CHAD Connection - January 21

Vaccines Distribution Major Focus for Community Health Centers

As we put 2020 in our rearview mirror and launch into 2021, vaccine distribution has become a major focus at community health centers (CHCs) in the Dakotas. Throughout most of North Dakota, that has meant active engagement in administering vaccines to staff and patients. In South Dakota, there have been more questions about how CHC staff and patients will gain access to vaccines, but CHCs have been advocating for their patients and communities and reaching out to public and private partners.

CHCs can and should have an important role in the vaccination effort because they have unique experience and expertise in serving many of the most at-risk populations of the Dakotas, including the unhoused, migrants, new Americans, American Indians, and rural, frontier, underserved, uninsured, and minority populations. At CHAD, we will continue to advocate for an equitable vaccine distribution approach that includes CHCs, and prioritizes effective strategies to serve vulnerable populations.

The incoming Biden Administration has announced a strategy that will impact how vaccines are distributed. So far, we have only seen high-level policy statements, but we expect that more detail will emerge shortly as the Biden team takes over the Department of Health and Human Services (HHS). Relative to CHCs, the plan states that the Biden Administration will:

"Launch a new partnership with Federally Qualified Health Centers nationwide. Federally Qualified Health Centers (FQHCs) serve more than 30 million patients each year — one in 11 people nationwide. Many are people of color, and many live in rural communities. FQHC patients are often individuals struggling to make ends meet. Given the critical role that these providers play in their communities, President-elect Biden will launch a new program to ensure that FQHCs can directly access vaccine supply where needed. At the same time, the administration will encourage jurisdictions to engage and work closely with health centers in their community vaccination planning. And to ensure that health centers have the resources they need to successfully launch vaccination programs, President-elect Biden has called on Congress to provide additional funds to support community health centers, and HHS will launch a new program to provide guidance, technical assistance, and other resources to prepare and engage these providers nationwide."

Other elements of the plan include:

Creating more vaccination sites by standing up federally-supported vaccination centers.
Emphasizing equity with a focus on hard-to-reach, marginalized communities. FQHCs are specifically mentioned as a partner in ensuring equitable access to vaccines in medically-underserved communities.
Increasing the supply of vaccines.
Mobilizing a public health jobs program to support COVID-19 response.
Leading a public health campaign to address vaccine hesitancy.

While the Biden Administration will certainly put their stamp on vaccine distribution in the country, I believe we can also expect a significant amount of continuity from the approach that is already underway. I would expect that states would continue to play a key role in vaccine distribution policy and that CHCs will continue to work with state partners. CHAD will share relevant policy changes and updated information as they become available.

Last week, then-President-Elect Biden released his COVID-19 "American Rescue Plan." Below is a summary of plan elements. The National Association of Community Health Centers (NACHC) expects the President to offer additional stimulus proposals after this one.

Mount a $20 billion national vaccination program in partnership with states, localities, and Tribes. This will include launching community vaccination centers nationwide and deploying mobile vaccination units to hard-to-reach areas. Also, ensure that everyone receives the vaccine for free, regardless of their immigration status.
Invest $50 billion in a massive expansion of COVID-19 testing, including purchasing rapid tests, expanding lab capacity, and helping schools and local governments implement regular testing protocols.
Funding 100,000 public health workers to perform vaccine outreach and contact tracing in the short-term and eventually transition into community health roles.
Address shortages of critical supplies, including personal protective equipment (PPE), by investing $30 billion to provide 100% federal reimbursement for critical emergency response resources to states, local governments, and Tribes, including the National Guard deployment. Also, invest $10 billion to expand domestic manufacturing for pandemic supplies.
Extend and expand emergency paid leave measures until September 30.
Reduce the number of uninsured persons by having Congress subsidize COBRA through the end of September and expand and increase premium tax credits for Marketplace plans.
Expand access to behavioral health services by asking Congress to appropriate $4 billion to the Health Resources and Services Administration (HRSA) and Substance Abuse and Mental Health Services Administration (SAMHSA).
Invest $20 billion in Indian country for COVID response.

President Biden has released his administration’s slate of health nominees and appointees. Former California Attorney General Xavier Becerra has been nominated to lead the Department of Health and Human Services (HHS). Andrea Palm was chosen for Deputy Secretary of HHS.

