By Chris Officer and pacbiztimes Thursday, April 23rd, 2020

For insight on how COVID-19 has impacted tri-county health care, the Business Times reached out to some of the region’s leading medical professionals.

In this edition of the Business Times Roundtable, our health care panelists include Dr. Kurt Ransohoff, CEO and chief medical officer for Santa Barbara-based Sansum Clinic; Ron Werft, president and CEO of Cottage Health; Barry Zimmerman, chief deputy director of the Ventura County Health Care Agency; and Chief Nurse Executive Officer Candice Monge and Chief Medical Officer Scott Robertson of Dignity Health Central Coast’s five-hospital network.

Q: What’s been the No. 1 strain put on your system since the COVID-19 outbreak?

Dignity: The availability of CDC guidance of personal protective equipment (PPE) has been, and continues to be, of high concern. We have never managed a supply chain with both global demand and global disruption and this has obviously impacted everything we do within our hospitals. Due to the national shortage of PPE, Dignity Health Central Coast hospitals have put additional processes in place to ensure we have an adequate supply to protect our health care workers and patients during this time.

Efforts include a team assigned on procurement of PPE, daily inventory accounting and projection of utilization rates, and education and training regarding appropriate PPE usage. Currently, we have an adequate supply of PPE, however, there continues to be a level uncertainty regarding sustained inventory due to the national shortage.

Ransohoff: Our first concern, of course, is the health and safety of our patients and our staff. Financial strain has been our next biggest challenge with COVID-19. Because of the pressing need to protect public health and safety, we intentionally limited non-essential medical appointments and elective procedures. Additionally, many patients preferred to stay home or reschedule visits. This resulted in a 50 percent drop in patient volume. As an independent, nonprofit medical foundation with smaller cash reserves than hospital systems, we had to make the difficult decision to temporarily furlough many of our clinical and non-clinical workforce to preserve our future economic viability. This represented about 30 percent or so of the payroll, and about 50 percent of our staff. It is something that we obviously wish did not have to happen. Our hope is that these hard choices now will ultimately allow us to be here when this global pandemic is over to offer care to the more than 130,000 patients we serve each year.

Werft: Of course the access to supplies is a well-known challenge. But our team at Cottage set to work early on to prepare and find solutions to challenges in this area, and our community has been very supportive in offers to help and donate supplies — and even design and manufacture supplies locally. It’s really an incredible community effort.

Hospitals and medical groups across the country are feeling the financial impact of elective procedures being postponed. As with many services and organizations, the decrease in services we can offer during this time comes at a significant financial cost.

Through it all though, I think the hardest part has been at a personal level for our care teams who have chosen a career of service and compassion — this situation has been unlike any other we’ve seen. Restricting visitors from the hospitals has been one of the hardest things we’ve ever had to do, because we know how important a support system is for healing. So while our care teams provide clinical care, they are also are there for support, standing beside patients in the hospital when family and friends can’t be.

Zimmerman: The greatest strain to the ambulatory care system and the hospital systems is meeting the demands for testing patients for COVID-19. The lack of test kits and PPE has been the greatest challenge. We were able to offer drive-through testing at multiple sites, but we had to limit which patients were tested based on CDC criteria and limited supply.

Q: What telehealth methods or other technologies have you introduced in the last 30 days, and will an increase of long-distance patient and clinician care practices carry on post pandemic?

Ransohoff: Our ability to launch a telehealth program in mere weeks has been an incredible thing to watch happen. In just one month’s time, 207 of our providers have conducted more than 12,000 telehealth visits. Patients are connecting with their doctors using their mobile phones, tablets and computers safely from their homes.

We created a Symptom Checker tool for use within our MyChart patient portal and mobile app that lets people evaluate their symptoms and receive next steps.

We’ve trained staff to launch and run a car-based COVID-19 testing facility, one of the largest in the county.

We’ve discovered a scientifically-sound process to internally sterilize N-95 masks.

We have had to be flexible during this time, making adjustments along the way. It can feel stressful while you are doing it, but long-term, it will make us a stronger organization.

Werft: Cottage Health was moving toward using telehealth more in our services well before the current health crisis hit. The hospital group used telehealth services for years and we wanted to integrate them more into patient care. In a timely development, Cottage rolled out CareNow in December, a platform that lets medical providers consult and treat 70 or so minor health issues. Through the platform, patients can either speak with a registered nurse or answer a series of questions asking them about their symptoms. The information helps providers have a better idea about what the patient is experiencing and gives them somewhere to start for treatment possibilities.

