Thank you for reading this special edition of the CHAD Connection. CHAD plans to release weekly editions of the COVID-19 Digest over the next few months to cover COVID-19-related news and updates for our members. We also encourage you to visit our COVID-19 webpage for up-to-date resources and links.

In this newsletter, you will find updates from the Bureau of Primary Health Care (BPHC), the National Association of Community Health Centers (NACHC), the Centers for Medicare and Medicaid Services (CMS) and both the North Dakota Department of Health and the South Dakota Department of Health. You will also find information we thought would be useful, including human resources guidance, federal legislative updates, and mental health resources.

CHAD will be publishing weekly data representing the number of positive COVID-19 tests for the current week as compared to the previous week, the cumulative number of cases diagnosed, current and cumulative hospitalizations, the percent of health center visits compared to the determined baseline, and the percent of visits that are being done virtually. This data will be compiled for North Dakota and South Dakota each week. This week’s data covers the week beginning Thursday, April 23 to Wednesday, April 29.
Federal Legislative Updates
Congress passed additional COVID-19-related legislation last week that was signed by the president on April 24. This $484 billion relief package included $310 billion in additional resources for the Paycheck Protection Program (PPP), $75 billion for the provider relief fund, and $25 billion for testing for COVID-19, which included $600 million specifically for community health centers which can be used for expenses beyond immediate testing including protective personal equipment and staffing. The total amount of money in the provider relief fund is now $175 billion.

Several members of the CHAD advocacy network team have attended meetings with congressional staff to update our members of Congress on the needs of health centers in the Dakotas. We have shared valuable data received from health centers on lost revenue, loss of average weekly visits, and telehealth reimbursement issues. The National Association of Community Health Centers (NACHC) has put together a list of asks that we are also sharing with our congressional offices. The latest federal funding ask from NACHC includes:

  • $7.6 billion over six months for health centers for COVID-19 response;
  • $41.9 billion is requested over five years to stabilize current services and expand care to 10 million additional patients;
  • $7.8 billion over five years for the critical expansion of workforce programs, including the National Health Service Corps (NHSC), Teaching Health Centers Graduate Medical Education (THCGME) and the Nurse Corps Loan Repayment Program;
  • $20 billion for critical infrastructure needs;
  • Telehealth reimbursement changes; and,
  • Protection for health centers’ ability to retain 340B pharmacy savings.
Distribution of Provider Relief Fund Dollars from the CARES Act
Money distributed so far from the provider relief fund in the CARES Act has reached health centers in two batches. The first round $30 billion was distributed on April 10 to Medicare providers based on their 2019 fee for service reimbursements. For the second round of funds (an additional $20B), CMS was allocating funds new funds so that the entire $50B would be based on 2018 net patient revenue (not just from Medicare). For more information about this disbursement from the Department of Health and Human Services (HHS), visit this page. Distribution guidance includes:

  • On April 24, a portion of providers will automatically be sent an advance payment based off the revenue data they submit in CMS cost reports. Providers without adequate cost report data on file will need to submit their revenue information to a portal opening this week at for additional general distribution funds.
  • Providers who receive their money automatically will still need to submit their revenue information so that it can be verified.
  • Payments will go out weekly, on a rolling basis, as information is validated, with the first wave being delivered on April 24, 2020.
  • Providers who receive funds from the general distribution have to sign an attestation exit disclaimer icon confirming receipt of funds and agree to the terms and conditions of payment and confirm the CMS cost report.

Find the FAQ document regarding the general distribution portal from HHS here.

CMS also announced that $10B would be allocated to rural hospitals and rural health clinics; $10B would be disbursed to hospitals with a high incidence of COVID-19 patients; and $400M would be targeted to the Indian Health Service.
State Update – North Dakota
Governor Burgum announced this week that he would let the executive order he issued in March closing bars, eat-in restaurants, personal care businesses, and others expire on April 30. Businesses will be allowed to open starting May 1, if they follow phase one operating guidelines. The May 1 start date is entirely voluntary, and more information on these announcements can be found here. Schools will remain closed for now, and the state recommends that anyone who can telecommute continues to do so.

