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 healthcare 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.
As part of our special COVID-19 pandemic coverage, we're continuing with a series of podcast episodes that can be helpful to nurses at this time and the communities they serve.
On this episode, our guests Zoomed in from Hawai‘i and Texas to share with us their latest insights, lessons learned and current approaches at this point in the pandemic.
First, we’re going to hear from Carl Hinson in Hawai‘i. Carl is based in Honolulu and is the Director of Workforce Development for Hawai‘i Pacific Health, which has led an extensive mobile vaccination effort across Hawai‘i. He’ll share with us how his organization has enlisted high school students to help vaccinate community members and converted motor coach buses into mobile vaccine clinics.
CARL: We now have three buses, we have one large motor coach that can go out and get to some of the larger venues and then we have to what we call mini buses that can go out and they're about 75% scale of the big bus as far as productivity, so they can go out and they can get into much smaller areas, they can maneuver in smaller spaces and set up clinics.
Then, later on the show, we’ll hear from Maria Saldiva in Texas. Maria is currently a Clinical Assistant Professor at UT Health San Antonio School of Nursing, and a family nurse practitioner at the college’s Wellness 360 Clinic. Maria is also a member of the National Nurse-Led Care Consortium’s Vaccine Confidence Advisory Committee. Maria and her colleagues have been working steadily throughout the pandemic and now are in the throes of determining when positive COVID-19 patients can return to work or school.
MARIA: That has doubled and, in some cases, tripled our provider visits. Another area of confusion has been for those folks who want to return to work or school, but their symptoms have not entirely you're almost completely resolved.
SARAH: Let’s turn to Carl Hinson now, director of workforce development for Hawai‘i Pacific Health. He’s going to tell us about the health system, the pivot to more telehealth during the pandemic and visiting nurses from other states to help with the various Covid-19 surges.
CARL: Hawai‘i Pacific Health is a four-hospital system here in the islands. We have three hospitals here on Oahu, which is Kapiolani Medical Center for Women and children, Pali Momi Medical Center and Straub Medical Center here on Oahu, and then on the island of Hawai‘i, we have Wilcox Medical Center. We now are up to 85 different outpatient clinic settings across all the islands. So initially, we were really hospital centric hospital focused with some outpatient clinics. And we've really grown our ambulatory presence, our primary care clinics, our specialty clinics throughout the state.
Our population is strung out among seven different islands, and we don't necessarily have all the same resources on every island. So, telehealth was really starting to take off. There were some pilots that were going on for a few years before the pandemic. But the pandemic has really shown I think not only us, but I think across the nation that virtual health or telehealth has a real solid place in our in our health care delivery system with what we had in place already and some of the technology that was already, we were aware of from the mainland.
When the pandemic struck when we closed down, we pivoted to what we call virtual urgent care or virtual clinics and kind of used the same structure. We had appointment structure set up and people were just instead either using their phone or their iPad, so we were minimizing the number of people that were coming into the clinic, especially early on when no one really knew how transmissible it was or what have you.
So, telehealth has been a huge piece and one that I know all our clinicians are hopeful will not go away. I mean, the, you know, CMS had relaxed some of the requirements for telehealth. And that has really shown to be beneficial. Especially when you figure out how widespread we are an almost every island except for Oahu was considered more of a rural setting just because of the distance and the lack of specialty care.
We had the initial surge last year where we did need to bring in additional nurses and travelers to help us get through, of course, with the Delta surge, you know, we saw that people got really sick really fast, and they stayed ICU type sick for quite a while. And so that really put a strain on our healthcare system. And, and thankfully, we were able to bring in about 700 nurses and respiratory therapists statewide to help all of our hospitals get through that first surge.
So, as we started to see in the, you know, with Omicron coming up, and the numbers starting to go up, we did the same thing, again, figured that our hospitalization numbers would go higher than we could possibly staff. And so, we put in another order for I think it was 717 nurses and respiratory therapists this time, and they started arriving January 3, in waves.