By seeking a consultation through CareNow, patients can get their questions answered and reduce the spread of COVID-19. The care service is usually $29 for an online interview, and $39 for a video face-to-face visit, but for people seeking guidance about possibly having COVID-19, the CareNow visit is free. In January, CareNow averaged five visits a day, but in March, there were 25 visits per day, and the number keeps rising.

Cottage is also shifting to telehealth solutions inside the hospital and in clinics. By using tablets in patient rooms, doctors and nurses can have virtual visits with patients to check in with them and see how they’re doing.

This helps reduce exposure for the medical professionals, but it also helps further reduce the amount of PPE the hospital is using. That helps the hospital maintain its stock for a longer period, which means it can treat current and future patients more safely.

Telehealth is also helping Cottage physicians social distance in other ways. The hospital group has a pediatric clinic in Pismo Beach, where it does consultations. It set up a virtual station at the clinic, so doctors can do physical exams there through telehealth.

Zimmerman: We implemented telehealth video appointments three weeks ago, with a robust adoption among physicians and positive feedback from patients. Patients have been able to stay in touch with their physicians through the pandemic, getting both their primary care and specialty care needs addressed. We will continue to offer telehealth visits after the pandemic subsides since it offers convenience and improved access to care.

Dignity: We have instituted telehealth video visits platforms for routine visits in each our of 42 Dignity Health clinic locations. We expect to see sustained use of video visits after the pandemic has subsided.
In the hospital setting, physicians are using telehealth methods to connect with patients and their families. Through the use of technology (iPads) we have been able to connect health care professionals, patients, and families despite visitor restrictions. This has been a benefit in discussing the plan of care through the hospitalization, but also in keeping patients connected to their loved ones.

Q: Have any modifications to your system’s facilities been made to better treat COVID-19 patients and will these changes stay in place for future infectious disease care?

Zimmerman: Clinic staffing and schedules have been modified to allow more people to work from home. For the doctors, this includes some doing telehealth from home while others remain at the clinics to address acute patient needs. Screening employees and patients prior to entry into the clinics has also been a change, and this would likely stay in place as long as it is needed to keep the clinics safe for patients who need to come in and be seen by their doctor in person.

Dignity: The hospital facilities have made modifications to create surge areas where higher volumes of patients can be seen. Surge tents have been erected at each hospital as well as our urgent care locations to create additional triage space, if needed. In the Emergency Departments, separate areas were created for screening of potential COVID-19 patients and flow of the departments were modified in an effort to reduce exposure to other patients and health care workers.

In the hospital settings, additional intensive care unit beds were developed to care for an additional number of patients requiring intensive care services. Additional areas were also modified to create supplementary surge beds, if needed.

Departments caring for COVID-19 patients were altered to include ante rooms used for safe donning/doffing of PPE and to reduce potential exposure in high risk areas.

Werft: Isolation and infectious disease protocols were well-established in the hospitals. With the new construction at Santa Barbara Cottage Hospital, we were able to quickly reconfigure entire units with negative pressure airflow for isolation of patients with COVID-19 systems, and make contingency plans for more space if needed. We moved some of our services into other locations within the campuses, but we will be able to flex back to standard unit configuration when the number of patients needing isolation normalizes.

We do hope that community awareness of hand and respiratory hygiene will remain, as those are important ways to protect against this and other harmful viruses.

The community partnerships throughout the county have also been essential to COVID-19 response. As in the past, the collaboration of Cottage Health, Lompoc Valley Medical Center, Marian Regional Medical Center, Sansum Clinic, Santa Barbara County Department of Public Health and Santa Barbara Neighborhood Clinics has been vital in emergency response efforts for our region, and beyond the initial emergency to the resilience of our communities over time.

Ransohoff: We are still conducting many essential, in-person, medical appointments with patients and needed to enact many changes at our 23 locations to keep them and our staff safe from viral spread. These measures include symptom checking at all entrances, requiring the use of masks, limiting all visitors, providing staff members with appropriate PPE, closing some department and pharmacy waiting rooms, and abiding by social distancing guidelines. At Urgent Care, we screen patients and separate those who may have symptoms of COVID-19 from those who don’t, to ensure people have safe access to needed Urgent Care services. We are also offering a car-based injection process for patients of our rheumatology department.

Q: What steps were put in place to help health care employees’ physical and mental well-being? How has the hospital combated stress and long hours?

