs, 26% had 1 ACE, 16% had 2 ACEs, 9.5% had 3 ACEs, and 12% had 4 or more ACEs. The top 3 ACEs were physical abuse (28%), household substance use (27%), and parental separation or divorce (23%). Secondly, there is a graded dose-response relationship between number of ACEs and development of negative adult health outcomes. For instance, when participants with 0 ACEs were compared to those with 4 or more ACEs, the latter group was 2.2 times more likely to be a smoker, 7.4 times more likely to consider themselves an alcoholic, 10.3 times more likely to have illicit IV drug use, and 12.2 times more likely to have a prior suicide attempt. In terms of chronic disease, participants with 4 or more ACEs versus those with 0 ACEs were 2.2 times more likely to have ischemic heart disease, 2.4 times more likely to have a history of stroke, and 3.9 times more likely to have chronic bronchitis or emphysema. Once the results came in the next question became, how exactly are these ACEs linked to risky health behaviors and diseases in adulthood? Is it simply that people who experience trauma are more likely to cope in unhealthy ways or is it linked to changes in the brain and other organs that occur during development? The answer is, it may be a little bit of both.
In terms of unhealthy coping mechanisms, smoking is a prime example. Nicotine has been shown to have positive mood regulation effects. Also, when used alone or with other substances such as alcohol, it can stimulate the dopamine reward pathway via increased dopaminergic neuronal firing. Individuals exposed to repetitive trauma may find solace in the short term positive effects of smoking or alcohol. Unfortunately, chronic smoking predisposes to emphysema, heart disease, and malignancy. Chronic alcohol use is a factor in developing cancer, hepatitis, and cognitive impairment.
Looking at neurodevelopment, trauma can have
many long standing effects on the brain. First, it is well known that the brain is not structurally complete at birth. The infant’s brain is extremely adaptable and changes via pruning and strengthening of neuronal connection which occur based on interactions between the baby and their environment. According to the Harvard Center for the Developing Child, there are 3 types of stress responses which occur in the developing child. Positive stress is characterized by brief increases in heart rate and mild elevations in hormone levels. This is the type of stress that is essential for normal development. Examples include trying something new, first day of school, getting a vaccine. Tolerable stress is the next level up, where an individual may have time-limited activation of the fight or flight stress response that is tempered by supportive relationships with a caring adult. After a short period of time, the child comes back to their emotional baseline and suffers no long lasting effects. Examples include, death of a loved one, natural disaster, or experiencing a frightening event. Lastly, there is toxic stress, which is characterized by prolonged activation of the fight or flight stress response system without adequate supportive relationships to ameliorate its effects. Examples include any of the ACEs (abuse, neglect, household dysfunction) which occur repeatedly or an accumulation of multiple ACEs. This prolonged activation of the stress response leads to changes in the developing brain, hypothalamic pituitary axis, and other organs of the child. Changes can also be seen at the epigenetic level with modifications to the way one’s DNA is read and processed.
While the ground breaking ACEs study along with other key neurodevelopment research have helped us identify the problem and effects of ACEs, it does not offer us a solution. What do we do about children already exposed or the adults walking around with numerous ACEs suffering from the known long term consequences? Is there hope for them or are they simply a lost cause? Have faith, all is not lost! The solution to the riddle of ACEs lies in the building of resiliency. Resiliency is defined as the ability to recover from or adjust easily to adversity or change. While this skill is easier to develop in a child when compared to an adult, both can achieve this goal. It is accessible to all people at all ages. So how do we build resiliency? Interpersonal relationships and connection to community are key factors for adults. We can be part of the solution by creating a space of love, safety, and connection for our children, for one another, and for ourselves.
Figure 1: The ACES Pyramid: https://www.cdc.gov/violenceprevention/images/acestudy/ace_pyramid_lrg.png
References: 1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study.American journal of preventive medicine,14(4), 245-258. 2. American Academy of Pediatrics. (2019). Adverse childhood experiences and the lifelong consequences of trauma. 2014.