We were experiencing full hospitals before this wave went on. A lot of people because of their decision to delay care because of COVID. We were starting to see a lot of that impact on our hospitals. Not as many on ventilators. So, the demand for critical care nurses is less than the Delta wave. But we are seeing a greater demand for telemetry med surge nurses with the Omicron surge. So, they're here, they're coming in from all parts of the country. So, for those of your listeners from all over the country, thank you. We appreciate the support to help us get through this latest surge.
SARAH: To further contextualize the workforce shortage Hawai‘i has faced during the pandemic, Carl is going to break down for us some key trends factors…and also share an innovative solution that took shape before the pandemic to start recruiting more high school students for medical assistant careers.
CARL: The challenge here is that we are providing some of the highest quality of medicine, and health care as anyone on the mainland. Our challenge is that we have 2500 miles of water between us and the nearest landmass. And so that makes our ability to attract a workforce a little bit more challenging. So, I mean, we can get the supplies, we can get the equipment. But what we're really finding challenging is we're limited in the educational programs that are here, limited in our ability to track people. And of course, our high cost of living is well known throughout the country. And so, I mean, it takes a lot of planning and a lot of serious thinking before someone can just up and move to Hawai‘i. So, workforce continues probably to be our number one issue. It was pre-COVID. It is even worse now.
We were having challenges with our various training programs. We had several training programs that literally shut down. We ended up going from just in the medical assistant training programs alone from over 400 graduates per year from all of our various medical system programs to under 100. And so, one of the things that we quickly pivoted and looked at and figured out we could do was we looked at putting our medical system training programs in the high schools. And so partnered with one of our forward-thinking principals who is now the superintendent of all the schools looked at putting the medical system program in our high schools. And so now, our children who are seniors in high school, who maybe had not thought about going on for higher education, are enrolling in the medical system program and coming out and upon graduation, becoming employed by our organization as a medical assistant in all of our clinics. And I mean, it's a phenomenal program. We've graduated 71 children so far and provided opportunities for them. Some of them have gone on to college and are working on their associate's degree or their bachelor's degrees but continuing to work as a medical assistant.
That was kind of where we were when COVID hit is that we had that program. We have a nurse a training program in our high schools, we have a surgical instrument processing tech program, a patient service representative program, those are the individuals who, when you walk into a clinic, they're the first people you see. They greet you; they check you in. They do your insurance. They do your follow-up when you leave and set your new appointments.
So, we put these programs in because we found pre-pandemic, that about 50% of our high school graduates were not going on to higher education. And there really were no opportunities for them to step into healthcare. So, they were stepping into other industries, mostly tourism because we're a heavy tourism dominated market. And we just thought there had to be a better way and with all the schools closing down. And so, we started this as a pilot. We started at one high school and had seven other high schools sending students into that one. We call it our hub and spoke model where we've got one school that's acting as the base and the other schools are sending in students. Had all the principals figure out the, you know, the bell schedules and everything they needed to do to make this work. And students from all these high schools went to, in this case, Waipahu High School. And we're in class Monday, Wednesday, and Friday and then on Saturdays, and went out to one of our clinics to do all of their clinical skills are clinical rotations. So, it worked really well. We expanded it now. We're in 18 different high schools. We have two high schools that are serving as the hub. And as of our third year now, we've had 100% certification rate on our national certification for all of our graduates.
SARAH: With this infrastructure in place, Carl says this young corps of medical assistants have been instrumental with mass vaccinations during the pandemic. He’s going to tell us about the mobile clinics Hawai‘i Pacific Health has created.
CARL: Our first cohort finished up in 2018. So, we had 34 students in our first cohort. And they were probably some of the ones that were most instrumental in helping us pull this off, because they all had just taken on jobs with us when we said we were going to do this and have it as an opportunity for the students. They all stepped up and volunteered time. We paid them but you know it's one thing to be paid, it's another to volunteer to be part of something.
So as an organization, you know, we were asked by the Department of Health if we could help with the vaccinations for COVID. And we had set up a mass vaccination clinic at the pier here where the cruise ships typically come in. We set up a model where we could actually have accomplished 5000 vaccinations a day through the pier. And we never quite got to that number, because the demand never really reached that high. But it was here based in downtown Honolulu. And it became really clear that a lot of the people weren't coming into town to get the vaccinations. And we were going to need to look at a more distributed model.