As part of the release of phase one of the ND Smart Restart plan, the governor reviewed eight critical goals that North Dakota will have to meet to reopen the economy. ND is comfortable with seven of the eight steps. The final step remaining is the protection of vulnerable populations. The steps and goals are as follows:

  • Widespread rapid testing – Goal: to be among the top ten states in testing per capita
    • North Dakota currently has the 5th lowest positive rate among states and the 6th highest testing rate per capita
    • Planned testing capacity is 4,000/day in May and 6,000/day in June
  • Robust contact tracing – Goal: statewide contact tracers with tools and technology
    • At the beginning of the pandemic, there were 18 trained tracers. Currently, 77 contact tracers are working, and an additional 275 who have been trained.
    • They need to have enough capacity for rapid follow up of positive tests.
    • The state believes the CARE-19 App will help with efficient contact tracing.
  • Targeted effective quarantine – Goal: an overall decline in transmission rates with limited community spread.
    • A 14-day rolling positive average is steady and below most states
    • Rates of community spread and close contact cases are declining
    • The governor feels the state has not seen a large peak due to effective distancing
  • Protections for the most vulnerable – Goal: individuals in long-term care and congregate living facilities are protected.
    • Agreement across facilities to transfer most vulnerable to the most appropriate setting
    • Rapid response teams in place to assist/intervene in testing and facility cleaning.
  • Sufficient health care capacity – Goal: excess and accessible health care capacity and PPE
    • Current hospitalizations are around 1% of total capacity.
    • Three-tiered hospital surge plan and supplies in place.
  • Adequate PPE available- Goal: the supply chain is sufficient and stable for the health care system and the public
  • Standard operating procedure – Goal: new standard operating procedures for all businesses
    • Initial guidance can be found here.
    • The state is expected to outline these policies at the Thursday, April 30 press conference.
  • Plans for virus resurgence – Goal: preparedness plans and expanded capacity available for future waves of COVID-19
    • Expanded state lab capacity up to 6,000 tests per day.
    • Antibody testing available.
    • Targeted procedures for closing/reopening with minimal impact.
State Update – South Dakota
This week, Governor Noem released her Back to Normal plan for South Dakota.

The plan lays out guidance, including:

  • Individuals need to continue to practice good hygiene and physical distancing and stay at home when sick.
  • Employers should encourage good hygiene and sanitation practices, encourage employees to stay home if sick, transition employees back to the workplace, and screen employees for symptoms where possible.
  • Enclosed retailers that promote public gatherings should resume operations that allow for reasonable physical distancing, good hygiene, and sanitation.
  • Schools will continue remote learning and consider a limited return to school for a "check-in" before the school year ends.
  • Hospitals treating COVID-19 patients should reserve 30% bed capacity and maintain appropriate stores of PPE to meet surge demand. Other hospitals and surgery centers must have updated transfer protocols and adequate stores of independently sourced PPE. Visits to senior care facilities should continue to be restricted.

There are four criteria to initiate the plan:

  • Symptoms
    • Downward trajectory of influenza-like illnesses reported within the last 14-day period
    • Have a plan in place so all personas with COVID-19 symptoms can receive a test upon recommendation from their provider
  • Cases
    • Downward trajectory of documented cases within a 14-day period in areas with sustained community spread
    • No clusters that pose a risk to the public
  • Hospitals
    • Treat all patients without crisis care
    • Testing program in place for at-risk health care workers, including emerging antibody testing
    • Adequate supply of independently procured personal protective equipment
  • State
    • SD Department of Health can investigate COVID-19 cases and initiate containment rapidly
    • SD EOC maintains a rapid response team to support high-risk businesses with a confirmed COVID-19 case
North Dakota’s Vulnerable Person’s Protection Program (VP3)
At the governor’s press conference on April 29, ND Department of Human Services Executive Director Chris Jones presented on the status of the Vulnerable Persons Protection Program (VP3). The state has been convening a workgroup to address protections for vulnerable populations, which includes homeless individuals, long-term care residents, residents of domestic violence shelters, corrections, and anyone living in a congregant living setting. The state is currently working on plans that include transfer and isolation protocols. They are also working to identify a basic care and memory care facility that can house residents that require isolation, and a protocol for rapid response teams to address any breakouts that occur. The plan is currently being enhanced, and more updates will come as the plan for ND Smart Restart advances.
DOL Ends Temporary Non-Enforcement of Paid Leave
On April 20, the US Department of Labor lifted its non-enforcement period, which initially gave employers time to comply with coronavirus-related emergency paid sick leave and paid family leave mandates that went into effect on April 1. The DOL will now fully enforce violations of the act, as appropriate and consistent with the law.

For employers that are required to or have chosen to offer the leave programs in the Family First Coronavirus Response Act (FFCRA), the US Department of Labor Wage and Hour Division (WHD) offers extensive plain-language guidance on the requirements of the law, including the most common questions and answers by employers and an in-depth FFCRA Webinar. The WHD has also created a employers’ resource section that offers critical information to guide employers toward operating businesses in full compliance with federal labor regulations.

Updated COVID-19 Diagnostic Testing Guidance for North Dakota
North Dakota has released new diagnostic testing guidance for COVID-19 patients meant to increase testing in the state. The North Dakota Department of Health (NDDoH) continues to recommend that clinicians use their judgment to determine if the patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Patients may be asymptomatic and still test positive for COVID-19. Health care providers (HCP) should not turn patients away for COVID-19 testing who have upper or lower respiratory illness. Close contacts to COVID-19 cases that have symptoms should also be tested for COVID-19.

The updated guidance is for clinicians to consider testing any patient with one of the following signs/symptoms with new or worsening onset:
  • Cough
  • Shortness of breath
  • Difficulty breathing


Two of the following signs/symptoms with new or worsening onset:
  • Fever (measured or subjective)
  • Running nose
  • Sore throat
  • Chills
  • Myalgia
  • Fatigue
  • Headache
  • Loss of taste and/or smell

HCP should not refer patients to the NDDoH for medical consultation or screening to determine the need for testing or diagnose a patient with COVID-19 without testing. As a reminder, COVID-19 is a mandatory reportable condition, and all HCP are required to report all individuals who tested positive or negative for COVID-19 to the NDDoH.

The NDDoH has validated serologic testing for surveillance purposes only. NDDoH serology is not available for diagnostic testing. Currently, there are no serology tests that are FDA approved for use in the point of care setting. For more information on COVID-19 serologic testing, the full health alert can be found here.
Updated COVID-19 Diagnostic Testing Guidance for South Dakota
South Dakota has released new diagnostic testing guidance for COVID-19 patients. The updated guidance is for medical providers to consider testing individuals, using a viral test, with the following signs and symptoms:
  • Cough or
  • Shortness of breath or difficulty breathing

Or at least two of these symptoms:
  • Fever
  • New loss of taste or smell
  • Chills
  • Muscle pain
  • Sore throat
  • Headache
  • Repeated shaking with chills

Testing at the South Dakota public health laboratory has been expanded, and the following groups of individuals with symptoms will be prioritized for testing:
  • Hospitalized patients
  • Healthcare workers, first responders, and active military
  • Individuals living or working in institutional settings, such as long-term care facilities
  • Underinsured or uninsured individuals
  • Low-income individuals or those unable to pay for testing
  • Homeless individuals
Bureau of Primary Health Care Updates
Although the Bureau of Primary Health Care has not added any updates to their frequently asked questions (FAQs) webpage, they did add to the section on other funding and resources. The new information is an overview of the funding options made available with the CARES Act and includes descriptions and links for more information on:

Reimbursement for COVID-19 Testing and Treatment for Uninsured
Providers who have conducted COVID-19 testing or provided treatment for uninsured individuals with COVID-19 on or after February 4 can begin the process to file claims for reimbursement for testing and treating the uninsured.

