COVID-19 Webinar Series Special Issue – Perspectives from the Veterans Health Administration

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)   0:07 Hello. I am Sarah – president and CEO of the Alliance for Health policy. Welcome to this special edition recording of our covid-19 webinar series for listeners new to the alliance. We are a non partisan resource for the policy Community dedicated to advancing knowledge and understanding of Health policy issues. 0:25 We launched this webinar series to provide insight into the status of the covid-19 response and shed light on remaining gaps in the system that must be addressed to limit the severity in United States you can find recordings from all the webinars in the series and additional resources on our website all Health policy dot-org Before We Begin The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation, and the Commonwealth fund for supporting our covid-19 webinar series again, you can find the materials that accompany this recording on our website at all Health policy dot-org. 1:04 The veterans Health Administration is the largest Integrated Health System in the country serving more than 9 million veterans today. I am so pleased to be joined by. Dr. Richard Stone who is the executive in charge of the veterans Health Administration to discuss the va’s response to covid-19 as executive in charge. Dr. Stone directs a healthcare system with an annual budget of approximately 87 Point 5 billion dollars prior to joining the VA. He was a vice. 1:34 Don’t at Booz Allen Hamilton. Dr. Stone is retired from the US Army where he served as the Army’s Deputy Surgeon General and the deputy Commanding General of support for US Army medcom. Dr. Stone welcome. 1:50 Thank you so much. I appreciate being here. 1:54 Thank you. Well, let me start by asking you a little bit about the situation on the ground. What are VA health centers around the country experiencing right now? 2:06 So we began preparing for the events that we’re experiencing now back in January. When the Chinese first reported that there was the potential of a new virus that had transmitted from animals to human. We went to full-time activity when the Chinese reported that there was human to human transmission and what that means is that we stood up our Emergency Operations Center which Then followed within about a week. 2:34 All of the emergency operation centers across the United States. These are operation centers that we use to accomplish our fourth Mission, which is the to be the backstop for the American healthcare system in the event of earthquakes fires floods and hurricanes for the most part and unfortunately over the last five years. We’ve been extremely busy doing that mission. Our first mission always is to care for America’s veterans. 3:05 Our second is to educate America’s doctors and nurses as they go through training. Our third mission is to do research in war-related injuries and illnesses. And then our fourth since 1982 is to provide care in the event that the American Health Care system could not fulfill its responsibilities to to the citizens of America today on the ground. 3:33 We are active in in fulfilling our fourth mission in multiple ways. We’re helping distribute bulk Pharmaceuticals around the nation to FEMA. We are supporting hospitals in New York City by taking varial covid patients. 3:49 We are also doing the same in New Jersey in Detroit in Ann Arbor and in Louisiana, we also are partially Staffing nursing homes in the Northeast that have had trouble with loss of Now we have also supplied ventilators to the Indian Health Service in New Mexico that are overwhelmed by by the covid epidemic it each day. We have additional missions and discussions regarding our capacity to fulfill our first mission, which is the care of veterans and to take on the responsibility for supporting individual Healthcare Systems under pressure. 4:39 Thank you so much. And and can you tell me in March the VA released a covid-19 response plan and I must congratulate you it was incredibly thorough to my eyes. But can you share some key Provisions in that plan? And how are you adapting knowing that the situation continues to change on a daily basis? 4:59 We recognized very early that this pandemic was going to challenge all of us and we felt that as a service to the American Health Care Delivery Systems that the ate a comprehensive view of how to approach Health Care in this type of environment was necessary. So that is just under 300 pages that that use how we are approaching this and really outlines the two lines of effort in every facility that has not been completely converted to covid therapy that protects patients without covid. 5:39 And also provides Optimum care to those with the virus and tries to avoid the intermixing across the facility. We’re very proud of the methods in which we began to limit visitation back in March at first our most vulnerable patients in our nursing homes, you know, we operate a hundred and thirty-four nursing homes with about 8,000 veterans that are the most frail and elderly and we felt that there was very substantial risk to them. 6:09 And therefore we began limiting visitation. We did believe that much of the American Healthcare System that exists in rural areas. It was very difficult for them on their own to reach the level of expertise that we had the ability to reach and therefore making that document public that is actually n X2 are high consequence infection document. That is existing. 6:39 Stood for over a decade, but I’m really quite pleased with it. And please that many Healthcare Systems have chosen to use it as a methodology to approach this pandemic. 