Implications for the Healthcare System Beyond COVID-19 Patients

A New Landscape for Routine Medical Care

Routine care has shifted towards telemedicine, which both reduces the risk of viral transmission and preserves the healthcare workforce. In addition to audio and visual virtual visits for established outpatients, telemedicine can be used in triage for patients exhibiting COVID-19 symptoms and monitoring in the ICU setting (Hollander and Carr, 2020). Prior to March 2020, reimbursement for telehealth services was limited. In light of the COVID-19 public health emergency and urgent need for social distancing, on March 6, 2020, CMS expanded telehealth coverage to “office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence.” While this expansion in coverage is temporary, the widespread implementation of telehealth during this crisis will likely change the landscape of telemedicine in the future. Module 6 describes best practices in conducting telehealth encounters.

Because patients with chronic conditions are more likely to develop complications, they are advised to be especially prudent in taking necessary precautions such as social distancing and handwashing. In one example, Fenway Health, a Boston health center serving LGBTQ patients, advised patients with HIV to confirm that their flu and pneumonia vaccines are up to date, that a 30-day (or more) supply of their medication is available on hand, and that they pay special attention to treatment adherence. In another example, oncologists carefully balance the timing and benefit of various cancer treatments with the risk of infection and hospital admission (Shrag et al, 2020).

Many non-urgent procedures have been postponed. On April 19, CMS released guidelines for re-opening certain non-essential procedures, a process that has started with caution where hospital capacity and infection control are thought to be adequate. However, as COVID-19 cases have surged across the country in the fall, threatening ICU capacity in some states, restrictions on elective procedures have been put in place again. The impact of delaying a procedure is balanced with the risk of hospital admission, both to individual patients and to a hospital’s capacity, though in-hospital transmission of COVID-19 is rare. Other impacts of COVID-19 on non-COVID-19 care include deferred dental care, postponed preventive care, and relocation of ambulatory and specialty staff to the inpatient setting. Surprisingly, emergency room visits for symptoms such as chest pain and weakness had also dropped. There is growing concern that this decline reflects patients avoiding seeking necessary and timely emergency care due to concern about exposure to COVID-19 rather than a true absence of patients with emergencies such as heart attacks, strokes, and appendicitis. There has been an increase in all-cause mortality thus far in 2020, with excess deaths including both deaths directly due to COVID-19 infection and other causes that were not able to be treated at hospitals such as heart disease and diabetes (Woolf et al, 2020).

The rapid rise of telemedicine has been regarded by some as an innovative transformation in healthcare delivery with the potential to reduce disparities in healthcare access among vulnerable populations. Nevertheless, the benefits of telehealth have not been equally shared. In the new era of telemedicine, the concept of healthcare access has changed - digital literacy, access to technology, and the ability to effectively communicate with providers through virtual platforms have become important determinants of access. Digital literacy in particular now plays a critical role in the ability of patients to access and fully engage with telehealth platforms. Of note, digital literacy is lower in individuals who are older, less educated, and Black or Hispanic. Accordingly, minority and low-income patients are less likely to utilize the internet to obtain health information.

Furthermore, over 21 million individuals in the US lack broadband internet access. Importantly, patients who lack broadband internet tend to have fewer telehealth visits and are less likely to utilize patient portals to communicate with providers. Even if patients are able to obtain a virtual visit, language or other cultural barriers may impair the quality of care. Certain primary care health systems have already encountered challenges regarding the equitable implementation of telemedicine, noting disproportionate decreases in visits by patients from racial/ethnic minority groups, patients over age 65, and patients with non-English language preference after the implementation of telemedicine. Poor management of chronic medical conditions in vulnerable communities due to inability to access primary care providers during the pandemic may result in downstream increases in acute medical conditions, including those unrelated to COVID-19. In this way, individual and structural factors that impair access to telemedicine may continue to impair access to COVID-related and non-COVID care during the pandemic despite the transition to virtual care platforms. As a result, the widespread implementation of telemedicine may contribute to COVID-related and other disparities in vulnerable communities if not performed with a keen focus on equitable access.

The Role of Skilled Nursing Facilities and Nursing Homes

Nursing homes became an area of focus in the COVID-19 pandemic following the initial outbreak at a Seattle-area nursing home in late February and early March. Nursing homes and skilled nursing facilities (SNFs) present a unique combination of factors that predispose them to widespread outbreaks of severe disease, including population density, elderly and frail residents with multiple comorbidities, and staff that travels among rooms to care for residents. If staff fall ill, they can easily transmit the virus from resident to resident and often feel pressure to continue working due to short staffing and/or lack of paid sick leave.

Infection control is the most common area of deficiency reported in nursing facilities. The CDC has concluded that most nursing home outbreaks are the result of visitors, staff, or healthcare providers importing the virus before it spreads between residents. As a result, CMS has instituted a nationwide no-visitor policy across nursing homes and SNFs. It has also restricted the presence of non-essential staff and volunteers and cancelled all communal and group activities, including meals.