The US Department of Health and Human Services (HHS), will provide claims reimbursement to health care providers at Medicare rates for testing uninsured individuals for COVID-19 and treating uninsured individuals with a COVID-19 diagnosis.

To submit claims, providers must have a current Optum ID and enroll as a participating provider through the claims portal at and attest to the following:

  • Providers checked for health care coverage eligibility and confirmed that the patient is uninsured by verifying that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, and no other payer will reimburse you for COVID-19 testing and/ or care for that patient
  • The health center will accept defined program reimbursement as payment in full. There will be no process for submitting for adjusted claims.
  • The health center agrees not to balance bill the patient to cover any portion of the cost.
  • The health center agrees to the program terms and conditions and may be subject to post-reimbursement audit review.

Important dates to know for this program
  • April 27 – Eligible providers may register to submit claims through the claims portal.
  • April 29 – On-demand training is available for providers.
  • May 6 – Registered providers can begin submitting claims electronically. All claims are subject to Medicare filing requirements.
  • Mid-May – Begin receiving reimbursement.

For more details, including covered services and reimbursement amounts, visit the HRSA webpage for claims reimbursement to health care providers and facilities for testing and treatment of the uninsured. For assistance in setting up and using the claims portal, see the COVID-19 uninsured program portal user guide.
Emotional Assistance for Survivors of COVID-19
As our society moves through the various stages of this pandemic, more experts are talking about the mental health of people who have survived this virus. While someone may be grateful for having survived, that does not mean that they immune from having a long-lasting emotional impact.

Research with cancer survivors demonstrates this. One study of women with breast cancer found that one in four women who developed the disease also developed symptoms of PTSD. Many cancer survivors, even after they have been in remission, still describe these symptoms and others, like anxiety and depression. Some describe the terror and worry of having a reoccurrence, and some describe flashbacks of painful situations and living with the long-term physical consequences that never let them forget that they had cancer. 

We can also look at previous viral outbreaks like SARS that occurred in 2003. Both health care workers and citizens who were required to quarantine developed symptoms of PTSD. But even if someone does not meet the entire criteria for something like PTSD or depression, the experience can still take a real emotional toll. The physical trauma of COVID-19 is bad enough, but we also have social isolation, the financial burden, the grief related to losing others, and the fear that this may not be over anytime soon.

One of the most important things we can do is start a conversation with patients about how this health care crisis can affect their mental health. People can minimize their emotions and experiences because they look around at others and think, "Well, at least I’m not dying," and while that may be true, it does not mean that they are not suffering.

It can help to normalize the patient’s emotional experience by explaining that many others experience the stress and worry they are feeling. They are not alone. Their feelings are valid. Screening patients for things like depression and anxiety and providing information on the signs of traumatic stress may be helpful. It is essential to provide patients with a list of mental health resources. One study of SARS survivors found that mobilization of emotionally supportive resources may have enhanced resilience in SARS survivors. We have an excellent opportunity to do the same with survivors of COVID-19.
May is Mental Health Awareness Month
To assist health centers with patient communication via social media, CHAD designed a marketing campaign toolkit for Mental Health Awareness Month. The campaign’s focus is to reach out to individuals who may be experiencing increased anxiety or depression or those with substance use issues and to highlight the availability, ease, and importance of using telemedicine. Materials are specifically branded for each health center and include customized graphics spotlighting a landmark in their community. The toolkit can be found here.
Webinars & Meetings
Find these and other events on the CHAD website.

Flattening the COVID-19 Curve: Dental Innovation and Services

The National Association of Community Health Centers (NACHC) will hold webinars for the next few Thursdays. The webinar will begin with updates from NACHC, CDC, and HRSA/BPHC. Health center leaders will also share their current economic survival strategies, teledentistry, patient engagement, and post COVID-19 implications for dental health.