Dignity: Daily communication with all employees and physicians during this time has been integral in addressing physical and mental well-being. The organization has established a hotline for all employees or physicians to call with questions or concerns and feedback is provided within 24 hours. Chaplains, social workers, and therapists have been conducting employee and physician rounds as well as receiving referrals for individuals.

Resiliency support has also been offered to employees who are interested. In addition, there have been spaces created within the work environment where staff can take time for reflective pause away from patient care. The hospitals have been able to combat long hours by establishing a labor pool where employees have been rotating assignments and receiving additional training to be able to assist in areas with higher needs.

Werft: Our first priority was to ensure we had the needed supplies of personal protective equipment and infection control precautions to keep our employees safe. Cottage Health quickly implemented a number of programs to support physical and mental wellness and job continuity for employees. A grants program ensures that donations received for employees are getting to those who need them most. We are offering our virtual health care visits for free to our employees. We transitioned our existing free fitness classes to online classes. We expanded telemedicine options for counseling support for employees and families, a transition of services offered by our established Employee Assistance and Employee Counseling programs. We also curated a collection of free online resources that include wellness offerings and support for remote work, and we are subsidizing additional child care so our frontline health care workers can continue to serve the community.

Zimmerman: To support the physical well-being of our health care workers, we have provided detailed training on the use of PPE. “Huddles” were scheduled three times per week to communicate and update staff regarding any changes in how and when PPE should be used.
Mental well-being has been addressed with weekly COVID coping sessions, lead by a psychologist and family physician and conducted over Zoom.

Ransohoff: The physical and emotional well-being of our team members has been a priority from day one. We have worked hard to properly inform our staff on all we know about coronavirus, and to provide them with the appropriate protective gear so they feel safe at work. We’ve tried to be flexible knowing they may have children out of school at home or family members that require care. We have connected our employees to important resources as they manage the effects of the pandemic personally and professionally. We held a Virtual Town Hall so everyone across the clinic could ask our leaders questions about our current operations and plans for the future. We offered a stress reduction webinar with our family physician Dr. Jay Winner to help ease some of the emotional weight we know our employees are feeling. I hope our employees knowing that we deeply care about them and are doing everything we can to keep them informed and safe has provided some comfort. We are incredibly proud of how our people have risen to the occasion under tough circumstances to continue to serve patients and we so appreciate the outpouring of generosity and support offered to us from our community. That has been inspiring and uplifting.

Q: How are other departments and specialists outside of the high demand of coronavirus care being affected during the pandemic?

Ransohoff: While we unfortunately needed to furlough some team members working in areas with greatly-reduced patient volume, we have transitioned other employees into different, new roles that have come about because of COVID-19. And in many cases, certain types of medical visits are occurring despite coronavirus. For example, infants still require vaccinations, cardiac patients should receive follow-up after procedures, and treatment for cancer patients has to happen. We have yet to find a medical specialty that can’t perform at least some types of appointments via telehealth. Our mission is still the same as its been for nearly 100 years, we just had to adapt quickly to this pandemic environment and learn how to serve our patients in new and different ways.

Werft: A staffing pool at Cottage Health works to redeploy staff as situations change, matching available employees to service areas in need of increased staffing. To help protect employees and patients, those who do not need to work in the hospitals are equipped to work remotely, to support the community wide effort to stay at home and prevent the spread of infection.

The significant reduction in patient activity due to postponement of non-urgent procedures has been difficult for staff who are dedicated to taking care of the community and health needs as they arise. We continue to provide treatment to meet urgent needs. Our hospitals remain open and able to provide care safely for those in need of hospital or emergency care, so it’s important that community members continue to feel comfortable seeking essential treatment if they have a health concern.

Dignity: With the exception of intensive care units, all areas of the hospitals are impacted by the reduced volume of patients. This includes operating rooms, emergency departments, radiology and the laboratory.

Other departments and specialists outside of the high demand of coronavirus care have offered to help in areas of higher need. There are health care workers who have additional skill sets that can be used in departments with higher needs at this time and/or who have an interest in learning how to assist in another departments so that they can continue to support the overall efforts of the organization.

Zimmerman: Specialists still need to be available for outpatient follow up as well as for hospital consultation. They have adopted telehealth for specialty clinic appointments. We have also deployed the use of iPads in the hospital, not only to improve patient communication with their families and with hospital staff, but also for specialists to provide consultations remotely via iPad video conferencing.