6:54 Thanks Aunt and tell if you could just take a step back talk a little bit more about just the the population that you’re serving. You mentioned. Rural you mentioned nursing homes. Obviously, we have a lot of frail and older Veterans as well as younger ones. How are you? Thinking about your response as it relates to just the the needs of the veteran population? 7:19 So that’s actually just a terrific question because it’s different in every community in large cities with large amounts of comorbidities and a very elderly population. 7:33 We’re seeing a very aggressive disease with large amounts of admission to I see use and as well as large amounts of ventilator use the Chinese had reported their Koreans was that about 20% of patients infected with the virus would be sick enough to need hospitalization. We are seeing just over that and that is appropriate Across the Nation but what they also said was that only about 5% of patients would need to go to the ICU and we are seeing in large cities tend to 12 percent of the patients needing to go to the ICU and about 50% of those going on ventilators. 8:19 The Chinese had also said that if they went on ventilators, they would be back out of the ICU within seven days and we are seeing ICU stays of in the 11 to 12 Day range. 8:33 We are seeing a dramatically different picture in wealthier small cities in those wealthier small cities where the population has less comorbidities. 8:47 We’re seeing a higher incidence of admission to med-surg units and so acute Medical Care units and less utilization of ICU and less ventilator use In rural populations, it is very difficult to get a handle on and we’ve been reaching out proactively Across the Nation to talk to Public Health officials and express our willingness to support them. 9:17 As you are well aware and your listeners are well aware small rural access hospitals have been under some very substantial pressure over the last number of years and their ability to Capitalize themselves as well as prepare for this type of event is is very difficult and therefore our ability to reach out to those those communities to provide support to express our willingness to accept patients or even support them using telemedicine is is one that that is just unique to this system. 10:02 You know, we are Largest provider of telemedicine services in the nation and our tella ICU Services extend our crop across our delivery system in our ability to deliver a intensivist on a virtual basis to the bedside in support of a nurse in a rural hospital has been been used by both the Indian Health Service as well as was offered to the Javits Center in in New York is it? 10:32 begin to establish that Center And can you paint a little bit more of a picture for us? What is at Ella? I see you you look like just you know from the ground. How does that how does that actually work for our facilities? There’s robust technology that literally allows a intensivist to sit at a desk in Minneapolis and see a hospital in New Orleans and to watch the monitors to see the patient. 11:04 Aunt using various cameras and then to work alongside the nurse on the ground to provide the intensivist guidance and care and the ventilator management that is necessary in other situations. It could be simply a handheld telephone call in which the attends intensivist makes themselves available listens to the problems in a typical telephone call. 11:35 But sort of in between that from the very robust platforms that we have in our hospitals or we cover some of the Air Force hospitals with our intensive us we can even work off of an iPad which would allow the the Intensive this to to actually see what was going on in to observe. The monitors. Our idea is to be as creative and Innovative as possible in this inning. 12:04 Spanned this as rapidly as possible to as much of the nation as we can. 12:12 Thank you so much. And I want to ask you about a little bit more of that Workforce question. You mentioned your intensive as you mentioned that the second mission of educating the workforce as I understand that the protocols for using ventilators for for managing this the ramifications of this disease can become be complicated. Are you seeing the need to ramp up the specific training in terms of the care of these patients? 12:40 Like, how are your how are your facilities handling that and the central VA organization handling that so we have been running intensive care academies Across the Nation probably the best example of that is in Florida. 12:56 Florida is a very robust system but a very at-risk population because the amount of elderly veterans present as we begin to take down our Ambulatory Care Network and we’re like all other Healthcare Systems over the last many years we have primarily become an Ambulatory Care System supported by a hundred and twenty five hospitals that have beds in various levels of complexity, but responding to the pressures on all of American Health Care to do more things out patient and less things with prolonged in patient care and therefore we began back in February reversing that and literally training many of our primary care physicians in things like Like ventilator management and up straining our nursing staff from the operating rooms and acute care to perform ICU Services. We do believe that Across the Nation for the most part in most communities the civilian Healthcare System will well be able to handle the number of cases in med-surg Acute Care Nursing units where we think that there will be pressure across. 