Other members of the Biden health team include:

Dr. Rachel Levine as Assistant Secretary of Health;
Dr. Vivek Murthy as US Surgeon General;
Dr. Rochelle Walensky as the Director of the Centers for Disease Control and Prevention (CDC);
Dr. Marcella Nunez-Smith as the COVID-19 Equity Task Force Chair; and,
Dr. Anthony Fauci as Chief Medical Advisor on COVID-19 to the President.

On his first day in office, President Biden issued 17 executive orders, presidential memoranda, and agency directives. Of particular interest to health centers and their patients are orders on coronavirus, equity, and immigration.

COVID-19

Launches a "100 Days Masking Challenge" asking Americans to wear masks for 100 days. The order also requires masks on federal property.
Stops the US withdrawal from the World Health Organization (WHO).
Creates a COVID-19 response coordinator position to manage efforts to produce and distribute medical equipment and vaccines.

EQUITY

Rescinds the Trump administration’s ban on race and gender diversity training and the 1776 Commission and directs agencies to review their actions to ensure racial equity.
Prevents workplace discrimination based on sexual orientation or gender identity.

IMMIGRATION

Preserving and fortifying deferred action for childhood arrivals (DACA).
Terminates the emergency and redirects funds regarding the southern boarder wall.
Revises immigration enforcement policies and priorities.
Ends discriminatory bans on entry to the United States.

More executive orders are expected in the coming days, including more directives on combating the COVID-19 pandemic. Expected by the end of the week are:

An order to require masks on public transportation including trains, buses, and aircrafts, and public health measures will expand for domestic travel. International travels will need to have a negative COVID-19 test before entering the US and will be required to quarantine.
Agencies are directed to use the Defense Production Act to increase the supplies need for COVID-19 tests and vaccines.
An order to accelerate the rollout of vaccines providing more funding and a sugar of health care workforce.

The Biden Administration has issued a "regulatory freeze" memo that may impact implementation of the FQHC/340B/insulin regulation. The memo puts a temporary block on all regulations that are not final and urges the Department of Health and Human Services (HHS) to consider delaying implementation for 60 days to allow time for reconsideration. As the order must be delayed or blocked today, Thursday, January 21, or it will go into effect tomorrow, information is likely to change at the day progresses.

The National Association of Community Health Centers (NACHC) has been assured that HHS is aware of the need to block the implementation of this harmful and misguided regulation today, so that Federally Qualified Health Centers are not unnecessarily diverted from their critical role in responding to the pandemic and economic crisis.

In December, Xavier Becerra, the Biden Administration’s nominee for HHS secretary, led a group of attorneys general in a letter calling on the agency to hold drug companies accountable for cutting off 340B discounts. NACHC feels this is encouraging as it signals Mr. Becerra’s opposition to the 340b regulation. South Dakota Attorney General Jason Ravnsborg also signed the letter in opposition.

CHAD will inform the 340B group as new information becomes available. To be added to the 340B distribution list, contact Carmen Toft. For more information on the 340B regulation see the resources page on the CHAD website.

On January 15, the US Department of Health and Human Services (HHS) postponed the first deadline for providers to report on how they used their Provider Relief Fund (PRF) funding. This deadline had been set for February 15, 2021; HHS has yet to set a new deadline.

On the same afternoon, HHS also issued updated PRF reporting requirements, which supersede all previous versions. The most significant update is the option to define "lost income" using "any reasonable method."

Governor Burgum presented his State of the State address to a joint legislative session on Tuesday, January 6, in Bismarck. Burgum opened his remarks by voicing gratitude to health care workers and first responders across the state who have worked tirelessly throughout the pandemic.

The Governor highlighted the following top priorities:

A $1.25 billion bonding proposal to fuel low-cost financing of infrastructure projects

Rather than paying for projects entirely with cash, bonding is a financial tool that allows the state to take advantage of low interest rates. The governor’s proposal would use earnings from the state’s Legacy Fund to retire the bonds and provide low-cost financing for roads, bridges, career and technical education centers, and other one-time infrastructure projects. Burgum’s is one of several bonding proposals being considered.

