Examining the Impact of COVID on Community Health Centers, Part 1

At the Core of Care

Published: September 21, 2020


SARAH HEXEM HUBBARD: This is At the Core of Care. A podcast where people share their stories about nurses and their creative efforts to better meet the health AND health-care needs of patients, families and communities.

I’m Sarah Hexem Hubbard, executive director of the Pennsylvania Action Coalition and the National Nurse Led Care Consortium.

This episode is the first of a two-part series about emergency public health preparedness for community health centers and the impact of the COVID-19 pandemic so far. On Part 1, we’re going to hear about the pandemic’s impact on Callen-Lorde, a major New York City community health organization that specializes in LGBTQ healthcare.

LARA COMSTOCK: “Callen-Lorde really is not only a place for people to get their medical care and the behavioral health care and their medications and care coordination needs. But like because a lot of the people who work here, are members of the LGBTQ community and it's a safe place. And for some people, one the only safe places they feel that they can go, it really provides a very special community feeling for people. And so telling people during this time when there's just so much anxiety, that they can't come to the place where they feel comfortable, is really difficult. And it was really, really hard for people to wrap their minds around that.”

SARAH: And then on Part 2, we’ll hear about the Connecticut River Valley Farmworker Health Program and how this community health initiative has had to pivot to provide care and step up education outreach about the pandemic.

JEANNIE MCINTOSH: “It was just a question of how to be strategic in providing care safely. We're in a situation where some of the farmworkers are coming from countries with much lower case burden than we have here, and we want to make sure that we're not increasing their risk by coming out to the farms. But also, you know, while telehealth is a huge part of our practice right now, there are limitations to it. And I think that in the case of a lot of the farmworkers that we're seeing, there may be difficulty with technology access, technology literacy potentially, and also just difficulty accessing health care. 

SARAH: With 12,000 community health centers nationwide, these safety net organizations play a key role in our healthcare system but have traditionally been under-resourced. And in terms of public health preparedness, the needs gap is even starker as we’ve been learning through our initiatives here at the National Nurse-Led Care Consortium or NNCC.

KRISTINE GONNELLA: NNCC had been working with some of our partners nationally to make emergency preparedness plans more readily accessible to health centers’ communications plans and templates more readily accessible. One thing that was recognized early on when we did the needs assessment was that there were a lot of resources for hospital systems, very little resources for health centers and safety net clinics.” 

SARAH: As part of NNCC’s ongoing effort to provide comprehensive and evidence-based resources to community health centers, we are collaborating with the Centers for Disease Control and Prevention and the National Network of Public Health Institutes. The work has consisted of consulting with content experts, health center staff, and stakeholders to create and adapt materials for health center utilization. And over this past year, we’ve focused on outreach and support for Primary Care Associations or PCAs and the needs of staff in emergency management roles.

As the COVID-19 pandemic took hold, we were able to activate this network and organize peer learning forums to provide PCAs and community health centers opportunities to discuss ongoing challenges and learn from each other. My colleague at NNCC, Kristine Gonnella, will be sharing her perspective with us later on in the series about how community health centers are often overlooked when it comes to emergency preparedness resources.

KRISTINE: What you see sort of in the news right now is very focused on the social determinants of health that are directly impacting your most highly vulnerable and underserved populations. So access to education, housing, you know, these are all things that already make our patients already vulnerable. And then you add sort of that pandemic on top of that and it adds another layer of vulnerability, and that's the space that community health centers sort of sit in. So they need to be well-prepared to not just sort of institutionally be able to continue their service delivery, but also then deliver their service delivery to a community that is already coming in with more vulnerabilities than maybe another community is.

SARAH: Right now, we’re going to spend the rest of this episode hearing from two public health professionals about what it’s been like to work in a New York City community health organization during the COVID-19 pandemic and the specialized care they provide to the LGBTQ community.

LARA: I'm Lara Comstock. I am part of the nursing team at Callen-Lorde. My pronouns are she and they.

We always knew something like this could happen. You never can adequately prepare for what it feels like when it does. Definitely around the middle of March, we were sort of on the edge, knowing that at any moment, our first patient with COVID could walk in the door. And so we're really preparing with trying to get our procedures in place, getting our PPE in place. Like what is an N-95? Kind of like trying to read all the guidance and figure out, like, you know, how it was going to happen and what was going to be the cascade. But I don't think anything could have prepared us for how quickly things did happen. Within a couple of weeks we went from having 16 providers in our largest site to down to 2. And we basically were trying to just meet the most urgent needs, trying to communicate out to patients that please don't walk in as you're used to doing.