For more information on ACEs, effects, and solutions: 1. CDC: https://www.cdc.gov/violenceprevention/aces/index.html 2. Harvard Center for the Developing Child- Toxic stress: https://developingchild.harvard.edu/science/key-concepts/toxic-stress/ 3. Dr. Nadine Burke Harris ,California’s Attorney General, Ted Talk on ACEs: https://www.youtube.com/watch?v=95ovIJ3dsNk 4. ACEs connection network: https://www.acesconnection.com/ 5. For information on Trauma informed care, ACEs screening, and primary care training for government reimbursement for ACEs screening see California ACEs Aware Initiative: https:/www.acesaware.org/
Meet Them hereW
They Are
BY FARIN JACOBSEN
Agencies collaborate to vaccinate hard-to-reach populations against COVID-19
Finding a COVID vaccination clinic and registering for an appointment can be confusing even for a well-equipped, tech-savvy individual. But for some people — namely agricultural workers, the elderly, and individuals experiencing homelessness — accessing and navigating government websites to find a vaccine clinic can be impossible without help. With such populations, local officials say, the best solution is to bring the vaccine directly to the patients. “Public Health is keeping those hard-to-reach populations top-of-mind,” said Madera County Public Health Director Sara Bosse. “That’s a really important role of the Department of Public Health is always to figure out how to equitably make vaccinations available. But how you do that depends on what resources are available and what partners you have.”
Collaboration is a mark of a crisis, with multiple agencies working together for the greater good. Madera County’s Department of Public Health has contracted with community-based organizations and collaborated with the Madera County Farm Bureau and Ag Commissioner as well as other agencies that work closely with the agriculture community to get farmworkers vaccinated. The Madera County Office of Emergency Services was also a huge part of the health department’s response to the pandemic from the beginning, Bosse said.
“I think that [the collaboration] has been extremely helpful given the high demand on Public
Dr. Oscar Sablan and Dr. Marcia Sablan have partnered with AMORE to deliver vaccines to ag workers in rural Fresno County. Over 1000 have been vaccinated at clinics at Pappas Family Farms, Holland Nut Company, Bar 20 Dairy and the Firebaugh Community Center.
Health to be able to take on things that we weren’t funded to do up to this scale,” she said.
Fresno and Madera County public health departments, along with several partner agencies and employers, have come up with dedicated and creative solutions to serve their ag workers, seniors, and unhoused populations.
VACCINES REACH AG WORKERS THROUGH THEIR EMPLOYERS
The Wonderful Company, which produces and packages POM Wonderful juice, Wonderful Pistachios,
and Halos oranges among other products, has vaccinated employees onsite through standing clinics and mobile clinics, said Dr. Raymond Tsai, the company’s executive medical officer.
“As an ag company, there is a lot of interest to be sure that our workers are vaccinated, both because it is good for business, frankly, to be sure that our workers are protected, but two, it’s just the right thing to do,” he said.
While vaccines are traditionally distributed by hospitals and clinics because of their existing infrastructure and staff, focusing on non-traditional ways to vaccinate atrisk groups is increasingly important, Dr. Tsai said.
“Thinking about how to get vaccines to people where they are, instead of getting people to vaccines, I think is something that we need to do more of,” he said.
The Wonderful Company offers COVID vaccines to employees at its two Wonderful Wellness Centers in Lost Hills and Delano in Kern County. But because produce for The Wonderful Company is grown throughout Central California, Tsai has headed pop-up mobile clinics to be sure that all employees have easy access to the COVID vaccine.
“As we know, throughout the pandemic agricultural workers, essential workers, and particularly Latinx communities have been disproportionately affected
by COVID-19,” Dr. Tsai said. “These are populations that don’t get the privilege of being able to self isolate, meanwhile are also taking on the burden of ensuring the supply chain of food. I think there is also an almost society debt to these populations that have put themselves at the frontline and literally risked their lives during this pandemic.”
Pop-up clinics have vaccinated employees at the POM facility in Del Rey in Fresno County as well as citrus farms in Visalia in Tulare County, and a pistachios and almonds facility in Madera County, Dr. Tsai said.
The Wonderful Company partnered with Del Rey
Packing Co., another ag company, to vaccinate their employees. First doses were given on February 10 and 11, and second doses were administered March 11, bringing the total to 605 people vaccinated.
“We’ve been using our mobile clinic to go out to those areas, and then doing one-day, large events to vaccinate our employees, but we always ask for extra vaccine because then we have the opportunity of advertising to surrounding ag employers to see if there’s interest in vaccination amongst their employees,” Dr. Tsai explained.
Another pop-up clinic held March 16 vaccinated more than 100 ag workers in the rural, westernmost part of Madera County.
Ease of access location-wise isn’t the only benefit of these employer-sponsored mobile clinics, Tsai said.
Leveraging pre-existing relationships with employers has been a working strategy for vaccinating ag workers because there is a level of trust and open lines of communication between the employers and employees.
“If this is company-sponsored, they don’t have to worry about losing time from work or that they’re going to get in trouble for not being at work,” Dr. Tsai said.
Fresno County Public Health Director Joe Prado said location is key, but there is another barrier to vaccinating food and ag industry workers: trust in the vaccine. In working to vaccinate people in those industries, the Fresno County Public Health Department found free education was key to getting closer to 80 to 90 percent of people accepting the vaccine.
