COVID-19 Webinar Series Session 2 – At the Front Line: Public Health and Health System Challenges

12:00 p.m. – 12:05 p.m.     Welcome and Introductions

Sarah J. Dash, MPH

President and CEO, Alliance for Health Policy, @allhealthpolicy

12:05 p.m. – 12:30 p.m.    Moderated Discussion

Adriane Casalotti, MPH, MSW

Chief of Government and Public Affairs, National Association of County and City Health Officials (NACCHO), @NACCHOalerts

Craig Cordola, FACHE

Executive Vice President and Chief Operating Officer, Ascension Health, @ascensionorg

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Good afternoon. I am Fair – president and CEO of the Alliance for Health policy. Welcome to the second event in our proven 19 webinar miniseries. We know that many of you listening today are on the frontlines of managing this Public Health Emergency. The alliance is committed to remaining a resource amidst this turbulent time today. We have two experts on the line to Share the experience of Health officials at the front line of the Cove in nineteen response.

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You can Add to today’s conversation on Twitter at hashtag all health-wise and follow us at all Health policy.

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Before We Begin The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation for supporting today’s webinar. I’d like to briefly Orient you to the go to webinar platform and review technical notes before we get started we’ve taken a screenshot of the attendee interface. You should see something like this on your computer desktop in the upper right corner. You can click the orange arrow to minimize and maximize this menu when you join today’s webinar you are muted and you will be throughout the presentation.

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Use the question panel to chat with us about any technical issues. You may be experiencing and you can send in questions that you have for the panelists at any time. We will collect these and address as many as we can during the broadcast.

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Next slide please.

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You will also find all of the materials that accompany this webinar including the panelists BIOS and additional resources and selected experts about give the 19 on our website. We will be updating these as additional articles and analyses are released and a recording of today’s webinar will be made available on our website soon. Now, I’d like to introduce our panelists. I am joined today by Adrian caselotti the chiefs of government and public affairs for the National Association of County and City Health officials.

2:24

Prior to joining NATO Adrian held positions at the FDA and on Capitol Hill. I’m also joined by Craig cordula the Executive Vice President and Chief Operating Officer for Ascension Health a non-profit health system that operates across the u.s. He is leading ascensions National Command Center. Ancova 19. Thank you for joining us. So I’m going to start with a few questions for our Frontline experts today, and then we’ll turn to questions from the audience. Let me first ask you Craig.

2:53

You’re overseeing the command center for Ascension. Can you talk about broadly the steps that Ascension is taking as a system to prepare for and protect against the novel coronavirus? Sure. Yeah. Thank you so much for hosting this panel today and happy to represent Ascension and all of our Associates to share how we’re approaching. What is a really tremendous effort on behalf of the entire country. Honestly to help impact our patients and families affected by Cove it I will say for us.

3:24

One of the good things we have a fantastic team of Emergency Management professionals within our organization. And as part of our Emergency Operations planning, we have incident command opportunities at all of our local health ministries and the national Command Center that we established about a week ago. And as a part of that we do things like working on surge capacity plans. So we have prepared for events like this. Obviously.

3:49

This is a much larger scale than what most have anticipated and I also have a national pandemic plan that provides additional guidance and resources that we’re able to work through and we regularly exercise these plans with our local communities as well as local and federal authorities and then specific to this incident I would say is that we had one of the first cases in the country was actually patient. Number two, there was admitted to our Chicago Health Ministry on January 20th with suspected covet. It was convert confirmed on the 23rd and then we had patient number.

4:23

I’ve shortly thereafter. And when that occurred we immediately set up our incident command to provide resources and thought partnership with our local teams there and Amita health system, which is in Illinois and helped to provide. So we had a little bit of an early warning and frankly a little bit of a practice run in January for our entire Health Ministry and then I would just finish on a couple of other components. I mean, obviously one of the things that’s critically important for us is keeping our own patients.

4:53

It’s and visitors safe through this time. And so we have infection control practitioners at the national level and embedded locally in all of our health care Ministries and working very closely with the Center for Disease Control and other local and public health authorities. And ultimately we are standing firm and following the CDC guidance and recommendations that are coming out in order to keep everybody safe. And so, you know started with early planning and now we are fully stood up all of our incident command and command centers to address.