The other thing is Callen-Lorde really is not only a place for people to get their medical care and the behavioral health care and their medications and care coordination needs. But like because a lot of the people who work here, are members of the LGBTQ community and it's a safe place. And for some people, one the only safe places they feel that they can go, it really provides a very special community feeling for people. And so telling people during this time when there's just so much anxiety, that they can't come to the place where they feel comfortable, is really difficult. And it was really, really hard for people to wrap their minds around that. And not only that, but we're asking people to get their medications by delivery and not everybody has an address to get medications delivered. We're asking people to do virtual visits. And not everybody has the desire to do that. The hardware to do that. The Wi-Fi to do that. The private space to do that. So it was very difficult. And then, you know, we did have staff. Some of our staff did become ill with COVID.

And so we were trying to gauge that really on a daily basis. We started an occupational health program pretty quickly and they would and still continue to call people who are experiencing symptoms to check on them and really support them through that very scary time. And we started doing things, like we had all staff meetings every single week, which we hadn't previously done, we had them like every quarter. We started using Zoom like nobody's business. And did Zoom meditation and yoga and things like that. So it was definitely a very kind of dramatic time in many ways, and, you know, unfortunately, we did lose some patients during the pandemic. It's hard to grieve, and I mean, staff members lost family members as well. 

And so it was definitely a lot. Head spinning, really.

Here it is, August 2020. I feel like we're finally at a point where we're a little bit calmer and we completely almost disassembled the clinic or shrank it to a large degree. And then we had some people who were sick and had a lot of patients who were sick and that was a lot. And  then, probably a couple months ago in earnest, started really re-assembling the clinic. And that was hectic in its own way. And, harder than in some ways breaking down is building back up again. So at this point, it's finally starting to feel a little bit calmer. But we are also sort of waiting for the next surge. So planning for that and a little bit holding our breath for that. That's where I am. 


SIMI PHILLIPS: I'm Simi Phillips. I'm part of the nursing team at Callen-Lorde. 

For me personally, COVID-19 has changed a lot of things in my personal life and the way I live my everyday routine. So it's been stressful. With COVID-19, me and a few of the other nursing staff at Callen-Lorde, we were assigned a very different assignment, very fulfilling assignment, serving those who from other standpoints, weren't able to get care at other places, housing and, you know, taking care of those who were tested and unfortunately, positive for COVID. With that, it's left a kind of a stain on the way I live my life and the way I see things. So even though, like, things are calming down and you're able to leave your house a little more often for people like myself, I still second guess every decision. I still try to learn how to cope with everything. I still haven't seen my parents. So just trying to maneuver everyday life and figure out where to go next and how to work the obstacles that are ahead of us. Just coping for me at this point. 

It's kind of hard to go back to it, because it just really changed a lot of things for a lot of the staff mentally. You know, I, unfortunately, wasn't able to be there for a lot of my friends. And when you work with people closely, they become your friends, your family, you know, and there was a lot of grieving. There is still is a lot of grieving. There still is a lot of healing from those who lost family members, who lost close friends. You know, the weight is still there. 

We're working hard to get through it. But, you know, looking at certain patients and we get unfortunately these notifications sent to our email about certain ones who have passed on. And, you know, to not only go through your own struggles, but to check your work email and to realize you've lost some of your favorite patients. You know, they all are our favorites. But you build relationships with certain patients and, you know, to come back on site and to do your best to try to help a grieving coworker who had lost close family members. It's taking quite the toll.


LARA: Community health primary care in general, one of the roles is to manage people's chronic health conditions and, you know, so having kind of better resources to be able to do that. Better preventive health means keeping people out of the hospital and the hospitals certainly play a really important role. But community health, you know, there is no substitute for that. So things like that, you know, we need resources for. 

Things that came up during the beginning was, you know, there was just a lack of a coordinated effort on a federal level regarding, you know, things like. And it's still honestly still going on. Getting N-95s is still a problem. We still can't get as many as we would like and are having to reuse them because we order them and order them and we don't know really when they're going to come in. Surprise. Maybe you'll get some someday. But so things like that just, you know, PPE is still an issue. And then things like, you know, equipment to do virtual visits. And I would say, you know, honestly, that is not just for the staff, but for the patients. The patients sometimes don't have computers or smartphones or Wi-Fi or any private area to do a virtual visit. And virtual visits, you know, can keep people safer in a certain way. So having the option to do that with people would be really important to the next wave to keeping people safe.