“As we continue to penetrate these vulnerable communities and populations, you’ll see an increased uptake with proper education and letting people make that decision of whether or not they want to be vaccinated,” Prado said.
PACE PROVIDES A SENIOR-SPECIFIC VACCINE CLINIC
In the early days of COVID vaccination drive-thru clinics, seniors 65 years or older were eligible to receive their vaccine according to state guidelines — but had to wait in their cars in line for hours.
“Nobody wants to do that, especially someone that is more frail, has more comorbidities, or is more sick than your average 65-year-old,” said Nicole Butler, center director for Sequoia PACE (a Program of All-inclusive Care for the Elderly).
WelbeHealth’s Sequoia PACE center at 1649 Van Ness in downtown Fresno was one of the first five COVID vaccination sites in Fresno County and began doling out vaccines in early January, Butler said.
To make things easier on the senior population, WelbeHealth made appointments available by phone instead of using online registration and caters specifically
to the 55 and older crowd.
Finding out where to get vaccinated and registering online for a vaccine is a common issue for seniors, Butler said.
“The [vaccine clinic] list is housed on the Fresno County website, which is not an easy website to maneuver,” Butler explained. “It’s go onto the county website, download 50 locations that are providing vaccination, and then start calling at the top of them.”
For those who don’t have the list or don’t have someone to help them schedule an appointment, this task can be daunting, time-consuming, and frustrating, Butler said.
“We tried to make our vaccination clinic a little bit easier, so we’ve only been vaccinating the senior population,” she said.
Sequoia PACE can vaccinate 120 seniors per clinic day; the clinic is held every Thursday.
Appointments are scheduled every 15 minutes and seniors are asked to come at their designated time, waiting in their car if they arrive early. Seniors can park right in front of the building, come inside to get their vaccine, wait 15 minutes in an observation area for any adverse side effects, and then go home, Butler said.
“We don’t want people lined up around the side of the building. We want it to be very calm and an easy experience for them — better than going to the doctor’s office,” she said. “It’s been really nice to do it in a setting that’s not as fast-paced as some of the other vaccination sites because this is not a fast population. I mean, they’re coming in with walkers and canes and wheelchairs and so it really allows for them to take their time.”
Sequoia PACE has reached out to local senior living facilities and provided transportation for their residents from those facilities to the vaccination clinic. Now they’re reaching out to see if the independent living facilities would
want staff to come to them to vaccinate seniors, but PACE is finding that most of the elderly living in those facilities who wanted the vaccine have already gotten it, Butler said.
SINGLE-DOSE SHOTS SEEM BEST FOR UNHOUSED POPULATIONS
People experiencing homelessness have a higher risk of mortality from COVID-19, according to the California Department of Public Health, and thus became eligible for the COVID vaccine on March 11. However, the Madera County Department of Public Health was a step ahead.
The department had already worked with the Madera Rescue Mission, which provides shelter to men, women, and children experiencing homelessness, to deliver vaccinations on February 10 and March 10 due to two COVID-19 outbreaks at the mission, said Bosse.
“Our health officer prioritized that group due to that vulnerability, and so we moved forward with people who are actually living at Madera Rescue Mission,” she said.
The health department administered 30 Moderna vaccines and 7 Janssen vaccines to people staying at the mission. The Janssen COVID-19 vaccine manufactured by Johnson & Johnson is administered as a single dose.
“We got feedback that the single-dose vaccine is ideal for the population, certainly because scheduling followup appointments is really a challenge for a lot of reasons,” Bosse said.
At this point, county health departments are taking whichever vaccines they are allotted and vaccinating as many people as possible, as quickly as possible, officials say.
“We’re looking forward to an increase in single dose vaccines and I think that’s really the ideal vaccine,” Bosse said. “It’s also easier to handle so that we can actually go out to encampments and … be able to set up a clinic that’s walking distance from locations where we commonly find our unhoused populations. That’s the plan in Madera County.”
Part of Madera County’s strategy is to engage with the unhoused population through a chronic disease staff member who is well-known and trusted in the unhoused community. The individual has worked with the county’s unhoused population for years with regards to testing and treatment of sexually transmitted diseases, Bosse said.
That staff member will be key in helping those unhoused individuals feel comfortable and — with the help of multilingual staff members and community-based organizations that speak indigenous languages — get their questions answered about the COVID vaccine, Bosse said.
“We need supports to be able to educate and inform that group as well about the benefits of vaccination — and we’re ready to do that,” Bosse said. “The strategy is to go to them and provide [vaccines] in a location that’s really convenient.”