14:10 The entire nation is in intensive care. And therefore we began this up training and cross training of our physicians and nurses. We’ve also begun pulling our crnas out of the operating rooms that are not doing elective cases because they have the expertise to run the anesthesia ventilators. That wouldn’t wear shorter ventilators in an ICU. They can run those and have the expertise to do so. 14:40 They have been an extraordinary asset throughout this because of their high level of competence and their ability to handle patients with compromised Vital Signs. Thank you and let me just ask one other follow-up are folks in the civilian Healthcare System. Are they able to access those trainings or take advantage of them or how are you working with Health Systems across the country to help enhance their capacity in that regard. 15:09 We have not had Request to export that training but would be more than happy to do. So, we believe that this backstop concept that the secretary has talked about that allows communities to get to their final end game. You know, when I say that America has well over six thousand hospitals with a million hospital beds are 16,000 hospital beds in a hundred and seventy-five. 15:40 Five sites is not going to replace that commercial Healthcare System, but we can create a bridge for those communities that feel that they need a thousand beds or 2,000 beds and handle the most complex patients. The other thing that we worry about is that the temporary hospitals are filled with volunteers are active component military for the most part. Those temporary hospitals did not have medical. 16:10 Formation systems that allow the recording of complex care and we believe that the sickest of these patients after up to two weeks in the ICU will need extensive Rehabilitation and Pulmonary Rehabilitation. 16:28 And therefore we believe that the VA is perfectly situated to take patients with those needs to make sure that when the temporary hospitals begin to atrophy that there is continuity in the care of patients that need our services that might exceed the capability of the of the American healthcare system or the temporary hospitals that have been established. 16:58 So you’re talking about taking on some additional Post Acute Care capacity for for the rest of the healthcare system that may not be able to handle it. Is that is that correct? It is but obviously this will all be at the request of the Healthcare systems that then articulate that through FEMA as they recover from this this pandemic. 17:25 Great. Thank you. So I do want to ask you a little bit about just coordination. You mentioned, you know, the Air Force. Can you just talk a little bit about the roles of the the veterans Health Administration and the department of offense defense and how would you distinguish their roles in addressing the medical needs during this emergency. Well, since most of us here grew up in the Department of Defense for the first half of our careers it it feels very comfortable in our relationships are excellent. 17:54 We have prior to this over a hundred and sixty-five sharing agreements with the Department of Defense across our system. So the relationship is closed its active and it’s collegial. 18:07 We do recognize the fact that the Department of Defense has been called upon to get both of their Hospital ships out quickly as well as the Thousand beds that were established in Javits Center as well as multiple combat or field hospitals that have been taken out that have Taken some of their capability away from their fixed facilities. The VA is its reconfigured itself has grown over four thousand beds since January and will grow another 6,000 beds by August of this year in order to make sure that we can fulfill whatever contingency is needed. But there were the other excellent thing is we’re in the early stages of establishing a common electronic. 18:54 Uh medical record between Department of Defense and and the VA as we do that as we do that it also makes it very easy for us to move patients throughout these systems without difficulty earlier in the pandemic. 19:15 We move patients out of New Orleans to make New Orleans and all covid ospital and as we move patients to Biloxi, A hospital in Biloxi or up to Jacksonville? It was very easy because we’re on a common electronic medical record. So we believe that although we’re early in this stage the ability to have health information exchanges, which have begun to come online have been incredibly important to our ability to operate as a common Federal delivery system. Whether it’s VA or Department of Defense. 19:57 Thank you so much for bringing that up around the common electronic medical record. And certainly it seems like information exchange and technology is an important component of this response. I want to go back a little bit to telemedicine because you mentioned that you’re the largest provider of telemedicine and you talked a little bit about how telemedicine is being used for the acute needs of patients. Can you share a little bit about how your you might be using telemedicine for those? 20:26 Those veterans who may be do not have covid-19, but who have other needs and mental health being one of them and you know, you mentioned your two tracks in your in your in your plan for the non covid and then the covid patient. So, how are you using an accelerating use of telemedicine in that regard? As you know, one of the most important things that we deliver is an integrated mental health system. 