5:24

covered 19 great. Thanks Craig and just ask a quick follow-up question just to our audience has an idea of how many sites how many health ministries are we talking about across the country. Can you give us a sense of the scale? You’re you’re dealing with? Yes, so we have right now about a hundred and sixty thousand Associates 2400 sites of care 151 hospitals and about 35,000 Affiliated Physicians. And so that’s the magnitude in the scope of what we’re working on and obviously we operate in multiple.

5:57

States as well across the country. We’re pretty much mid west to east and pretty large Health Care Ministry that we are trying to do the best we can to care for patients and families and Community great. Thanks. Let me turn to Adrian now Adrian casalotti. What is the role of County and City Health officials in the Corona virus response?

6:22

So it well, thanks Sarah in the alliance for having me. I really appreciate it. Our members are all the local Health departments across the country nearly 3,000 of them and every Community is activated on coronavirus response and they have been really since January and even miring it earlier when it was more localized in China. So Health officials and their staff are really on the front lines of this work. They are doing a ton when it comes to Community Education both.

6:51

Helping those who are the worried. Well trying to figure out what calm fears comment anxiety helping to make sure people know what are the symptoms and what to do. We don’t necessary want people who are exhibiting symptoms to rush into urgent cares or to Physicians offices. We want to make sure that they know who to calls and they can be triaged appropriately and not put other people at risk.

7:15

They’re working with Healthcare Providers to make sure they know what they’re looking for and to really coordinate resources and Since they are doing a ton of Data Tracking and surveillance to have a good understanding of what the situation is in their Community as they make a determination of where they should be on this Continuum of containment. Whereas we’re trying to stop the spread to Mitigation Of how do we recognize this bread is here and we need to be preserving resources for those who are most sick and try and flatten the curve and slow the spread of the disease in the community. They are also working with their state and federal.

7:51

Nurse of course and to make sure that we have a good response nationally and then one thing they’re really they’re doing now a lot of is really being that advisor to other aspects of local government. So helping to inform County councils and mayor’s offices about restrictions on how many people can gather and large events working with school systems help them determine.

8:15

Should they be closed and if so for how long as well as working with housing and some things like what do we do when this reaches the whole population and the Metro going to get exported structures?

8:38

Great, so let’s get to some more details. So so Craig just go back we heard a lot about supply chain issues. We’ve heard a lot about the need for supplies and equipment at the front line. Can you talk about how you as a pension or handling supply chain issues and and broadly, you know help this is across the country. What is what is being done? What are your biggest challenges? And what do you think needs to be done next?

9:09

Yeah, thank you. That is clearly one of the most important issues for us right now in order to keep our Associates safe and we get we have a fantastic Resource Group through a suspension.

9:20

One of the largest gpo’s in the country that have been sourcing supplies for us for weeks in order to prepare for what we’re up against right now and we track four times a day essentially isolation gowns are Loop and tie masks in 95 respirators as well as face Shields we Addition to that we’ve sourced when I would say is non traditional Healthcare sources for those PPE as well the personal protective equipment and have gone through some of our construction vendors that we use that support all of our Ascension facilities as well to ensure that we have an adequate supply of protective equipment for our staff and Physicians. This is something that we are monitoring frequently. I believe that Ascension is in a very good position as it relates to personal protective equipment. However, it is a limited resource.

10:08

And given the demand that we’ve seen for all of our patient needs compounded by the requirements for PPE around Kovac 19 patients. We have implemented some guidelines around PPE usage so that we can make sure that we are preserving what we have and an example of that was we immediately began to follow CDC guidelines around elective procedures. And in fact on Sunday after meeting through the week and we began to cancel all elective cases.

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Has throughout organization beginning Monday morning in an effort to preserve primarily PPE and to ensure that we have the appropriate staff that could be redeployed to care for covert 19 patients. So those are some examples of what we’re doing proactively as well as monitoring and I have heard that there are several Health Systems not surprising that you know PPE is a very significant concern for them and their ability to care for patients and families given the fact that this is a worldwide pandemic and everybody is essentially reaching.

11:08

To the same Distributors and suppliers for PPE product but believe essentially it at this point is well positioned to continue to care for patients and families and looking ahead through some modeling to make sure that we have both capacity and supplies for the next several weeks as well.