Virtual care should not just be for people who have that and can afford it. That's the huge glaring inequity. So and then things like, you know, we don't have enough isolation rooms. You know, if multiple people came in with COVID, that would be really, really challenging and was challenging in the first wave. Testing is still an issue. At the beginning, we did test and then we stopped testing because the city told us to stop. And that it should only happen in hospitals. And so we weren't able to test our patients. We are testing again, but it's still difficult to get testing kits. And the turnaround time to results is still not that helpful to do contact tracing and, you know, to contain the pandemic that way. So those are just a few things, and I'm sure I'm forgetting things. It's also just like a bandwidth issue. You know, we're all working really hard and pretty stressed and focused on taking care of patients and the planning part is just as important. 

And so we're stretched thin. So, you know, resources just for, you know, keeping people on staff, you know, making sure I mean, the other thing I think, that's a huge issue is the staff with children and that there's not really any coordinated effort to help. And, you know, it feels really difficult that, you know, there's not really a good solution and there's not a lot of help for parents out there.


SIMI: Mental health accessibility at this point is very short hand. There's hotlines. They give you numbers to call. But with everything going on, there is such an increase of people needing and relying on mental health services that there really aren't many outlets available for people who may need someone to talk to, depending on your mental state and where you are. As Lara said earlier, definitely a need of PPE now, there's a lot of us who are utilizing our mask and gowns much more than we probably should because of the shortages. But I would definitely say mental health.

And before the pandemic, you know, not that there was an abundance of providers available and open, but there, you had options and with everything going on, I feel, you know, because the world itself is just in, you know, crisis with everything going on. And it's very important to have those work family relationships, you know, just not always for what you yourself can get mentally out of it. But sometimes just listening. Being there for your coworker, being there for your team, making yourself available, even if it's, you know, an extra fifteen minutes out of your day, it's really helped, you know, being able to share experiences, team build, build each other up, you know, just having each other's backs. Being aware of, you know, certain signs of emotional distress. Some of us it's not exactly easy to come out and say, 'hey, you know, I'm really down in this moment. Can you help me? But if you have, you know, a relationship with your work family, sometimes it's really easy to be able to key in on them needing you in that moment or just like I said, just being around for them. That's what's helped me through a lot of this, you know, sharing experiences with people who've been in the trenches with me and who need me just as much as I need them. 


LARA: We had about a hundred thousand visits or over that actually in 2019 and about 17,000 unique patients. We serve the LGBTQ IA community in all its diversity and regardless of ability to pay. We have really a wide diversity of patients and people come because of the LGBTQ sensitive care. And so people come from all walks of life and all really we have people even from other countries sometimes coming to our clinic. Pre- pandemic, we had two sites in Chelsea and one site in the Bronx. We were planning to open a fourth site in Brooklyn right as the pandemic hit. We actually got the site inspected and pretty much ready to go. But then honestly, we were having trouble getting supplies even for the clinic. And when we definitely were not able to open it in the timeframe we had. But we were able to open it. Then we also closed one of our sites in Chelsea because it didn't really make sense to keep it open. And so we currently are at three sites.


SIMI: A little bit about our services within those three sites. We provide Article 28 and 32 Behavioral Health. We're open right now and all of our locations, especially our Brooklyn and Bronx, for primary care. We are still taking patients for our sexual health clinic. Those who are in need of pap and prep. We offer teaching and B services, HIV care, women's health, health outreach teams. We call it our hot department for our kiddos, as well as a mobile unit for medical needs. Dental, we'll be resuming those services soon enough. Care coordination that offers our patients access to food, shelter, legal services, mental health services. And we have three onsite pharmacies, pharmacies at each location that does free home delivery through UPS. We're really trying to piece it together here and keep it going. So rock out for our community. 


LARA: We have a very small department that works in advocacy, two person department. But it’s gotten a lot done. I think, allocating resources to clinics and health centers in addition to hospitals is really, really important because, you know, the role that we play in preventative care and is going to keep people out of hospitals. So making sure that our communities are really strong and in a good position moving forward is going to be really important. The first federal relief package went for hospitals and clinics, clinics got really not a lot of money. So, making sure that the clinics are getting the financial resources to do what we need to do is important. 

And we are planning contingency plans for the surge, just focused on, you know, what did we learn from the last time and what can we do differently this time? How can we be better prepared? And how can we be more transparent in what we're doing and communicate? You know better. I feel like that was a really hard part. I mean, for me, it was a hard part just communicating out guidance coming from all different directions and trying to suss through all that and figure out what we should be following. And, what was like keeping our staff as safe as possible and our patients as safe as possible, was difficult. 

