AMGA CEO Council Meeting: Preparing for COVID-19

AMGA COVID-19 Resources

Meeting Summary
March 17, 2020

This summary is based on a presentation to the AMGA’s Chief Executive Officer/Board Chair/President on March 17, 2020. For more information about the CEO Council, please click here.

Presenters: Theresa Frei, R.N., B.S.N., M.B.A., President and CEO, Sutter Valley Medical Foundation, and Lizz Valardo, M.D., Mountain View Medical Center, Sutter Health, Sacramento and San Joaquin Valleys and San Diego, CA (March 17, 2020)

Theresa Frei: Most of you have been involved in disaster planning for other things, but this is different. COVID-19 may not be affecting your community, but you need to prepare with urgency now. You will need to drastically change processes, and you really need to have new lines of communication. Our big learning has been to rely on all levels of management.

I actually think that this is a pretty critical point for not-for-profit health care in the U.S. This is a time for us to lead the country in a public health crisis. Decisions we make and how we react now will be critical in how we as a nation respond to COVID-19. How we run with it will be able to change the direction of health care in the U.S. Lizz and I believe what we are doing will be changing healthcare delivery systems to be better and quicker.

At Sutter, our healthcare leadership cascades down. Tell people the status of supplies, other things that are going on, and how system is supporting them. In the clinics, we are surge planning and have walk-in care (retail clinic staff with APPs and a basic charge for video and in-person visits).

As you hear my and Lizz’s story, keep in mind that on the left side of the map (orange) is bay, where Lizz is, and the right side of the map (blue) is valley, where I am. Bay area counties—7 million people—are clustered in place. The valley area is much more dispersed, which is both good and bad during a pandemic. When I talk about where I am and where she is, you will see how quickly it spreads. We have two different roles: Clinics and hospitals are responding differently. Hospitals are focused on isolating, and clinics are committed to communities.

  • Triage for COVID is similar to multi-casualty. If we stopped allowing our doctors to see frail, elderly patients, these patients may be harmed. We are changing our care model very quickly to achieve zero harm to patients and clinicians.
  • Daily communication to the front line is very important. We are doing succinct, daily flashes to affiliates, including only what they need to know today to make it through the day.
  • Leadership meetings are scheduled and divided up for decision making. Focused on front-line needs. We come together to make decisions for clinicians, staff, and patients. Canceled all meetings non-essential to COVID-19.
  • Sutter Health set up clinician and employee emergency line for help.
  • CDC has changed guidelines and adapted from California. Started a few weeks ago. Anyone with potential exposure, everyone who touched that patient, was sent home for 14 days. One of the decisions we made in the last 3-4 days is that we are going to allow people who have had contact with patients who have COVID to come to work. Anyone with a fever needs to stay home; influenza A is still in our community, so hard to know the difference. We need to stay open for our patients and be a calming force in the community. Our doors are open.
  • Because of complexity of what we do every day we are going to have to allow certain decisions to be made locally and learn from them. Float them up to the top and make decision of spreading that quickly.
  • PPE management: If you are going to count masks and gowns, you need a way to do that. N95 requirement and airborne precautions have decreased (to droplet precautions).
  • You really need a single point of contact to county health department. CDC puts out guidelines and county public health discusses those, so you need to have one single point of contact with them.
  • Need partnerships with vendors to help you get supplies. Contact public health office and they will release supplies to you if you need help.
  • Set up a separate advice line for COVID-19; nurses in clinics to go into an Epic pool to call people back (95% of people calling are looking for advice that nurses shouldn’t be giving). If they have a place to call, it will release some tension.
  • Infectious Disease physician at top of organization to help make protocols.
  • We have nurses moving patients to urgent care after triage. If the patient needs to be seen in a few days, we have a video walk-in clinic link. We are limiting where we are sending patients.
  • Over the weekend, many elective surgeries started being postponed due to blood bank issues. We are very limited on blood banks. We are making decisions on which appointments to postpone too.
  • Constraints with technology related to video; All IT resources are provisioning laptops so people can be working from home (just this past week, we had 50 RNs get laptops to work over the weekend). Not just primary care, but specialists too.
  • In the valley right now, we have dyad leadership, which is very important to have. We have a physician, CMO, and CEO working on telephone, another CEO and CMO looking at which appointments need to be done in person, and another CMO and CEO for postponing procedures and where can we redeploy specialists to help.
  • Where we are at on Week 5: Our advice line went live last week, and we are going live with physician video visits in 6 locations. We have looked at guidance to clinicians and other folks to look at patients over 65 or with other conditions. If you do in person—in clinic or in the emergency room—we are holding testing for those at high-risk for complications. In the valley, we have under 65 and not high risk still coming in, and if providers want appointments for these people to be pushed, they can do that.