11:25

Great. Thanks. Let me follow up on that point that you made about canceling elective surgeries. Another tactic that we’ve been hearing is being pursued a strategy that’s being pursued obviously people without Cove in nineteen continue to be sick or fall till we last week an expansion of telemedicine capabilities.

11:48

Can you talk a little bit about how are you thinking about meeting the needs of people who you know are are just dealing with They’re the regular illnesses that you know continuing. Yeah talk about that. Yeah, absolutely. And I really appreciate the follow-up question at the end of the day. Our fundamental premise is to follow CDC guidelines, but at the same time we are deferring to local clinical decision making at that facility and our Health Care Ministry.

12:18

We will never override the clinical decision-making of our physicians and staff, but we are providing pretty strong guidance around Electoral procedures as an example and our teams have been fantastic and fully support our decision on Sunday night to essentially eliminate all of our elective procedures throughout our health care Ministries to your point around telemedicine of fantastic point. We’re fortunate that we had a huge platform already in place through Ascension connect and also our Ascension Medical Group, which is are employed Physician Group for virtual care visits and virtual provider offices.

12:52

And so we accelerated our work around that so That we could keep patients from showing up in our emergency departments in our physician offices that might be an infection risks and order to protect them from being infected themselves. And so I just pulled some stats to this to date just in the past five days. We’ve had over 50,000 downloads of the Ascension app that gives individuals virtual care capabilities and in the past six days, we’ve had 8700 virtual visits and are now training an additional thousand Ascension Medical Group.

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Options to be activated on the platform so that we can continue to provide virtual care to all of our patients and families throughout the country and we’ve dramatically reduced our expense on that and it’s a $20 charge for anybody for a face-to-face virtual care visit with one of our physicians and clinicians.

13:46

Great on that note. Let me let me turn to Adrienne because Adrienne you talked about making sure that patients even if they start feeling sick if they start feeling symptoms of a potential coronavirus that they’re not just rushing into their nearest doctor’s office or urgent care or emergency room. Can you talk about how or the city and county and local Health Department really trying to educate the public about the population about that? What challenges are you seeing? What feedback are you getting?

14:18

Sure. And so this is really where the two sides of Health public health and Healthcare really neat work together to help preserve the resources on each. So Health departments are doing a ton of work when it comes in their local communities.

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So local press working through community-based organizations and other thought leaders in the community to get this information out many have stood up call centers, which is really critical and some are really Even we have a Workforce shortage in in public health. And so they’ve called In Medical Reserve Corps volunteers and others who can be trained up to answer some of those calls one also people can can get information and not just get a recording. They’re doing a ton on social media trying to get that information out there. There’s been officially a little bit earlier in the response when I hate to say it, but there was probably a little bit more time for creativity. There were some really amazing targeted messages.

15:15

So for example in Colorado they were trying To explain to people what social distancing was and they said you’d be six feet apart and what they used were skis so not a call not from Colorado but apparently all know it’s keys look like and that’s how far we need to be from folks others in New Mexico were saying, you know wash your hands like you just cut hatch chilies and you take your contact out there trying to make these messages easy to remember and easy to digest for their community and there are these unsung heroes of Health Department’s Unfortunately they don’t all have one, but it’s called your public information.

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Officer and that’s that person who is really the that link point between the science and the expertise in the health department. And how do you get that information to the community and then back again? So really relying on the expertise of those folks of how do you build public health literacy and also ensure that people have access to the resources that they need, but it’s definitely not perfect and people are really trying to find ways to digest more technical.

16:17

Payments are coming out of the federal government make that useful for people at the local level calm fears and anxiety. But also make sure people get the accurate information they need so they’re making the best Healthcare decisions at the point of that they are today.

16:33

Great. Thanks, Adrian. I do want to ask you one other follow-up question, you know, you talked about the importance of the work that city and county health departments are doing to get the information out there to educate people on social distancing and flattening the curve in order to preserve those resources that we talked about that Craig talked about making sure that what resources we do have are used and put to the best of use.

16:58

So if you’re not want to ask you, you know, the Latin In the current social distancing or words that I think, you know, maybe only in the last seven to ten days have served jumped into the national Consciousness. Can you talk about how do you think things are going across the country? What is how successful are the efforts so far and what more needs to be done?