Thursdays in April
11:00am MT/ 12:00pm CT
Visit NACHC’s website to register or view past recordings.

Cost Accounting for Behavioral Health Integration using Telehealth

The Health Resources and Services Administration (HRSA) Center of Excellence for Behavioral Health Technical Assistance is hosting a webinar to assist health centers in cost accounting for behavioral health services. Presenters will share strategies that health centers can use to assess their organization’s level of behavioral health integration and identify strategies and resources they can use to guide telehealth billing during COVID-19.

Thursday, April 30
1:00 pm MT/ 2:00 pm CT

To register for the webinar, set up an account on the new HRSA Center of Excellence for Behavioral Health TA website. Account access requires approval, as this site is only available to select HRSA programs. HRSA recommends participants create an account as soon as possible to ensure access on the day of the webinar.
I’ve Had Just About Enough of This: A Virtual Coaching Re-Charge for Senior Leaders

Join Joe Mull, M.Ed, CSP, and Alyssa Mullett, SHRM-CP, PC, for a 30-minute leadership-recharge webcast. Designed to help you re-fill your personal gas tank, speakers will tackle the energy drainers, emotional traps, and leadership challenges senior leaders are facing right now and identify evidence-based strategies and tactics to ensure you are showing up as your best leadership self in these unique times. The program is free, and capacity is limited.

Friday, May 1
10:00 am MT/ 11:00 am CT
Register here

Today with Macrae: Health Center Program Updates

Monday, May 4
12:00 pm MT/ 1:00 pm CT
Call-in: 800-779-1622
Passcode: 1843682

Tuesday, May 19
12:00 pm MT/ 1:00 pm CT
Access details coming soon

Missed recent Today with Macrae calls? Recordings and transcripts are posted on the Bureau of Primary Health Care’s Emergency Preparedness and Recovery Resources for Health Centers webpage as soon as possible after each call.
COVID-19 Response Open Discussion – Members Only

CHAD will host a weekly call for health centers to convene to share any questions, concerns, ideas, etc. as they continue to develop and execute their COVID-19 response plans.

Tuesday, May 5 (reoccurring)  
2:00pm MT/ 3:00pm CT
Contact Carmen Toft to be added to these meetings.   

South Dakota Department of Health COVID-19 Update

The South Dakota Department of Health hosts a weekly COVID-19 webinar for health care facilities, medical providers, laboratorians, long-term care facilities, EMS providers, and other health professionals.

Thursday, May 7 (reoccurring)
10:00am MT/ 11:00am CT

For weekly call-in information, please join the listserve here. Find archived calls and slides here.
The Power of Rural

This two-part webinar series is presented by the Wyoming Telehealth Network (WyTN). Participants can submit questions in advance here.

  • Telehealth at 90 Miles an Hour
Presenters from WyTN and the Wyoming Department of Health Medicaid Office will discuss staffing appropriately for a telehealth workflow, discern between equipment options, discuss the common implementation pitfalls, and identify benefits to continuing telehealth after COVID-19.

Wednesday, May 6
12:00 pm MT/ 1:00 pm CT
Register here

  • Cybersecurity, Not an Afterthought
Presented by Cyber Wyoming, this webinar will teach participants to spot phishing emails, obtain a phishing policy template, and identify the next steps to embed cybersecurity throughout your organization.

Wednesday, May 13
12:00 pm MT/ 1:00 pm CT
Register here
CHAD Network Team Meetings

Tuesday, May 5 at 12:00 pm MT/ 1:00 pm CT – GPHDN teledentistry implementation discussion

Thursday, May 7 at 10:00 am MT/ 11:00 am CT – Human Resources (weekly)

Wednesday, May 13 at 11:00 am MT/ 12:00 pm CT - Clinical COVID-19 response call (bi-weekly)

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