Examining the Impact of COVID on Community Health Centers, Part 2

At the Core of Care

Published: September 28, 2020


SARAH: 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.

This is Part 2 of our series about public health emergency preparedness for community health centers. If you missed Part 1, make sure to go back and listen to that first.
So on this episode, we’re going to first hear from nurse practitioner Jeannie McIntosh about the impact of the COVID-19 pandemic on the Connecticut River Valley Farmworker Health Program, and how this community health initiative has had to adapt to provide care and do education outreach.

And then later on, for a broader perspective around these issues, we’re going to hear from my colleague Kristine Gonnella, senior director of strategic initiatives at the National Nurse-Led Care Consortium or NNCC. Kristine will talk about how community health centers are often overlooked when it comes to emergency preparedness resources and the ways in which NNCC is working to build up support.

JEANNIE: My name is Jeannie McIntosh. I'm a family nurse practitioner at Community Health Center Inc in Connecticut, which I'll refer to as CHC. And through my work at CHC, I work with the Connecticut River Valley Farmworker Health Program as well.

The farmworker health program is run by the Massachusetts League of Community Health Centers, and they basically contract and support different health centers along the Connecticut River Valley in Massachusetts and Connecticut to provide health care to seasonal agricultural workers. There are a lot of smaller cities in the Greater Hartford area and up towards Mount Holyoke and Massachusetts and then kind of quickly outside of the cities, it becomes rural and there's farms all over. Along the Connecticut River Valley. So it's through central Connecticut and north. But where I am and where most of our clinics are headquartered through CHC is more urban. But very quickly, outside of the cities, you get into farmland.

There are many seasonal workers that are more, quote-unquote seasonal that are actually here more year-round and work in greenhouses during the cooler months. And many of those workers do live in the New Haven area or possibly the Hartford area and commute to the greenhouses and farms. But the majority of the workers who are here entirely, seasonally tend to live at the farms in shared housing areas.

Just a little bit about my practice in general. I work at CHC for a program called the Center for Key Populations and the Center for Key Populations is a program really focused on reaching patients who might fall through the cracks in more traditional health care models, either due to different kinds of stigma or due to just lack of access to health care.

The program includes HIV care, substance use services, LGBTQ health, and kind of, later on, we adopted the farmworker health program in our umbrella. So that's kind of the focus of my practice. And we really started coping with COVID and really making some major changes in our clinic prior to the arrival of most of the seasonal agricultural workers that I'm seeing through the farmworkers program in mid to late March. And basically fairly quickly moved to an almost entirely telehealth practice. We have about at this point have about 20 percent of our care provided onsite and then the remainder is provided via telehealth. So starting in March were approaching the impending arrival of seasonal agricultural workers and how we were going to kind of adapt the farmworker branch of our program to this model. And yeah, basically, we've come up with a system where we're still providing a lot of telehealth care to the farmworkers, but also doing monthly outreach clinics.

We have a small kind of skeleton crew going out to the farms because we're trying to minimize the number of people there. It's an outreach worker, a nurse myself and maybe someone involved with community-based events organizing that works with other types of events that we do. And what we'll do is, first, the outreach worker does a lot of legwork ahead of time. She's going to go visit the farms and talk to the farm owners about whether they're interested in having us come, whether they feel comfortable having us come. And then also if there's there seems to be an interest and need among the workers. So that's a big part of before we even arrive. And then on the days that we go to the clinics, we set up a tent making sure that there's both privacy but good airflow through the tent. And I'll be in the tent seeing patients while the outreach workers and nurses are doing intakes and prepping patients for the visits. Through the farmworker program, we're serving rural areas, but in close proximity to more urban areas. There definitely are a lot of cases around. And it's just a huge part of what we're responding to right now and dealing with in our daily clinical practice. 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.