17:19

Yeah, so I think there’s really this combination of individual education and then also policies are being implemented at local levels to try and reinforce those messages and also to make the choices easier to make the right choice. So for example at the federal level there yesterday the Senate passed the next the newest coronavirus 2.0 bill that included provisions.

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Around paid sick leave and FMLA expansion while they’re still debate about how the final results came out. Those are both ways to try and make it easier for people to make the right choice when it comes to working from home staying at home helping deal with family issues when their kids schools are closed which I am personally dealing with and it is hard there. So that’s something that the federal level at the local level here in Washington DC. For example, we saw a lot of people taking those messages.

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making the choices to be away from folks trying to keep their distance and then we saw a bunch of people also going out to bars after that weekend the governor or the mayor stepped in and said, hey, we’re changing our rules because we want to make sure that if you’re not making the best choices where I can to help you make the best choices by not having those places open anymore for that and there’s big economic consequences and but at the same time it’s trying to help ensure that all Policies are going towards helping people make the best choices to slow the spread of this disease. I’m actually really impressed with how flatten the curve has really taken hold in a way. It’s not something I would have guessed a couple weeks ago, but I think people are looking around the globe and seeing what the result is when you don’t and really trying to heed those messages, but when you put that into an individual’s context and you realize hey, I’m out of milk and my kid needs them too.

19:18

I go back to the grocery store today or I’m someone who is an at-risk population, but I need my diabetes medication. Do I go into the pharmacy today? It gets a little bit more messy. Thank you so much. Okay, I want to ask each of you one more question and then I would like to turn it over to audience questions and I’m seeing some come in. So as a reminder, you can ask the question in the questions panel and then we’ll get to as many of them as we can in the next 10 to 12 minutes.

19:47

So I want to ask the question about Testing because obviously that has been very much in the news and you know, we understand that there are guidelines that are coming out of the CDC out of state and local Health departments that are being implemented in in health system. Can you talk about what is the process for testing patients with who potentially might have over 19 and then for reporting those results and Craig it we haven’t heard from you in a while. Do you want to chime in on that one first?

20:18

Hadrian start as far as what the public health officials are doing and how that’s being coordinated and I’m happy to speak specifically on the implications for Health Systems. Terrific Adrian. Go ahead. He just punched the hard questions. So it is testing is the huge issue right now and I would say that it actually the situation is different depending on what community you’re in.

20:44

I mentioned earlier this spectrum of containment to mitigation and so depending Khan the disease burden localities are having to make choices around what their parameters are for testing from the federal level. We’re hearing that testing is really necessary for people with symptoms that seems severe of the illness people who are health care workers and may have been exposed as well as those in the more medically fragile populations. They in certain communities that is working and others.

21:18

These are they’re actually not focusing on testing as much there are huge resource problems with testing right now just because you have a testing kit which was one of the first resource issues doesn’t mean you have all the accessories to testing that you need to be able to do it. It doesn’t mean you have the Personnel time to do it.

21:36

It doesn’t mean you definitely want to be using up all your personal protective equipment to be doing testing on people who aren’t showing any symptoms and probably if you don’t have clear exposure links, so there’s a Of calculus that goes into this. So for example in Pitkin County in Colorado, they have actually said we’re not testing anyone anymore. We don’t have the resources and the equipment to do so, so what happens is if you have if you’re just mildly sick stay home.

22:05

If you have more severe symptoms call us and we will find a place we will we will figure out if you need to come in for more to the hospital and we will find a bed for you, but that’s really where they’ve shifted their efforts and Resources because they don’t have what they need to be doing just that broad testing to really have the information to know what the disease burden is Pitkin County. I should have mentioned is where Aspen is they have a health department of eight people. I might have just added a person it might only be 7 and while they only have about a hundred thousand population of people they or their populations actually small they have tons of people who come in as Travelers.

22:43

So they have a much bigger group that they’re trying to take care of even though they’re A quote small area. So that’s the decision that they have had to make in other locations. They’re trying to find ways to do more of that testing without putting people into using ways to keep more social distancing be able to do it.