Development of a permanent Higher Education Stabilization and Transformation Fund for North Dakota public institutions

The governor requested that the legislature, North Dakota University System, and State Board of Higher Education collaborate on the study and development of a permanent Higher Education Stabilization and Transformation Fund, with the goal of initiation and implementation by 2024.

A Unified Spill Reporting System

Governor Burgum announced the launch of a new unified spill reporting system, with the intention to streamline and simplify reporting of hazardous materials spills.

On the pandemic, Burgum provided a hopeful outlook, praising North Dakota’s ranking as third in the nation for the number of people per capita who have received their first dose of vaccine and highlighting the state’s relatively low unemployment rates.

In December, the governor announced his proposed budget for the 2021-23 biennium. The proposed budget totals $15 billion from general, federal, and special funds, up from the current $14.7 billion because of the $550 million in appropriations for infrastructure projects within the bonding proposal. In addition to the priorities described above, the governor’s proposed budget includes cuts to higher education, steady K-12 state funding, and $8 million for the Housing Incentive Fund to increase affordable housing across the state.

Within health and human services, the budget includes:

$95 million in COVID-related funding;
Reducing the Medicaid expansion fee schedule to match traditional Medicaid rates (proposed change would become effective July 2022);
Additional funding for the substance use disorder (SUD) voucher program through the Department of Human Services; and,
Construction of a new state hospital in Jamestown through a public-private partnership.

For more on the State of the State address: https://www.governor.nd.gov/news/video-burgum-presents-2021-23-budget-proposal-holds-line-general-fund-spending-invests
For more on the governor’s budget: https://www.governor.nd.gov/news/video-burgum-presents-2021-23-budget-proposal-holds-line-general-fund-spending-invests

Governor Noem joined the legislators to give her annual State of the State address on Tuesday, January 12. The governor started her speech by saying that South Dakota achieved many things envied by other states, including a balanced budget, low taxes, smart regulations, exceptional state parks and outdoor opportunities, and staying "open" during the pandemic. She only briefly mentioned COVID-19 by complimenting the systems for dispensing the vaccine within the state and thanking health care workers.

The governor recommended the telehealth changes made to address the pandemic be made permanent. She also noted that South Dakota has made progress on drug and alcohol abuse, suicides are down, and mental health programs are working.

Governor Noem noted that her chief priority is to promote South Dakota. She pointed to the $2.8 billion in capital investment in the state last year and the 2,100 jobs that investment will create. She also shared that 135,000 homes in the state are still without access to high-speed internet, and she wants to close that gap with her proposal to fund broadband completely. This access will allow people to live where they want and work remotely or age in place. She sees this as a small-town growth opportunity.

The 2021 legislative session will run through Monday, March 29, to complete a 37-day session. The legislature will be in recess beginning Friday, March 12, through Friday, March 26

The Bureau of Primary Health Care (BPHC) announced a significant reorganization on Tuesday, January 19. The reorganization is part of a larger restructuring at the Health Resources and Serves Administration (HRSA) as part of the multiyear transformation effort to reassess and improve upon how the BPHC accomplishes its mission and goals called BPHC REACH. The announcement to HRSA staff last week stated that "the Bureau of Primary Health Care is renaming two of its offices and updating functions in order to increase attention and focus on Health Center Program compliance and funding oversight."

BPHC will maintain the same core, six-office structure with some key changes to provide greater flexibility to address current priorities and to pivot for future priorities quickly. The shift will allow BPHC to better leverage staff’s variety of talents to customize support to each health center’s unique needs, resulting in roles such as specialized project officers (or teams of staff) that can help address certain quality and performance focus areas.

The public announcement for a Federal Register Notice (FRN) describing this new structure became available on Tuesday and will be published in an official form on Thursday, January 21. BPHC Associate Administrator Jim Macrae will discuss some of the key changes during Thursday’s "Today with Macrae" session.

Thursday, January 21
12:00-1:30 pm MT/ 1:00-2:30 pm CT
Join the day of the session or watch the recording once it’s posted on the COVID-19 information for health centers and partners webpage.

