CHAD Connection - COVID-19 Edition

Thank you for reading this special edition of the CHAD Connection. We’re calling this our COVID-19 Digest, and we plan to release this type of newsletter weekly as long as the information continues to arrive fast and furiously. At CHAD, we are so grateful for each and every one of our members. We know that in this time of considerable uncertainty, lack of supplies and clear direction, each and everyone one of you is taking extraordinary measures to care for your patients and flatten the curve.

In this digest you will find updates from HRSA and the Bureau of Primary Health Care (BPHC), the National Association of Community Health Centers (NACHC), and the Departments of Health in both North Dakota and South Dakota. You will also find information we thought would be useful, including legislative updates, direction for human resources and employment law, and behavioral health resources for your patients.

At CHAD, we are taking every precaution by working from home and practicing social distancing (as much as our children and our pets will allow). We remain committed and available to you without an interruption in service. Please don’t hesitate to reach out to anyone of us at CHAD if we can be of assistance. Stay safe and keep up that hand washing!

HHS Secretary Alex Azar announced this week that health centers are being asked to begin filling out a twice-weekly survey to help track the number of patients who have undergone testing at each health center, along with other critical information about health center operations during the pandemic.

Each health center will receive an electronic survey twice a week via email (reducing the need for telephonic, email, or other methods of gathering critical COVID-19 related information), on Monday and Thursday afternoons. The first survey, with instructions, will be sent on March 19.

HRSA will use the information collected to assess health centers’ needs throughout the COVID-19 response, to share critical information related to testing, cases, and impacts at health centers, and to better understand training and technical assistance, funding, and other resource needs. Frequently asked questions will be forthcoming at Health Center Program COVID-19 FAQs.

Given the direction from our public health leaders to curtail large gatherings, we have made the difficult decision to cancel the 2020 CHAD Annual Conference that was scheduled for May 6 & 7. We have also cancelled the Board Boot Camp governance training scheduled for April 17.

We were excited about the educational material planned we had planned for this year’s conferences, so we are evaluating what can be moved to a virtual training platform and what might be moved to our 2020 Fall Quality Conference if we are able to hold it. We look forward to the opportunity to see you all in person again soon and – in the meantime – through Zoom.

The April 16th Rural Recruitment Workshop that was planned for Bismarck and hosted in collaboration with the Center for Rural Health will be postponed until June and will move to a virtual format. We will share more details as they become available.

We have been hearing from health centers across the Dakotas who – along with providers across the country – are actively working to increase their telehealth capacity. Telehealth could be used to support triage efforts and care for COVID-19 patients who are quarantined. It can also be used for non-COVID patients to enable them to continue to receive needed health care without coming into a health care setting where this is some risk of infection. This is particularly important for elderly patients and those with chronic health conditions.

North Dakota and South Dakota Medicaid programs have both announced that they are expanding reimbursement for telehealth visits that originate in a patient’s home.

Here is the North Dakota Guidance.
Here is the South Dakota Guidance.

South Dakota had previously allowed telehealth visits from home, and the state is just lifting the limitation on visits in the same community if the need for the visit is COVID-19 related.)

At the direction of the President, the Centers for Medicare and Medicaid Services (CMS) have greatly expanded reimbursement for telehealth visits when they originate from a patient’s home. Our current understanding is that federally qualified health centers (FQHCs) and rural health clinics are still prevented from serving as distant sites, which means they would not be able to bill for needed telehealth services. As noted below, CHAD and others are advocating for this change so we can serve our elderly and disabled patients covered by Medicare through telehealth.

For those health centers that are working to quickly stand up a telehealth program, please feel free to reach out to Kyle Mertens at kyle@communityhealthcare.net or 605-351-0604. He is also planning an open discussion on telehealth that will allow health centers to share questions, concerns, barriers and best practices. More to come on that soon!

Congress has been moving swiftly in recent weeks to address the COVID-19 pandemic. We have been tracking and then providing input to our members of Congress (with your help) on three separate pieces of legislation.

The first bill passed and signed by the president was HR 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act. This bill allocated $100 million to health centers for protective equipment (PPE), facilities, and supplies. These funds will be available in March and they will cover expenses going back to January 20. For that reason, we are advising all health centers to begin accurately tracking their COVID-19 expenses now. We expect the funds to be allocated based on number of patients and number of uninsured patients.