And so, as we were looking at this, one of the things that we talked about was we have all of these programs in all of our high schools. Could we look at going out to the schools and doing vaccination clinics at all of our schools? And of course, we reached out to, again, the principal at the one school and, and he put together a group of all the principals and we were communicating. And they were absolutely like, yes, we can have you come on campus, we can do vaccination clinics on the campus. And then we said, you know, we've got all of these students, they could help. And so, we made sure that all of our medical system students were at that part in their instruction, where they had been taught how to do IM injections. And then we actually then gave them the opportunity to stand side by side with either another medical assistant or a nurse, depending on who was staffing that day, actually helping them to administer vaccinations. And then over time, as they graduated, they then started working with us with our mobile clinics.
But at the same time, we were like, if we're going to get distributed, we've got to have a way to get around. I mean, it's one thing to throw everything into a truck and have a truck delivered. But we came up with the idea of a bus we had, we had been a busing company here. And of course, in Hawai‘i with tourism, we have tons of motor coaches. But one of our bus partners called and said, Hey, would you have a need for a bus for any transportation needs? And at the time, we were like, no transportation needs, but we'll keep you in mind. And so, as we were talking about, we want to do this just this distributed model, so why not try to see if we can't retrofit a bus or two, make it a vaccination center and then it carries all the supplies from one location to the other. Called them up and they were like, Okay, we'll bring buses by tomorrow, you tell us which one makes the most sense. And I mean, and it literally went that fast. I mean, from the day the idea of having a bus came up, two weeks later, we deployed our first mobile vaccination bus, affectionately called the Vac Squad. But it was primarily staffed with our medical assistants, students and our medical assistants who had finished our program. And then some of our team and our nurses that were working with them in the clinics.
CARL: Thus far, we have vaccinated just shy of 40,000 of our children and teachers and community members that have been able to come out to our mobile clinics. We started with one they reconfigured it. The way it works is you go on to the bus to get your vaccination. But all of the check-in and the monitoring is done off the bus. So, in areas where we could go on to a school campus, we parked the bus next to a gymnasium and the gymnasium ended up being the check-in area or the monitoring where they didn't have a building that we could use. We set up tents and you would go onto the bus and get your vaccination and then you would go under the tents to do your monitoring time. It has worked out really well. We've been able to scale it. We now have three buses, we have one large motor coach that can go out and get to some of the larger venues and then we have to what we call mini buses that can go out and they're about 75% scale of the big boss as far as productivity, so they can go out and they can get into much smaller areas, they can maneuver in smaller spaces and set up clinics for whether it's a houseless camp that, you know, we have a number of here. We've been able to help. We have the US Vets houseless shelters that we have been able to go out to. And then of course, you know, just schools and other community partners that have wanted to be able to host vaccination clinics.
This is all on Oahu. We do have a mobile van now over on the island of Kauai. And that's in partnership with not only us, but also the Department of Health and the mayor's office who, you know, saw that the strategy on a walker was working and, and actually donated a city and county minibus so that they have a minibus on the island of Kauai. And they're doing the same going around to all the different schools and, and they don't have some of the same medical assistance students because we don't have our program deployed on Kauai yet, but they are using medical assistant students from the community college and it's working really well.
CARL: In all of our vaccinations that we've done since we started this, in December of last year, 2020 is when we actually got the clearance to start doing health care workers. I mean, we are about 340,000 vaccinations that we've accomplished for both first second doses, and of course, now counting boosters. But that's never been what, you know, we were about, we're always about providing care for our community. But it's always been from the standpoint of the acute care hospitals and, and then, of course, our clinics. So, the whole idea of us maybe being a public health participant in this process is relatively new. But what was interesting was we were able to quickly pivot and make it so that we were able to be very productive and get large numbers of people in and out in a very short period of time.
We set up the pier, where the cruise ship stocked and the best that we were able to do or get to because of demand was 3600 a day, were going through the pier. Or patients were so complimentary because no one spent more than 30 minutes in the place. I mean, from check in to vaccination to monitoring time to leaving, it really flowed well. So, we certainly won't say that we're the experts at this, but we think we came up with some really good fast ideas and, and through the whole process, you know, always tweaked, and made modifications, if something didn't work, or we found that we had issues in one area, we would make changes.