23:03

So things like drive through testing where you’re able to just come through with an appointment knowing that you should actually be in that line versus I’m feeling fine today, but there’s a drive through testing window you that’s not useful kind make that people who need it can go through that type of mechanism. And then also questions around will there in the future be a at home self swab self test that I know some people are really trying to rush to have put into existence the testing issue. I think from a scientific perspective. We would love to know the exact disease burden would be great so we can Target resources, but we don’t have enough of the resources to do it.

23:43

And so that’s what communities are making those determinations about – I think Adrienne did a fantastic job answering that in completely concur with what she had said. And so I don’t know that I would have anything additional to add. I think she described it perfectly.

24:01

Actually one thing I was one thing I would add is that there’s a complexity in the reporting now that maybe didn’t exist three weeks ago. So you have the public the public health lab testing pipeline I guess is one way to call it. But now you have private lab coming on board large Hospital Systems have their own Labs epic academic medical centers.

24:23

And so it’s great because it opens up more doors for that testing but it also does add complexity of how do You count and measure and ensure that things are being reported quickly and accurately so it’s just as it does add another level of complexity there.

24:41

But I’m glad you brought that up Adrienne because we did have an audience question asking how can good epidemiological analysis be carried out without massive testing and understanding the realities on the ground, you know, can you is there anything more that you could add about, you know as we look at the numbers coming in as we look at the number of cases being reported. Do you anticipate an increase in the number of cases being reported that you know, maybe yes already there, but just weren’t detected.

25:11

Okay. Yes.

25:16

Agree concur the more people you test the more you’re going to find especially with a virus like this that that Steven’s to spread pretty quickly. I think at the end of the day whether it’s a couple months from now and you know, it gets funny and all of a sudden the virus has done with us or 18 months from now if we actually have a vaccine or however long it’s going to be really important for us to take the lessons of coronavirus and learn something from them.

25:42

We were behind on testing so you don’t Have the luxury to do all that that work that would give us the best scientific data to be able to really model and do the work we’d like to and if nothing else we should really learn from this experience of what do we need? And how can we be more prepared in the future? So that the next coronavirus we’re starting a couple of steps ahead instead of starting from a deficit.

26:11

Great. There’s another audience question about testing which is its testing free. So can either of you address that.

26:19

This is Craig. I think it varies. I mean there’s there are a lot of Health Plans. A lot of communities are doing it for free other payers may be charging, but I would tell you at the end of the day certainly within Ascension. That is absolutely not a barrier to get tested.

26:34

And actually the bill that passed the house in the Senate yesterday that I one of the listeners might actually know if that’s when the president is going to sign it. I feel like every time I’m giving a presentation that the news is happening right while I’m doing it is it does have different Provisions for ways to reduce or to eliminate out-of-pocket co-pays for testing depending on what your health insurance status is so Public Health lab testing has always been without.

27:04

Cost to the individual there’s a provision in there to make it so that private insurance should be covering it without co-pays.

27:13

I think there might be a question there around what type of plans and if there are any other grandfather that wouldn’t include that they put in Provisions for Medicaid Medicare Tricare the VA so that Bill maybe soon-to-be law was supposed to cover and get rid of that perceived that real barrier to to actually get tested.

27:38

And so and Adrian there was another question actually about that legislation and the question was whether city and county health receive any additional funding through the recent action of Congress.

27:50

So this most recent well the bill that there may not become law doesn’t have anything necessarily that funds local and State Health departments, but the first emergency supplemental Bill does so we on February 26 Which seems like four years ago. We had we had our board and a bunch of other partners here. We partnered with the state health officials as well. And we’re on the hill talking about what we needed for Appropriations. Like so many others are but really were able to talk about coronavirus and we feel like the hill heard us in the legislation specifically eight point three billion dollars total which actually doesn’t seem like all that much money.

28:29

Now when things are being floated at the one trillion dollar amount includes nine hundred and fifty million dollars specifically Set aside for state and local Health Department response. That’s it. Also included. So having it as a specific set aside was really important to help Grease the wheels of the federal government, which can be phase flow if if they’re committed and there was no you put in place and they had to get those dollars out at least half of those dollars out of the federal government within 30 days.

29:00

The funds are not going are going to State tear it all States territories and And directly to only six cities across the country every other city and county needs to get funding through their state. And so the 30-day deadline was to get the dollars out of the federal government and we are working with our state partners and our health department on the ground to help them facilitate the the flow of those dollars so that they can get out of the state level quickly and to the local level that law also.