The first bill/law also includes provisions allowing the Health and Human Services Secretary to more broadly use telehealth in Medicare. However, the language in HR 6074 does not address the current billing limitations health centers face as distant sites in Medicare. CHAD has asked our members of Congress to address this oversight in subsequent legislation. Changes that are possible with HR 6074 include waiving the geographic restrictions for originating sites for telehealth, including one’s home as an originating site, and easing flexibilities on the types of telehealth technology, allowing telephones with audio and video capabilities. Additionally, the Office of Civil Rights (OCR) announced, effective immediately, that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency.

A second bill, HR 6201, passed the Senate on March 18 after passing the House on March 14. The Family First Coronavirus and Response Act offers many provisions for employees and employers, granting paid sick leave to hourly employees and expanding unemployment insurance. Here is a more detailed summary of that legislation. We will continue to help health centers understand the implications of the bill as more information becomes available.

Congress is looking to pass a third bill aimed at economic stimulus. While the contents of this bill haven’t been laid out yet, it is expected that it will include up to $1 trillion dollars for the many distressed sectors of the economy, as well as two rounds of direct payments to citizens. Health centers are advocating for long-term funding for our program to be included in this bill along with increases to address COVID-19-related costs. Senate Majority Leader Mitch McConnell has said that the Senate will not leave Washington until it passes what they are calling the "phase three" package.

Given the fluidity of the rapidly developing COVID-19 situation, CHAD will strive to keep employers up to date on specific HR laws and items that employers need to be aware of and updating during this time.

What can employers do now?

Ensure that sick leave policies are flexible and consistent with public health guidance and that employees are aware of these policies.
Adopt an infectious disease policy.
Actively encourage sick employees to stay home.
Do not require a health care provider’s note for employees who are sick with acute respiratory illness to validate their illness or to return to work, as healthcare provider offices and medical facilities may be extremely busy and not able to provide such documentation in a timely way.
Stay compliant with the EEOC’s Pandemic Preparedness in the Workplace and the Americans with Disabilities Act.

On March 14, 2020, the U.S. House of Representatives passed the "Families First Coronavirus Response Act" (H.R. 6201) by an overwhelming vote of 363-40. The bill passed in the Senate 90-8 on March 18. There are key provisions that directly impact employers included in H.R. 6201.

Public Health Emergency Leave

Division C of H.R. 6201 is known as the Emergency Family and Medical Leave Expansion Act and uses the existing Family and Medical Leave Act (FMLA) as a framework to provide certain employees with the right to take up to 12 weeks of job-protected leave.  

Under the bill, eligible employees may take leave if the employee is unable to work (or telework) because they must care for a child (under 18 years of age) whose school or care provider is closed or unavailable due to a coronavirus emergency as declared by a Federal, State, or local authority.

Emergency Paid Sick Leave

The Emergency Paid Sick Leave Act requires certain employers to provide employees with two weeks of paid sick time if the employee is unable to work (or telework) for the following coronavirus-related reasons:

The employee is subject to a Federal, State, or local quarantine or isolation order related to the coronavirus;
The employee has been advised by a health care provider to self-quarantine due to concerns related to the coronavirus;
The employee is experiencing symptoms of coronavirus and is seeking a medical diagnosis;
The employee is caring for an individual who is subject to a quarantine or isolation order or advised to self-quarantine by a health care provider;
The employee is caring for a child whose school or care provider is closed or unavailable due to coronavirus precautions; and
The employee is experiencing any other condition substantially similar to the coronavirus, as specified by the U.S. Department of Health and Human Services (HHS).

Exception for Health Care Providers and Emergency Responders. Employers who are health care providers or emergency responders may elect to exclude their employees from the public health emergency leave provisions of the bill.

Unemployment Insurance

The bill provides for the Secretary of Labor to make emergency administration grants to states in the Unemployment Trust Fund. States are directed to demonstrate steps toward easing eligibility requirements and expand access to unemployment compensation for claimants directly impacted by COVID-19. The legislation also appropriates funds for states that aim to establish work-sharing programs that permit employers to reduce employee hours rather than laying them off. Under such programs, employees would receive partial unemployment benefits to offset the wage loss.