Lizz Valardo:

  • On full lockdown on all counties over last night.
  • We are scrubbing schedules and postponing appointments with elderly people, and now we are really only seeing patients who need to be seen and can’t be safely taken care of on phone or video visits.
  • We have respiration clinics up. We had 256 patients drive through our respiratory clinics (These are people who had been screened through nurse calls or triage calls or a physician saw them and said they need to be seen). We learned to have them turn their engines off in cars so they don’t have to jump cars when waiting in line.
  • We are a very large organization, with 144 clinics and more than 2,000 providers. Getting information to them quickly and in a way that can be digested has been a real challenge. We are using all sorts of communication—email, texts, and underlining changes to documents in yellow and putting them on their desks—to help them keep up with what they need to do. It’s been a logistical challenge.
  • What we are thinking is if someone gets postponed, they will be 30 days postponed at least and likely 60 days, so we are trying to keep in mind that it is a longer postponement than a week. We are still doing cancer care, and if someone has an abnormal mammogram, we do biopsy.

Theresa Frei:

  • Lizz has been educating me. When we talked about delaying appointments, we told providers to consider putting patients over three months.
  • Email communication last night and today has been focused on how we continue to support the clinics and people who could potentially be in leadership roles by having them work from home. Even though the testing right now is 84% negative and 16% positive, we are thinking all leadership has been exposed and 16% could be positive and could develop symptoms in the next five days. How will we lead clinics without leaders and managers and directors? How do we replace you with clinicians?
  • There’s an important need to communicate that things are going to change and everyone is learning; CDC and PHD all are learning. They are giving you guidance, but you decide if you want to change now based on what they say or change the next day. We try to make change that is not disruptive to the front line but helps. For instance, a guideline went out for people to work from home, but it is not our intention, for valley, to send all these people home. Focus on what has not changed so it gives people reassurance. We have decided to temporarily not allow My Health Online for two weeks. Those are the decisions you need to be prepared to make. If you think you are overreacting, you aren’t reacting enough. It happens very fast. Next thing we know we are on lockdown. What happens if we are on lockdown? What will we do with our patients and communicate it so people know the plan? One day at a time.

Question 1: How are you handing childcare with schools and work being shut down? How are you dealing with providers with children at home?

  • Lizz: We don’t have any childcare right now. We are working with the Y to see about childcare. Y is prioritizing hospitals and, frankly, hospitals are not as overwhelmed yet as the clinics are. As we have de-escalated clinic visits, we have more staff now.
  • Theresa: Innovation team working with organizations to create kind of, and we are looking at innovative solutions. Furloughs impacted us a lot in the beginning, but starting to taper off.

Question 2: We are getting a lot of ED physicians quarantined. How have you dealt with that?

  • Lizz: We did have quite a lot of people exposed, but changed furlough and exposure guidelines. Now we are stopping people at the door and not allowing them to come in unmasked. Things have changed a lot now that it is identified as droplet-transmitted. We have them managing My Health Online and calling patients for those on furlough.
  • Theresa: If you can work with your public health officer, they may feel more comfortable with healthcare workers coming back. Look at level 3 CDC surge planning and consider having healthcare workers and asymptomatic workers coming back to work with mask. We may get to the point where we have COVID-19-positive people coming into work. Considering at what point valley will have the shelter in place.

Question 3: What are you doing with older docs and how are you using n95 vs regular masks?

  • Lizz: We are using the same masking. We have told the physicians and staff that if you and your doctor agree that it’s inappropriate for you to see patients, you shouldn’t be seeing COVID patients and should see other patients. Many are wanting to stay because they are healthy.
  • Theresa: Pregnant physicians are the ones we are going to look into for doing video visits. Really invest in video visits; this will help if clinics close down or schools close down. Finance people are tasked with figuring out how to pay the group because we will get through this and we are not going to back off of having people doing video visits.
  • Lizz: No evidence pregnant women are at greater risk. In the bay, we have made no change for pregnant women.

Question 4: Are your reference labs giving you results or do you have a backlog?

  • Lizz: We started using Stanford for many tests and they state they have a three-hour turnaround, but it is really a three-day turnaround. Also three days for county and maybe two for reference lab. Not enough test kits for everyone is the problem. We have the lab and equipment so that we could easily test everyone if we had reagents and test kits.
  • Theresa: We aren’t testing now in any of our labs. We are using the labs as curriers for the reference labs. We are collecting viral transfers and sending them to other labs. Many clinics not testing, only certain areas.

Question 5: How are you going to address provider comp in the next 60 days?

  • Lizz: There is no insurance to cover this, so we may have some difficulty compensating them beyond RVU credits.
  • Theresa: In California, we have a foundation which has separate for-profit medical groups. With the coding, make sure it is compliant. We are paying them the work RVU rate with telephone and video. We told our financing contact team that your job is to go out and make sure we are getting paid fairly for this and that they are paid the same. Regardless of if the patient or the physician is at home, we are not changing comp and not making physicians bankrupt.