As hospitals reach capacity, some are looking to nursing homes and SNFs as potential sites for patient overflow or patients with COVID-19 requiring post-acute care. States have taken different approaches, with New York ordering all nursing homes to accept patients regardless of COVID-19 status, and Massachusetts designating specific facilities for patients recovering from COVID-19 and relocating patients without COVID-19 to other facilities. CMS has temporarily lifted the requirement that patients be hospitalized for three days before returning to a SNF in order for hospitals to be reimbursed (the “three day rule”), allowing patients to move more quickly between hospitals and SNFs. In addition, the suspension of elective surgeries has freed space in SNFs usually occupied by patients recovering from elective orthopedic procedures. Moving patients from the acute care setting provides needed beds but may expose the densely populated and highly vulnerable residents of the facilities into which they move. Strategies requiring separation of COVID-19 and non-COVID-19 populations rely on widespread testing availability, which remains a challenge in most of the U.S. Additional solutions for temporary post-acute care settings are surfacing around the country, with many focusing on currently unused buildings such as previously closed hospitals and nursing homes, college dorms, and even summer camps.

Healthcare Workers Falling Ill

COVID-19 has affected a high proportion of healthcare workers. In Italy’s Lombardy region, at one point 9% of COVID-19 cases were healthcare workers. Academic articles studying infections in China have proposed a number of reasons for these increased infections: lack of knowledge about the virus and inadequate personal protection at the beginning of the outbreak, subsequent PPE shortage, suboptimal hand hygiene after exposure to infected patients, high exposure to the virus, and long work hours in high-risk environments (Wang et al, 2020 and Ran et al, 2020). Many of these issues apply to the United States. Thousands of healthcare workers in the U.S. have tested positive for COVID-19, and many have already died. Thus far, it is unknown whether the mortality rate is higher for healthcare workers than for the general population. Some steps that U.S. hospitals have taken to reduce transmission risk both for staff and patients are universal masking, daily symptom monitoring for staff, and COVID-19 testing of all admitted or procedural patients.

As healthcare workers become ill or are required to self-quarantine, systems have been forced to consider creative solutions to alleviate healthcare worker shortages. In the spring of 2020 medical schools in several states graduated their fourth year students early to augment this workforce. The healthcare workforce in “hot spots” is also supplemented by workers coming in from other states. It is important to consider the implications of the COVID-19 outbreak on the physical and mental health of these frontline workers. Physical exhaustion, increased workplace demands, anxiety over personal illness or viral transmission, viral infection, and ethical dilemmas are just some of the stressors outlined by the U.S. Department of Veterans Affairs. Please see Module 4, Module 6, and Module 8 for a more in-depth discussion of the impact of COVID-19 on mental health overall, support for healthcare providers, and ethical considerations, respectively.

Health Care for Housing-Unstable and Homeless Communities

The housing-unstable and homeless populations are uniquely vulnerable during this pandemic. For this population, implementation of many of the social distancing practices recommended by the WHO and CDC, including frequent handwashing, disinfection of commonly used surfaces, and quarantining if necessary, is difficult given the lack of stable housing. Shelters may further increase the risk of infection, given the close quarters in which shelter residents must stay. As public bathrooms shut and soup kitchens close due to lack of volunteers, individuals with housing instability are increasingly turning to shelters for respite, increasing the density of shelter residents. As a result, shelters are unfortunately becoming some of the many epicenters of disease transmission. In Boston, more than one-third of the residents at a local shelter tested positive for the virus in one prevalence survey, confirming that the housing-unstable population is highly susceptible to the disease.

To combat disease transmission within the homeless and housing-unstable community, states have implemented a number of unprecedented health delivery systems. These have the potential to persist and meaningfully improve delivery of health care for this population even after the pandemic. In New York City, for example, Mayor Bill de Blasio called for 6,000 homeless individuals to be housed in empty hotel rooms to prevent transmission of COVID-19. In Massachusetts, 5 hotels across the state (including Lexington, Massachusetts) are being used to care for homeless patients with COVID-19. These efforts are aided by a federal aid bill passed in late March, which provided funding for homelessness assistance and public housing, among other needs. It is still unclear if these innovations to healthcare delivery for homeless populations will be useful and permanent after the pandemic. Please see Module 4 for more discussion of patients experiencing homelessness.

Further Reading

• Crowding and unstable housing conditions in Chelsea, Massachusetts: In a crowded city, leaders struggle to separate the sick from the well
• Resources for preventing spread of infectious disease among those with unstable housing: Infectious Disease Toolkit for CoCs
• Insight on why housing the homeless will be critical: Why housing the homeless in the age of COVID-19 will be essential

Thought question:

• What types of public health and health care delivery interventions introduced during this crisis have staying power (e.g. telemedicine, expansion of sick leave, respite care for persons experiencing homelessness), and why?