Ensuring disinfectant cleaning products are effective on COVID-19 is critically important for controlling the spread of the virus. The CDC recommends that health care facilities reference the Environmental Protection Agency’s (EPA) List N, which includes over 80 registered products that meet the EPA’s criteria for use against SARS-CoV-2, the cause of COVID-19. This link points to List N and frequently asked questions regarding environmental disinfection to protect against COVID-19. The list can be sorted by manufacturer, product name, EPA registration number, etc. for ease of finding specific products. It also provides the required contact time needed to ensure the effectiveness of the product.

The Occupational Safety and Health Administration has issued temporary enforcement guidance that allows healthcare employers change from a quantitative fit testing method to a qualitative testing method to preserve integrity of N95 respirators. For a clear description of the difference in quantitative and qualitative fit testing, click here for a short video and transcript that outlines the details of each testing process.

In addition to the allowance of the qualitative testing, OSHA field offices have the discretion to not cite an employer for violations of the annual fit testing requirement as long as employers:

Make a good faith effort to comply with the respiratory protection standard;
Use only NIOSH-certified respirators;
Implement strategies recommended by OSHA and Centers for Disease Control and Prevention for optimizing and prioritizing N95 respirators;
Perform initial fit tests for each healthcare employee with the same model, style, and size respirator that the employee will be required to wear for protection from coronavirus;
Tell employees that the employer is temporarily suspending the annual fit testing of N95 respirators to preserve the supply for use in situations where they are required to be worn;
Explain to employees the importance of conducting a fit check after putting on the respirator to make sure they are getting an adequate seal;
Conduct a fit test if they observe visual changes in an employee’s physical condition that could affect respirator fit; and
Remind employees to notify management if the integrity or fit of their N95 respirator is compromised.

The temporary enforcement guidance is in effect beginning March 14, 2020 and will remain in effect until further notice. CHAD is aware that not everyone has been able to procure the equipment and supplies needed for respirator use. If your health center needs assistance locating respirators or fit testing supplies or equipment, contact Mary Hoffman at mary@communityhealthcare.net or 701-751-1226.

With a move to full activation of state emergency operations center, all requests for PPE from the South Dakota Department of Health (SDDOH) must be emailed to COVIDResourceRequests@state.sd.us, faxed to 605-773-5942, or called into 605-773-3048 to ensure prioritization and coordination of requests. Medical facilities should have received an order form through their emergency preparedness contacts. If needed, forms may be requested by calling the phone number listed above. Although there is not a list of what is available, all requests will be reviewed and sent to the emergency operations distribution centers for fulfillment. Should the requested items not be available, notifications will be made by telephone.

Health Center Program COVID-19 Frequently Asked Questions (FAQs) on the Bureau of Primary Health Care webpage was updated with responses to many new questions as of today, March 19th. Much of the new information pertains to Funding, Resources and Oversight, Providing Care during Emergencies, and Service Delivery. Click here to view the comprehensive list of FAQs that have been addressed by BPHC. Here are the highlights of the most recent updates:

Health centers will be able to accelerate the drawdown of their grant funds as a needed response to the COVID-19 emergency.
HRSA is expediting the award process for the $100 million that has been allocated by Congress and anticipates awarding COVID funding in March. Pre-award costs will be supported by this funding and may date back to January 20, 2020, for costs incurred relating to preventing, preparing for, and/or responding to COVID-19. HRSA will provide official guidance on the terms of the award.
Health center volunteers are not automatically eligible for liability protections under the Health Center FTCA Program; however, deemed health centers may apply for such protections for their individual volunteers through a Volunteer Health Professional (VHP) deeming sponsorship application. This can be found in the FTCA application section of the HRSA Electronic Handbook. PAL 2017-02 will provide guidance for temporary credentialing and privileging of volunteer providers.
HRSA strongly advises that health centers exercise caution and consult with private counsel before allowing a provider employed by another health center to volunteer at their health center. FTCA liability protections may be placed at risk if it is not clear in what capacity the provider was acting should an event become the subject of a claim or lawsuit.
Health centers can conduct screening and triage to new and existing health center patients in locations outside of the health center service site as within its scope of project. This includes providing such screening and triage to patients in the parking lot of the health center or in other community locations.
Health centers may provide in-scope services through telehealth to individuals who are not currently health center patients during the duration of this COVID-19 public health emergency.
Health centers may request a change in scope to add a temporary service site in response to emergency events as long as it meets the service site definition defined in PIN 2008-01: Defining Scope of Project and Policy for Requesting Changes. Requests must be made no later than 15 days after initiating emergency response activities through a streamlined process outlined in PAL 2014-05. HRSA approval is not required for the provision of in-scope health center services at the following locations already within the approved scope of project:

o  The addition of any modular units or trailers on the grounds of the 5B site;

o  Mobile units (on Form 5B), including driving mobile units to additional locations in the health center’s service area;

o  Home visits (on Form 5C) to health center patients, including visiting health center patients in assisted living facilities and nursing homes;

o  Portable clinical care (on Form 5C), where health center staff conduct clinical care outside of health center sites (for example, conducting screenings and consultations in a parking lot, on the street to individuals experiencing homelessness).

The COVID-19 pandemic is causing incredible levels of fear and worry in patients and health care providers alike. Anxiety naturally occurs in stressful situations with an uncertain outcome, and COVID-19 certainly qualifies. There are some things to consider related to patients and health care providers as they perform the frontline tasks to keep patients safe, even at their own risk.

For patients:

Patients are reporting fear and anxiety, and this is not an uncommon response when there is so much that is unknown at this point. Some patients may be at higher risk for COVID-19 due to certain psychosocial risk factors, such as homelessness, substance use, health illiteracy, and others. A few things that may help patients:

CHAD is working on a one-page handout that health centers can provide to patients that will give some ideas about how to manage stress and anxiety during this time. This handout will offer strategies to patients and hopefully help them feel more empowered.
Patients’ responses to this pandemic will change over time, depending on what stage we are in. For now, we are dealing with the first wave of this crisis, but as more people become infected, people will begin to experience great grief. Offering a safe place to discuss fears and worries can go a long way with calming and reassuring patients.

For providers:

Providers are reporting even longer working hours. They are working under conditions where they are not certain they have the proper safety provisions. They are concerned about suddenly becoming patients or even bringing this disease home to family members. Health care providers, in general, are at risk of developing compassion fatigue because of the mentally and physically challenging work that they do. Here are a few ideas to help combat compassion fatigue:

Be aware of some of the warning signs: feelings of apathy, symptoms of depression, an increase in the use of substances or alcohol to cope, intense fatigue, feelings of helplessness, anger, and in some cases, symptoms of trauma. For example, some medical providers are describing having nightmares and overwhelming fear and hypervigilance.
Focusing on work, love, play, and health: in times of crisis, this may seem impossible, but it can absolutely be necessary for health care providers to avoid significant burnout. Nurture primary relationships. Try to find a moment for a walk and to eat a good meal. And finally, remember that you can only do so much. You are doing the best that you can in extraordinary circumstances.

Federal Tort Claims Act (FTCA) Coverage & COVID-19
In order to reach patients efficiently and effectively, many health centers are exploring new ways to provide care to patients. For example, these services may include telehealth visits with non-health center patients, mobile testing of at-risk community members, and requests to participate in ER diversion programs. However, it is not always clear what will be covered by the FTCA.

In this complimentary webinar by Feldesman, Tucker, Leifer & Fidel LLP, attendees will explore FTCA coverage for various COVID-19 activities and discuss how you can best ensure malpractice liability protection for your health center and staff members in these unusual times.

Friday, March 20
11:00 am MT/ 12:00 pm CT
Register here

Update for Rural Partners, Providers, and Communities on the Coronavirus Disease 2019 (COVID-19) Response
The Centers for Disease Control and Prevention (CDC) will hold a webinar specifically for rural stakeholders on Monday, March 23. The CDC’s deputy director for infectious diseases, Dr. Jay Butler, will share guidance with partners, public health practitioners, health care providers, and others working to protect the health of rural communities. He will describe what the CDC knows at this point and what CDC is doing in response to this outbreak. Time will be made for questions and answers.

Monday, March 23
11:00 am MT/ 12:00 pm CT
Register here

Please email eocevent337@cdc.gov to submit questions in advance and indicate that questions are for the March 23 call. This event will be recorded. Questions not answered during the session may be sent to ruralhealth@cdc.gov.