We even got to a point where our IT teams set up robotics. And they, they made it so that everything that we were entering in the medical record, it then auto populated into the VAM system, so that we over time, were able to get away from them manually entered in everything into VAMs. So, it was all done by Autobots, we have this cute little computer area set up that we call bot city. And all it was doing was taking the information from all the vaccinations and then auto populating it right into VAMs. And we cut out the need for so many people as a result of that. So, there was constantly this innovation going on to make it a much more high productivity and trying to reduce demand on the number of people it would take to accomplish that.
SARAH: Given these various innovations, Carl is going to share with us his final thoughts and lessons learned that could be relevant for other communities interested in replicating some of the approaches taken on Hawai‘i.
CARL: When we look back, we already had very strong relationships with our schools, because we were doing the workforce training programs. And, you know, we already had a good reputation with our school system, because of the work we've been doing. And so, it was natural to be able to look at, if we could do the training programs, and now we've got this pandemic that the entire community understood, and how serious it was to be able to then pivot and say, we can use a lot of these same students to give them real world experience with what's going on. They can apply what they've been learning to an actual clinical environment, and they can be some of the first in the in the country to be able to participate in a program like this. It was all of these things coming together that really made this special because we had the relationship with the schools. We had teachers and administrators that were supportive and thought that this would be a great way for the schools to be able to help their communities. And then also get faculty and other staff from the various schools vaccinated because that was certainly a big push at the time. But just recognizing that you can't just set up a mass vaccination center and expect that everybody's going to get there. I mean, with all the transportation issues, the people that are working nights and days, and it wasn't going to work with everybody. And I think early on recognizing that and being able to pivot to make sure that we were able to provide a more of a mobile strategy and get out and get closer to the community. All of these things just all came together. And I know, it sounds like it was really easy. I mean, it was a lot of work.
But it also goes back to the relationships we all had before the pandemic started. And I think it's easy to forget those when we're in the midst of a crisis. And so, I would say anybody that's still struggling to find, go back to your relationships that you had pre-pandemic, look at the programs that your workforce development professionals were working on, capitalize on those. We found through this, that there were there were very few barriers, if any, that were put up by the principals or the administration of our of our schools, or the students or the parents. Everyone was willing to help and, and quite honestly, I think that's why the engagement was so high of all of the staff, all of the students, because everybody was coming together for a common goal. Everyone knew what the pandemic was everyone know, knew what COVID was, and, and the impact it was having on our community and our family and our friends, and to be able to all come together and first with the mass, but then looking at the mobile and being able to be a part of maybe the mobile vaccination bus coming to your school in your community, and then you being able to actually be the one that administer some of the vaccinations to your, your family members and, and other members of the community. So, we had, you know, these were seniors in high school that were not only vaccinating their peers in school, but then their parents would come. We had students who were doing their turn on the bus, and they were vaccinating mom and dad and, and their brother and sister. And that was really a rewarding experience for everybody.
SARAH: Now from Hawai‘i to Texas…where we’re going to hear from Maria Saldiva. Maria is a member of the National Nurse-Led Vaccine Confidence Advisory Committee and currently a Clinical Assistant Professor at UT Health San Antonio School of Nursing. She’s also a family nurse practitioner at the college’s Wellness 360 Clinic.
MARIA: The School of Nursing Wellness 360 health centers provide nurse run services at more than seven clinics, primarily in the Bexar County area. We provide primary care services for adults and pediatric patients, urgent care, acute care, immunizations, travel health services, mental health services, nutrition dietary consults, occupational services in person and via telehealth. Our clinics also serve as valuable sites for undergraduate and graduate nursing students. While we are not a federally qualified health care center, or a FQHC, some of our clinics are part of the nation's safety net system, including providing care for the uninsured and the underinsured individuals and families. I work with patients from diverse backgrounds. Many of my patients are the students. Many are uninsured. And poverty has really complicated their lives. So many of them have not had access to care in many years.