There are definitely some barriers to telehealth in terms of tech access into and tech literacy. Definitely the farmworker health program. They've done a lot to in terms of outreach to farms and trying to provide technology. There are a lot of resources for that. But I think that the other potential barrier and this is just generally a barrier, I think, in working with this specific population is insanely long work hours. The workers are coming here to work. That's what they want to be doing. And they don't want any interruption in those months when they're working. And so often, you know, the telehealth visits are occurring in a traditional eight to five clinic schedule. And the great thing about the outreach clinics is we are able to be a little bit more flexible with that. And we usually go on Sunday afternoons or Sunday evenings because that's one of the few times that workers typically are taking a break during the week.

In addition to kind of coming here to work and wanting to work, I do think, you know, it's such an essential job. Our food system would come to a halt without them here. And I just in my communications with a lot of the workers that I'm seeing, I think that there are many workers who feel a huge sense of purpose and responsibility to work our farms to help provide food. And I think that there's a lot of pride and a sense of responsibility in that that we need to respect and kind of work around the schedule that accommodates a very intense role for all AG workers. In terms of like COVID outbreaks or COVID cases across the farms where we work, it's been very quiet this summer. And I'm not too surprised because the workers come here are tested and quarantined for 14 days before they go to the farms. I think the farms have largely changed their policies about workers coming and going. A lot of times the growers or the farm owners are the ones going out to run errands on behalf of the farmworkers. And people are mostly just staying put on the farms. But that varies somewhat from farm to farm.

And I think there's some more coming and going depending on where an AG worker is staying. But recently, at one of the farms, a worker tested positive. And one of the one of our partner community health centers. So this wasn't a farm that we typically go to as one of our partner organizations asked us to go do mobile testing. It wasn't rapid. It was just the regular test because we do a lot of mobile testing and nearly a third of them. So far, 90 tests that we did for this farm have come back positive. So it's a huge outbreak and it's just you have to respond to it uniquely because what does it mean to isolate or quarantine when you live in barracks with that many other people? So you really have to think outside of the box of how to give counseling around precautions and also isolation after a positive case. And so we're really trying to navigate that right now and figure it out. I think that it requires some foreign specific logistics, thinking about how to separate workers who may not have been exposed yet, how to separate workers who are symptomatic. And so we're that's kind of an area that we're trying to figure out right now, working with this particular farm. And definitely, we did not keep this to ourselves in terms of how to respond. We're gonna reach out to whoever we think might know something and be able to help. So, of course, the Department of Public Health has been looped in and then also just the larger Connecticut River Valley Farmworker Health Program. We're reaching out to them to see. Have you thought this through? Like what? What ideas do you have about how to manage this? And so it's a joint effort of a lot of people. I think the biggest issue that comes up in visits with the farmer is patients that I see are many of the workers supporting families feel this huge pressure to not get sick or this giant fear of getting sick because the livelihood of the family depends on their work so much. So I think it's this added layer of stress where that family might be entirely here because of that work that's occurring this summer. And just the potential ramifications of getting sick are really high. So I think that there's kind of a secondary anxiety among a lot of the workers knowing that, you know, they're here to also help support their families. And that's a lot of pressure in the middle of a pandemic where you're already worried about getting sick.

So we're an integrated primary care model and definitely have a large behavioral health presence that we're trying to extend access to for the seasonal AG workers who we see through the farmworkers program as well. Prior to COVID, I bring a nurse practitioner, resident, and fellow with me, usually to the clinics. And we're trying to extend that to have a postdoctoral psychologist join us as well. That's been temporarily postponed. But we have a lot of behavioral health clinicians providing telehealth care. And our patients through the farmworker program can access those services as well. One thing that's a little bit difficult, particularly with the outreach clinics, but in general, even for the telehealth visits, where a worker might be talking on the phone with 10 friends nearby because it's a communal living space. But it can be hard to screen for behavioral health issues and find a kind of comfortable way to talk about them in these very communal living situations.
But I think that is kind of an added complication. And so, you know, sometimes it will come up where you don't get a direct complaint of anxiety or depression. It's maybe more of a vague chronic pain issue that doesn't seem to be attached to any kind of underlying physical issue or some kind of dizziness or other kind of somatic complaints that, as you dig deeper, might be actually related to depression or anxiety. And that can be harder to tease out. But I definitely feel like I'm seeing a little more of that during the COVID pandemic than I did before.