20:51 We found that about a month before the pandemic really began to take Take off our mental health patients began canceling their appointments and we became very concerned about that in the continuity of care. We begin first telephonically reaching out to to our Mental Health Community and all of our mental health teams were placed on with the following Direction. 21:20 And that was they worked to reach out to every veteran that was canceling appointment or that they felt Was was being what was not being seen in was at some risk. I’m really pleased yesterday. We took a look at the statistics between Telehealth and video Telehealth. We are now and our inpatient correction are in-person visits that are still occurring. We’re now doing more Mental Health visits each day than we were before the pandemic and it’s an effort to make sure. 21:55 Sure that we’re fulfilling our mission of taking care of this at-risk population that the stressors that come from Community isolation, which we think creates such danger in our veterans that I already have problems with isolation is is absolutely essential. So I’m really pleased at the effort. That’s an ongoing. I’m pleased at the fact that we have such a robust. 22:26 Pharmacy mail order pharmacy system that can fulfill this and the integrated teams of our Mental Health Providers as well as our specially certified mental health pharmacists have done a great job in medication management as we’ve gone through this and been able to deliver the medications and the therapy that’s necessary to maintain this population. 22:56 Great. Thank you. And I didn’t get a chance to ask you about the supply chain. But if you have a brief moment to kind of share what steps you might be taking as far as the supply chain is concerned and is their special role for the VA. They’re roasted because of our fourth Mission. We keep not only our acute our levels are our usage levels, which is normally two-week supply of PPE and and medications. 23:25 Began back the end of January increasing that to a 30-day power level. In addition to that. We keep contingency stocks for our fourth mission for hurricane season and things like that that is about equal to R power levels. And so we had been up to a 40 day to 60 day supply we offered to act for FEMA as Regional Supply Depots for the Strategic National stockpile. They have a pretty robust and well-developed system. 23:55 Item and did not need our support for that and but we’re appreciative of us leaning forward in that offer. We are however really subject to buying things around the world the same way as everybody else in healthcare is and for just full transparency. We have worked really hard to cross level the areas under extreme pressure like New Orleans, Detroit. 24:25 New York with those like the Upper Midwest that are not seeing much covid and therefore we move mask and face Shields and even ventilators around the system as only a large integrated system can I’m quite pleased that as of today. 24:43 There are no sites that have run out of any of our PPE although I will tell you that we’re not at the depth of reserves that I would like to have and we’re hopeful for the Americas medical supply chain to begin to recognize the benefits of the defense production act and come back to the robustness that we experience before this started. 25:10 Thank you. We are almost out of time. I want to ask you just in closing just a couple of questions. Number one. I think everyone in America shares the gratitude for our veterans for their service to our country. So is there anything that regular Americans can do to support the veterans community in this time? And then secondly, if you could answer as the head of of one of the largest Health Systems in the US, what advice do you have for other health care leaders? 25:38 As they’re navigating this crisis. So first what this country needs to do is really come together as communities and therefore with the imposed isolation on all of us. 25:56 I think picking up the phone and calling a veteran is would be a great thing and if you know a veteran and haven’t talked to him for a while pick up the phone and call them because the country as a whole Needs to come together and take care of each other and as Melancholy as that might sound I would say to you that that’s probably the most important thing your listeners could do to help an individual veteran or all veterans in this nation. 26:26 I think the second issue as a leader of one of the largest Healthcare systems or the largest healthcare system in the nation my advice to other Leaders is that although we seem to have a glimmer of hope in the bending of the curves for this this disease, we believe that this will continue to percolate through America as we go through the next number of months and whatever time we have that this becomes a seasonal virus if we’re that fortunate we need to prepare for the next wave. 27:07 And as we prepare for the next wave it means continuing to do the things that you and I have talked about training our Force hiring as many people as we possibly can making sure our supply chain is stable making sure we bring our supply chain back on Shore and then to be hopeful that the research Community can deliver us a vaccine and adequate therapeutic medications that will allow us to defeat this virus. 27:36 – thank you so much. 27:40 Thank you so much, dr. Stone for joining us. We are great grateful, and we are appreciative now as a reminder to our listeners. You can find additional information and resources on our website all Health policy dot-org again. Dr. Stone. We thank you and wish you a blessed day. Thank you. 28:00 Bye.