29:36

That localities and States could be reimbursed for work. They’ve done since January 20th, which is really important. I don’t know how many people on the phone lived through the zika Congressional. I’ll call it fun for almost a year of trying to get money out of out of Congress. So this was a really important step of doing it and doing it quickly because we had health department saying I don’t know where the money’s coming from, but I need to do what’s best for public health and this at least gave them some understanding that there.

30:06

Were funds in the pipeline and we’re just trying to make sure they get down to the front lines as quickly as possible.

30:12

And Sarah, this is Craig. I would like that one thing if I can. I know we’re running up against the time, but look we fully support the measures that Congress has made and the additional funding in particular for our local Health Department’s it’s critically important, but ultimately the vast majority of not-for-profit Health Systems operate on pretty thin margins in the one to three percent range, and eventually there will absolutely have to be some provider emergency funds to sustain the caregivers the providers and the health systems that are on the front lines.

30:41

He’s along with the Health Department’s making a difference for these patients. I think this is going to be both an emerging in a concerning problem unfortunate that our health system is incredibly strong financially, but recognize that this is a very difficult issue that by the day will continue to create challenges for the vast majority of not-for-profit Health Systems.

31:02

I just it just two weeks ago and yet and we thought wow, that’s an incredible amount of money and in two weeks. It’s like wow, that was a great down payment and now we got to keep going because this is not something that’s ending in a couple of days or a couple of weeks.

31:19

Weeks. Well, I want to thank you both for joining us. We are up against our time before we before we close. I do just want to ask you, you know, Adrian you mentioned Lessons Learned if you could each spend just a minute and give a quick. What do you think is the biggest lesson learned so far from this pandemic and feel free to make it as broader super specific as you want.

31:44

Sure, so I think there will be many Lessons Learned From the obviously there’s a lot to be learned around testing. But I think it really comes down to what are what’s the infrastructure in our systems?

31:55

So Public Health departments have loss of quarter of their Workforce since 2008 in the recession and they haven’t recovered their budgets are at best flat since that time for many especially large Health departments are looking at about 30% decrease in their budget not adjusting for inflation when you Have these issues you never know what the next coronavirus is going to be. But if you don’t have the system in place that’s strong and you’ll have the people in place that strong then you’re going to find the cracks in the system and we’re trying to build upon something from a deficit instead of starting even at even so that’s really important for us to think about we don’t just need to fund things when the crisis happens.

32:35

We need to be thinking about those broader pieces so that the system is there for us when we need it because we never know when that will be Craig do you want to chime in have the last word Fisher just a couple of comments on this, you know, every Healthcare disaster or event that occurs is unique in its own way and you know, many of us have been through several different aspects of hurricanes tornadoes fires bombings everyone brings their own unique element to it and I think for us a couple of good lessons learned that will definitely be briefed on after I think broadly the Supply chain in production and sourcing of our equipment and PPE is really important that is critical for us to be able to care for patients and families. And so how that whole supply chain process works for our health Ministry and others I think is important. The other element for us is just the coordination that it takes for an emergency response at this scale both across our own Ascension Health System, but also the local Partnerships the local Health authorities.

33:47

So that we can provide consistent guidance to our clinicians on both what to expect and how to better care for patients and families. I think has been something critical and and candidly us standing up our Command Center at the national level. That was the goal was to be able to provide consistent timely materials and communication to our Frontline caregivers so that we can reduce the ambiguity and increase Clarity so that they can do what they’re trained to do, which is take great care of patients families and community.

34:17

So for Those are a couple of the key elements.

34:22

Great. Well, thank you so much. We are out of time. I want to thank Craig and Adrian from taking time away. You are both at the front lines, and I’m sure working double and triple time to work on this crisis. So we thank you for taking the time to our audience. Thanks for sticking with us. We will be joined tomorrow by Mike Leavitt who previously served as Secretary of the Department of Health and Human Services and the government and the governed as the governor of Utah and he’ll talk about responses at the federal state and local levels.

34:51

So, please take Time to complete the brief evaluation that you’ll receive immediately after the broadcast ends, and you can view a recording of This webinar on our website soon, Adrian and Craig. Thank you again for joining us. Thank you so much privilege. Thank you. This is wonderful. Thank you terrific, bye-bye.