The health department hasn’t surveyed the unhoused population to see if the group is apprehensive about getting vaccinated, but Bosse said the vaccine seemed well received at the Madera Rescue Mission.
“People were really open to getting the vaccine,” she said. “But with any group, especially those who have challenges with accessing information that’s largely digital… we want to make sure that people are well informed and when they’re making a decision that they have all the information.”
Bosse looks forward to the day everyone is eligible for the COVID vaccine, as long as the doses are available and the infrastructure is in place to administer doses to anyone who wants to be vaccinated.
“I think the most important thing for people to know is that Departments of Public Health want to vaccinate people. We don’t want to prevent people from getting vaccinated,” she said. “So the eligibility process that we’re following is really because I don’t have enough vaccine for everyone. It would be, honestly, easier for us to just open enough to be able to vaccinate anybody.
“As soon as we have enough vaccine, we’ll get around to everyone.”
SEQUOIA PACE
WELBEHEALTH IS A PHYSICIAN-LED, CALIFORNIA PACE OPERATOR WHOSE MISSION IS TO UNLOCK OUR MOST VULNERABLE AND FRAIL SENIORS' FULL POTENTIAL WITH EMPATHY AND LOVE
Its teams coordinate every aspect of their participant's care so they can live in their own homes and communities rather than a nursing home. This care coordination includes all necessary medical and dental care, therapies, long-term care and services, meals, socialization, transportation, day center services, and activities in a fully coordinated 24/7 program. WelbeHealth delivers these services through PACE (Program of AllInclusive Care for the Elderly), a Medicare and Medicaid program. PACE is a well-established financing and care delivery model for older adults age 55 and older who meet their state definition of needing nursing home care. The PACE model of care aims to keep frail elders as well as possible, manage any medical crises at home, and reduce admissions to both hospital and long-term service and support (LTSS) settings.
BETTER OUTCOMES WITH COST SAVINGS
Among the 138 PACE organizations operating in 30 states, ninety percent of participants are dually eligible for Medicare and Medicaid, 9 percent are eligible only for Medicaid, and less than 1 percent are eligible only for Medicare. The typical participant has 5.8 chronic medical conditions, including dementia, coronary artery disease, cerebrovascular disease, and diabetes. These people have a 24 percent lower hospitalization rate using PACE than dually eligible beneficiaries who receive Medicaid nursing home services. At the same time, states pay on average 13 percent less than the cost of caring for a comparable population through other Medicaid services, including nursing homes and home and community-based waiver programs. This model of care makes a significant positive impact on quality of life for medically frail seniors and is essential to communities at a time when more than 10,000 baby boomers turn 65 each day. PACE has demonstrated significant improvements in participants' quality of life, life expectancy, depression rates, and sense of health empowerment and engagement. It also serves as a helpful partner to families and caregivers. It generates significant taxpayer savings by improving participants' health and well-being.
For frail elders, whose needs span both medical care and LTSS, the impact of Covid-19 has been catastrophic. High morbidity and mortality rates among those infected have been widely reported, with the most severe impact occurring in the nursing home resident population. However, less than 7 percent of PACE enrollees have tested positive for Covid-19 and 1.66 percent have died of the virus. These rates are below other care models serving nursing homeeligible individuals, according to the National PACE Association.
A SHIFT TO TECH
At the onset of the pandemic, WelbeHealth rapidly shifted to a fully remote home-based care model. In a matter of days, its teams deployed senior-friendly technology allowing low-income patients to access integrated care teams from the safety of their own homes on a 24-hour a day basis. These internet-connected WelbeLink computer tablets not only kept participants better protected from COVID-19 by facilitating remote care, WelbeHealth teams also invented new programming to combat social isolation through group therapy. In late 2020 when vaccination disbursement began in California counties, WelbeHealth was among the nation's first PACE programs to begin rapid and safe vaccinations among its participants. Its teams vaccinated the majority of its elderly patients and team members by utilizing strong relationships with healthcare partners and county governments. It is also acting as a community vaccinator, successfully vaccinating thousands of Californians against Covid-19. Since 2019, WelbeHealth has maintained its standing as one of the fastest-growing PACE operators in the U.S., opening four California programs to serve greater Stockton and Modesto, the Pasadena-GlendaleBurbank region, the greater Long Beach area, and Fresno. It has plans for additional expansion in underserved communities.
For more information, visit https://welbehealth.com
Advanced Treatment for Major Depressive Disorder
Very often patients su ering from depression obtain no relief from multiple medications. In many cases drug therapy can cause signi cant side e ects resulting in non-compliance.
Safe and E ective Technology No anesthesia required No memory loss No down time from normal activities Accurate Neuronavigation System