So how can we do that better for next time? How can we keep all of our staff fully employed? Because we need everybody, we need all hands on deck for sure. And so we're doing a lot of planning for next time and hoping, of course, it doesn't happen again. But, you know. Sort of waiting at any moment, you know, sort of an on-edge kind of feeling for sure. 


SIMI: Still a lot of work to be done. Just like like Lara said, just learning from this, you know, this first evilness of COVID and just learning from it, building from it and it's strategizing for the next wave. And really crossing every finger that we have that it doesn't happen, even though all signs are pointing to it definitely happening again. And just, you know, the only good thing about going through something is trying to prepare yourself for the next time. And so you're even better at it when it happens. It's just, you know, building and trying to be much more strong and better for our community and our patients.

Being a member of this community, I can tell you firsthand experience, I completely empathize with those of our patients who had not been able to receive services or had to wait on services because going to an E.R. or outside urgent care facility. They are not always the most understanding. I've been turned away personally going to certain urgent care facilities. Instead of going in for any ailment, you find yourself in a position to have to explain yourself. You know, if you're asked about your sexual experiences, if you are possibly pregnant, if you say no, I've had, you know, say, well, there's always a possibility when you then have to explain to them that it's not a possibility for you. Then the questions arise or sometimes you're uninvited to be in that space, sometimes instead of, you know, waiting to be uninvited, to be in a space. You just don't go because you don't want to be in a position to seek assistance and find yourself explaining who you are and why you are the way you are. You know, telling them, this is my wife. And they stress the point of this is your friend or, you know, make it that you're uncomfortable filling out paperwork. 

For our patients, I completely empathize with the way things had to close as it were, you know, the limited availability of services or a space where they can come into be themselves or just be comfortable, because there really isn't many other places. Working in the medical field in the nursing department, I can honestly tell you right now, I don't have a primary care doctor because I've gone through so many experiences where I'm either not invited in that space or I'm uncomfortable to be in that space. I'm questioned, sometimes ridiculed. I've had Bible verses thrown at me. So being a member of this community, I definitely am proud to be a part of our, community health center that's going out of our way to open as many appointment availability for our patients as as many as we can within the pandemic to try to meet the services and meet the needs of our community, because there isn't many places for us to go. Not without leaving completely sad or angry or just feeling as if you're unwanted or don't belong there. It's really upsetting and difficult topic, you know, because there's not many places you can go to shop for a primary care provider or a place where you can feel, you know, accepted. It's very challenging, even in such a diverse place like New York. It still has its challenges.


LARA: The fact that in 2020, you know, that there is still a huge need for an LGBTQ specific health center, just, you know, says a lot. Fooling ourselves, if we think there's not a need still, you know, definitely is. 

We were previously closed to new patients for years, we have not really been except for a small degree open to new patients. And the wait time was long. And so we opened a site during the pandemic, which is in Brooklyn, which had been in the planning stages for probably 10 years, and were able to take new patients and schedule new patients. And clearly there's, like I said, still a need. And so I'm hopeful about that. 


SIMI: That is the one great takeaway I can honestly say that, you know, since COVID has been going on. We have so much more open availability for our locations, for our patients. I've been able to have such great conversations with people who've, like Lara said had been waiting for years to come on board with us, who are so excited to receive services, can't believe they are able to receive services. And just to be a part of introducing them to our community health centers, being able to hold their hands because it's so difficult finding a place and not being 100 percent sure about what you'll be able to receive. What's not possible, what insurance covers and just being able to be there for those patients. And, you know, just guide them through it. Sometimes listening to their experiences with COVID and everything they've been through and just providing that security blanket for them, being able to open up for so many people who have been in need and so grateful to have services. 


SARAH: And be sure to check out Part 2 of our series. We’re going to hear from a nurse practitioner about how the pandemic has affected healthcare delivery for farmworkers in the Connecticut River Valley. And then for some broader perspective, we’ll get a sense of how community health centers are often overlooked when it comes to emergency preparedness resources, and how national public health organizations are working to build that support.

Special thanks to Lara Comstock and Simi Phillips for taking time to talk with us.

And for more about our various initiatives and current outreach efforts, visit us online at paactioncoalition.org And you can always follow us on social media @PaAction.

Support for this podcast comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP, and the AARP Foundation.

Special funding for this episode came from the National Network of Public Health Institutes through a Cooperative Agreement with the Centers for Disease Control and Prevention>

Stephanie Marudas of Kouvenda Media is our producer and we had production assistance from Brad Linder.

I’m Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.