SARAH: As we’ve heard throughout this series, the day-to-day operations at a community health center during the COVID-19 pandemic are nothing short of challenging. Right now we’re going to turn to my colleague Kristine Gonnella for the bigger picture around this issue and the role community health centers especially play in providing care for vulnerable patients. Kristine is the senior director of strategic initiatives for the National Nurse-Led Care Consortium.

KRISTINE: NNCC has been working in the pandemic flu space for a number of years. We partner with a national network of Public Health Institutes and now our pan-flu work has really just sort of been infused into a lot of our programming. But we started out doing some work in a flu on-call project with CDC and looking at it, developing a nurse triage line and did some evaluation on that with the poison control centers, optimizing sort of the poison control centers and their sort of network and to be able to support that effort. And then over the course of the last couple years, we started to look at sort of safety net health systems, health centers that may be able to absorb surge on hospitals in the event of a pandemic influenza.

And so it's so interesting to be sitting in this space of August of 2020 in a very real pandemic and sort of reflecting back on some of the things that we had looked at and questioned and looking at how our systems might respond to pandemic influenza. We looked at what retail health centers would do? And what would community health centers do? And how would they help minimize the surge on hospitals? And I think we have recognized what was never overly stated before, was the utility in telehealth and the role that telehealth would play in helping to minimize that surge. And so I think the opportunity that NNCC has had to really sort of take the experience that we've had leading up to the COVID pandemic and sort of help to translate that in our lessons learned from our work leading up to this has been a really exciting opportunity. Many of the people that we worked on with our Pandemic influenza project over the years were called to respond to the COVID pandemic. And so just to sort of see in real-time how everything has evolved, has been really humbling and really eye-opening. And I think what NNCC is well-positioned to do is to continue to be supporting our nurse-managed health centers, our nurse leaders, our nurses on the front lines in there and helping to support them in their response and their continued response during the COVID pandemic.

SARAH: Much of NNCC’s work in the public health preparedness space has been to help determine the capacity of the nation’s community health centers to respond to a pandemic influenza. And in doing so, our team has spent time conducting needs assessments of community health centers across the country to determine what kind of training and technical assistance they might need. Here’s Kristine to explain some of the issues we identified and how the COVID-19 pandemic has reinforced those needs.

KRISTINE: 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. And so I think that that is something that an NNCC has really tried to recognize over the last couple of years, is some of those hospital resources are easily translatable and some of them just don't translate at all because we have different methods and structures of the way that we deliver care. Our patient populations are much more vulnerable. So I think 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. And so I think that the community health centers have responded to that robustly as providing the ability to do testing. Certainly looking at how they need to be able to pivot care and looking at sort of unique models of care delivery.

SARAH: While federal entities, including the Health Resources and Services Administration or HRSA, have helped community health centers adapt and increase capacity, they are still under-resourced when it comes to support for emergency preparedness, response, and recovery. Hospital systems still tend to get more attention, even though community health centers are a critical safety net for highly vulnerable and underserved patients.

KRISTINE: I think HRSA and the federal government has been very supportive of giving health centers the flexibility to be able to provide care and modalities that are sort of outside of the scope of the way that the health centers would typically deliver care. Again, I think our our our community health centers have responded and ideally are minimizing the surge on hospitals by engaging their clients and their patients who are historically vulnerable and underserved and minimizing the impact to the ERs and being able to address whether it's sort of a worried well that you think you might be vulnerable or you actually are sick being able to arm our patients in our communities with the tools and the resources and the information and the testing to be able to give them the right and the needed care that’s required of them.


SARAH: Special thanks to Jeannie McIntosh and Kristine Gonnella 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.