From a very young age, my maternal grandmother, my Abuelita as I called her, early on, shaped my perspective on health and community. An indigenous folk healer in a rural town and while we love which is the northern state of Mexico, she was a valued member of community. She dedicated her life to addressing the spiritual and the health needs of her community. And that was through the use of rituals and medicinal herbs for people who had limited resources. People trusted her and came to her with all sorts of ailments. While my nursing career took a more traditional approach to health care, there's no doubt that my grandmother had a significant influence on my decision to become a nurse. My career in nursing now spans over 25 years. And it's always been focused on meeting the health and social needs of underserved populations, here and abroad. I remember that as a young woman, attending undergraduate nursing program in El Paso, Texas. I was doing some of my clinical experiences in colonias. I learned so much about people in the communities in these colonias. They had a significant impact on my professional journey.
Now, I chose to work at this university because growing up in the community, I always somehow knew that their focus was on making health culturally and financially feasible, accessible to the community. As a kid, I remember my parents taking me to the dental school clinic to receive care they would otherwise not be able to afford if it weren't for the school. These were the earliest memories of UT Health San Antonio. So, it was a natural decision for me to work at the university.
SARAH: Throughout the pandemic, the clinics where Maria works have remained open continuing to provide care in-person. But they have increasingly turned to telehealth as well. And in addition to standard day-to-day care, Maria and her colleagues have also been providing Covid-19 specific care. She’s going to share how they’ve managed testing, vaccinations and most recently the latest isolation guidelines. She’ll also talk about the uptick in provider visits that happen when patients test positive and now need to be cleared in order to return to school or work on campus.
MARIA: In a matter of a few weeks, in early March of 2020, Wellness 360 you began to see the first cases the COVID-19 infection and persons who had been traveling. While we had the responsibility of screening and evaluating the patients for the condition, we also needed to take measures to contain the spread of the disease. As we look to the infectious disease and the public health experts at our university for guidance, the CDC also begin publishing, testing and contact tracing guideline guidelines that we'd find essential in our practice. In these early days, one country that stood out in the battle against the virus at the time was South Korea. Early on, their response to COVID-19 had effectively flattened the epidemic curve. South Korea’s experience with handling Middle East Respiratory Syndrome or MERS implemented effective measures included the establishment of curbside drive-through testing centers.
One of the nurses and I set up a small table right outside the school of nursing parking lot. We donned full PPE and we began providing curbside COVID testing that first day. It started as a small operation, but it would grow exponentially in a few weeks. The school would set up a large tent in the parking lot, a system for delivering specimens to a university lab for processing, and a cadre of university frontline workers who’d be tasked with screening 1000s of people. Eventually, I transitioned back into my provider role.
MARIA: From both a clinical and academic perspective, the School of Nursing immediately begin to mobilize all its response capacity before the first case of COVID-19 detected here in San Antonio. In early 2020, school administration immediately began to rally resources to put infection control processes in place to combat the spread of the virus and keep people safe. Our clinic waiting rooms were set up to avoid overcrowding, among other interventions. Our COVID-19 vaccine efforts also became very robust, administering 1000s of vaccines through our mass vaccine clinics at the school and through our mobile unit efforts, and our in-clinic vaccination programs. Our school's vaccine campaign is still going strong in the school has been instrumental in the COVID-19 vaccine effort.
As you all know, the CDC recently updated its isolation and quarantine guidelines at the end of December. Now, regarding the isolation period, the CDC shortened the recommended time for isolation from 10 days for individuals with COVID-19 to five days for those experiencing mild or no symptoms. That means that it must be five days from initial symptom onset or test date if the person is asymptomatic, and 24 hours with no fever, without the use of fever reducing medications. I understand why the CDC published these guidelines. But things have been changing so fast, science keeps learning new things about the virus. And all this has brought some confusion. We know that people who have received a booster are for the most part experiencing only mild symptoms. Now the symptoms may not feel so well for some, but they are in the grand scheme of the virus. Now things get more complicated, especially with the unvaccinated. The patients I have referred to the hospital recently have all been unvaccinated and have had pneumonia.