Call-in: 800-857-9804
Passcode: 9473292

The Centers for Medicare & Medicaid Services (CMS) recently issued guidance to state health officials designed to drive the adoption of strategies that address the social determinants of health (SDOH) in Medicaid and the Children’s Health Insurance Program (CHIP). The new guidance is so states can further improve beneficiary health outcomes, reduce health disparities, and lower overall costs in Medicaid and CHIP. SDOH is used to describe the range of social, environmental, and economic factors that can influence health status—conditions that can often have a greater impact on health outcomes than the actual delivery of health services.

The new guidance describes how states can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH. It will also support states with designing programs, benefits, and services that can more effectively improve population health and reduce the cost of caring for our nation’s most vulnerable and high-risk populations. The guidance also noted that the adoption of value-based care arrangements could better provide opportunities for states to address SDOH and disparities across the health care system.

For the full CMS press release, visit here. To view the Opportunities in Medicaid and CHIP to Address Social Determinants of Health letter, please visit here. At a local level, CHAD will work to understand how our states are responding to this guidance and how this may impact health centers.

The North Dakota Department of Health Oral Health Program (NDDoH OHP) works to ensure North Dakota residents have good oral health. One of their many activities includes providing care through medical-dental integration (MDI). A public health hygienist (PHH) was hired to offer preventive services at the University of North Dakota’s Center for Family Medicine. In six months, the PHH completed 298 dental screenings and referred 107 individuals for further dental treatment.

Read the full evaluation report or the program brief to learn more about the reach and impact. If you are interested in a similar model of care, access the North Dakota MDI Manual.

The NDDoH OHP has also supported dental student rotations, placing seven students in ND federally qualified health centers (FQHC) over the course of two years. Students provide clinical care and gain experience working in an integrated community health setting. Read the short brief to see the impact or access the full report for more information. Roughly 60% of procedures performed by students were restorative in 2019, and students were responsible for over $60,000 in Medicaid services. Students also reported amazing experiences, and one has taken employment at a North Dakota FQHC.

The North Dakota Oral Health Program continues to support oral health care with programs and resources that strengthen and enable dental care in North Dakota. For more information, please visit https://oral.health.nd.gov/.

On Friday, January 15, Lutheran Social Services (LSS) of North Dakota announced it had suspended all programs and issued staff layoffs, citing chronic financial issues. The change came as part of a controlled liquidation plan, which may include a bankruptcy filing. LSS has been a staple of social services across North Dakota for over 100 years, with many individuals and families relying on their support.

Most recently, the organization provided a range of services, including mental health therapy, affordable housing, pregnancy counseling, youth interventions, senior services, and more. LSS was responsible for refugee resettlement and humanitarian services in North Dakota and provided a wide range of support to New Americans, including initial housing and necessities, caseworkers, citizenship classes, English classes, interpreter services, and more.

The agency has announced that certain programs (including the Unaccompanied Refugee Minor program) will continue under different leadership. The North Dakota Department of Human Services will coordinate the transition of LSS programs and clients where possible, and they have committed to sharing those plans with North Dakota community health centers as they are developed. CHAD will continue to share updated information as it is available.

As community health centers (CHCs) across the nation feel the pressures of COVID-19 and the lack of trained and qualified staff, the pandemic has emphasized the importance of growing a diverse and robust workforce. One way to achieve this is by designing training programs for health professionals.
Health centers around the country have been invited to participate in the Bureau of Health Workforce/ Bureau of Primary Health Care strategic workforce initiative. It is important to make sure the Dakotas’ health centers’ input is included by filling out the Readiness to Train Assessment Tool (RTAT) survey.

The RTAT is a survey designed to look at health center readiness to develop and improve health professions training. In partnership with Community Health Center, Inc., CHAD is inviting all CHC staff in the Dakotas to join in the first step of creating an ever-growing and replenishing workforce by completing the RTAT survey.

For several years, CHAD and community health centers in the Dakotas have emphasized developing and improving behavioral health and substance use treatment services. CHAD has provided training and technical assistance on topics ranging from medication assisted treatment to behavioral health integration and is now excited to share some of the upcoming training opportunities in 2021.

CHAD has designed the 2021 training calendar to look at health conditions with a behavioral health component. The subject matter and information will be appropriate for both primary care and behavioral health providers. Behavioral health integration in primary care is unique in many ways. In many settings, physical health and behavioral health are still thought of separately, even though the patient’s chief complaint is related to both.