As a result of the recent surge in COVID-19 cases fueled by the fast-moving Omicron variant, the school adopted the new CDC guidelines and implemented actions to keep folks safe and prevent an even worse surge that already are overwhelming centers of care in our community. Now one of these actions includes that if any employee or student has a positive test result, they must be cleared by a provider before returning to work or school. They can also contact our clinic to be cleared. A large portion opted to come through Wellness 360 for clearings. That has doubled and, in some cases, tripled our provider visits. Another area of confusion has been for those folks who want to return to work or school, but their symptoms have not entirely or almost completely resolved.
Now the CDC has also recommended that the person continue to use a mask for an additional five days after a five-day isolation. But we know that the challenge there is that the unvaccinated don't always wear masks. The CDC also recommended that if a person is returning back to work or school, they do have the option to test and that's through a rapid test or going to one of the testing centers. You know, finding testing in some areas has been very challenging. And I know that the CDC has said that it's not mandatory to test after the five-day quarantine period.
Now at the clinic, you know, it's been challenging sometimes to decide whether, you know, I'm making the right decision about sending somebody back to work, as opposed to keeping them at home for additional days. But, you know, for the most part, you know, it's been very clear about who needs to go back to work and who needs to stay at home. The CDC has also put out guidelines on identifying the different stages of severity for the Omicron variant and so that's also been a good resource for me in the clinical setting.
MARIA: Nurses have always played a vital role in understanding social determinants of health, identifying what their outcomes are, and providing patient-centered care. To witness the part of the School of Nursing ensuring equitable access to health care, to COVID testing and vaccines to treatment for the community in San Antonio has really been the silver lining here.
Now we know that COVID-19 disproportionately affects individuals and families experiencing social, economic and health disparities. This really underscores the nursing emphasis on supporting science informed evidence-based strategies to protect the communities. It's essential to engage in community collaborations, to build partnerships outside the box, outside the healthcare system to address complex health and social needs. If we learned anything from this pandemic, it's that in health care, we must remain flexible. We must remain open-minded. We must make decisions based on science as we deal with the fluctuations inpatient visits and health needs and staffing needs.
We feel like, you know, our patients need us. But we also need to be cognizant that if we don't take care of ourselves, we can’t take care of our families. We can’t take care of our patients. We can’t take care of the care of our communities if we can't sum up that energy to do that. And so, you know, self-care is such an important component of our lives. Because we know we are going through so much and we're having to deal with so much illness, and it could get very, very taxing. And so yeah, definitely, I think that as strong as we think we may be as individuals because, and nurses, we are tough as nails. We also have all our vulnerabilities. And so, it's important that we become cognizant of those signs and symptoms of burnout. So that it doesn't have to be someone else that comes to us and tells us, you know, hey, I think you need to step back or, you know, affects our practice.
At this point, in the pandemic, there's a really strong sense of fatigue among health care workers. And that's why self-care has become very important. I think that we need to really take care of ourselves. We need to take care of ourselves physically, mentally, emotionally. My hope is that with this Omicron variant, there'll be an end to just pandemic and it will go into a more endemic status. But we also need to keep in mind that this pandemic may go on for many years to come. And so personally, you know, having time with my family, having time with my friends, staying within that circle of friends and family has become really important to me. It's a great source of support.
SARAH: And just like Maria has touched on here, we’re actually going to be devoting several upcoming episodes of At the Core of Care to talking specifically about burnout… and the creative outlets nurses can pursue to help prevent it as well as cope.
With that in mind, Maria leaves us here with this final note on some of the self-care approaches that she’s adopted in her own life.
MARIA: Once in a while I do go out for walks, I enjoy art. I do some jewelry making here at home. I spend time with my animals. And so really, it's very important for each individual to identify self-care strategies.
What may help me may not always help the next person. I mean, each person needs to identify their own self-care techniques and especially in those things that they find interesting.
CREDITS:
SARAH: Support for our special COVID-19 pandemic coverage comes from the Centers for Disease Control and Prevention.
You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at paactioncoalition.org.
For more information about related upcoming webinars and where to find COVID-19 resources, log on to nurseledcare.org. And you can stay up to date with us on social media @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