The season will kick off with training on psychosis in primary care that will be of particular interest to primary care providers. Additional topics will include treating patients who have experienced infertility, pregnancy loss or postpartum depression, eating disorders, and disability with an emphasis on sexual health.

In late spring, CHAD will offer a one-day training followed by a one-and-a-half-day workshop on chronic pain and opioid management in primary care. This training and workshop will be led by leading national expert, Dr. Jennifer Murphy. She serves as the Department of Veterans Affairs (VA) director of behavioral pain medicine and is a master trainer for the VA’s cognitive behavioral therapy for chronic pain (CBT-CP).

In the fall, CHAD will offer an extended workshop on focused acceptance and commitment therapy (FACT), which is an evidence-based treatment model developed specifically for brief intervention use in primary care. Drs. Bridget Beachy and David Bauman are former students of the developer and are recognized throughout the nation as experts in FACT and behavioral health in primary care.

In addition to scheduled training, CHAD is working with the National Association of Community Health Centers (NACHC) and Opioid Response Network to offer technical assistance to community health centers to develop and improve substance use disorder screening and intervention through telehealth. Details for this will be forthcoming. This robust and diverse training calendar is designed to meet health centers’ needs and offer unique learning opportunities to primary care and behavioral health providers.

CISA Releases Cybersecurity and Physical Security Convergence Guide

The Cybersecurity and Infrastructure Security Agency (CISA) announced the publication of the Cybersecurity and Physical Security Convergence Action Guide, which provides guidance on converging cybersecurity and physical security functions to better position organizations to mitigate cyber-physical threats.

Convergence is defined as formal collaboration between previously disjointed security functions and is anchored by communication, coordination, and collaboration. Organizations with converged security functions are more resilient and better prepared to identify, prevent, mitigate, and respond to threats targeting both physical and cyber assets.

The action guide provides information on convergence and the benefits of a holistic security approach that aligns cybersecurity and physical security functions with organizational priorities and the cyber-physical threat landscape. In addition, the guide describes the complex operating environment, the risks associated with siloed security functions, convergence in the context of organizational security functions, and provides a flexible framework for aligning security functions.

For more information or to access the guide, visit www.cisa.gov/cybersecurity-and-physical-security-convergence. "CISA Releases Cybersecurity and Physical Security Convergence Guide" HPH Sector Highlights - Cybersecurity Edition - January 8, 2021

Treating Long COVID: Clinician Experience with Post-Acute COVID-19 Care

For some people, the effects of COVID-19 can last well beyond the immediate illness. Patients and clinicians across the United States are reporting long-term effects of COVID-19, commonly referred to as long COVID. During this CDC clinician outreach and communication activity (COCA) call, presenters will share their firsthand experiences with treating long COVID, focusing on the pulmonary, neurologic, and psychological aspects. They will also describe their experiences with establishing clinics that provide care for patients with these long-term effects.

Thursday, January 28
12:00 pm MT/ 1:00 pm CT
Advanced registration is not required. Link to join:
https://www.zoomgov.com/j/1606808037?pwd=NUx3a1hQd2tVWVZBU0JobFgxUDJ2Zz09

CHAMPS 2021 Resiliency Collaborative

The CHAMPS Resiliency Collaborative is a facilitated peer support group using concepts from the evidence-based framework, Finding Meaning in Medicine, online. Each session will incorporate the practice of mindfulness techniques and practical body awareness exercises. The remaining time will be comprised of group discussions on topics selected by the participants. For more information or to register, visit the CHAMPS Events and Trainings webpage.

First and third Wednesdays of the month (reoccurring January through May 2021)
12:00 pm MT / 1:00 pm CT

Psychosis in Primary Care Clinics

Presented by CHAD, this webinar will provide an overview and discussion of common diagnoses that manifest in psychotic symptoms. Participants will learn to identify common etiologies of psychosis in primary care and define common benefits and risks of antipsychotic medication. Dr. Andrew McLean will describe management strategies of psychosis and include evaluation and treatment options.

Tuesday, February 16
11:00 am MT / 12:00 pm CT
Register here.