Safety-net health care systems that serve large numbers of uninsured or Medicaid-insured patients have been doubly challenged by the pandemic. Not only are they more likely than other institutions to care for patients at high risk of becoming seriously ill with COVID-19, they also have fewer resources to acquire personal protective equipment and other supplies. We interviewed leaders of four institutions that care for vulnerable populations to ask how they have been grappling with these challenges. We found they shared a common approach that relies as much on community outreach as on hospital preparedness: they’ve been reaching beyond their own walls to offer education about the coronavirus, help in obtaining COVID-19 tests, and support in finding social services.
Operating on razor-thin margins or even at a loss, many safety-net health care systems — those that serve large numbers of uninsured or Medicaid-insured patients and offer care to all, regardless of ability to pay — have had fewer resources and donors to lean on during the pandemic than other health systems. This meant they were often outbid by wealthier institutions as they sought to acquire personal protective equipment (PPE) or other supplies. They are also busier: on average, safety-nets have two-and-a-half times as many emergency department visits as other U.S. hospitals in a year (72,028 vs. 29,556).
Despite these challenges, the close ties that safety-net institutions often have with their communities position them to play a pivotal role in serving people of color, those with low incomes, and other groups hit hard by the pandemic. In recent months, we reached out to four health systems to find out how they have leveraged this strength and what policy supports may be needed to enhance their capacity to respond to the pandemic.
Located in Cleveland, Los Angeles, Seattle, and the Washington, D.C., and Baltimore metropolitan area, the four health systems were in recent months bracing for a surge of COVID-19 cases. They had begun conducting community outreach to offer information about the coronavirus, assistance with obtaining COVID-19 tests, and support in finding social services. All also enhanced access to virtual services, as well as treatment in alternate settings like shelters and people’s homes.
Shortly after its first patient was diagnosed with COVID-19, Harborview Medical Center in Seattle, a hospital owned by King County and operated by the University of Washington as part of UW Medicine, launched home-assessment teams of doctors and nurses to test patients who reported symptoms consistent with COVID-19. The goal was to keep them from coming into the hospital to reduce risk to staff and other patients.
Once the hospital established drive-through testing six days a week, Harborview Medical Center curtailed home visits, but it has continued to deploy teams to test high-risk groups, including people living in homeless shelters. Making the rounds of shelters would not have been possible without a $2 million grant the medical center received from the Paul G. Allen Family Foundation and a van leased from the Seattle and King County Public Health Department.
With a separate $1 million grant from UW Medicine’s COVID-19 Relief Fund, Harborview Medical Center has increased testing among communities of color and those with limited English proficiency. Nationally, both groups are testing positive at a rate more than three times higher than that seen in the general population, says Paul Hayes, R.N., Harborview Medical Center’s chief executive officer. To provide education about COVID-19 and support in accessing treatment to those who don’t speak English, Harborview Medical Center has leveraged bilingual community health workers who serve as cultural mediators in its Community House Calls program.
In mid-March, MetroHealth, a public health system in Cleveland, Ohio’s Cuyahoga County, launched a COVID-19 hotline staffed by nurses and physicians who triaged calls day and night. The clinicians arranged for coronavirus testing and virtual visits with physicians as needed and answered general questions.
In six months, the health system has fielded 30,000 calls, including from medical assistants at nursing homes who couldn’t afford the coronavirus tests required by their employers, from clinicians at other health systems, and from people living on the streets. In the early days, when tests were in short supply, MetroHealth recommended that those who had symptoms suggestive of COVID-19 should quarantine, and had social workers call them within 24 hours to find out whether they needed food or other supplies. “We delivered diapers, prescriptions, and food, and we connected people to social services because what’s the point of telling people to quarantine if they can’t be safe in their home?,” says Brook Watts, M.D., M.S., MetroHealth’s chief quality officer. In all, MetroHealth referred half of callers for telehealth visits.
Martin Luther King, Jr. Community Hospital, a 131-bed public hospital serving southern Los Angeles County, launched “Ask Mia,” an AI-driven chatbot that provides answers to common questions about COVID-19 in English and Spanish and facilitates referrals for telehealth visits. Over those four months, the chatbot handled 1,074 inquiries, leading to telehealth visits for some 500 people.
Staff at the MedStar Health system, which operates 10 hospitals across the Washington, D.C., and Baltimore area, leaned on existing programs to extend their reach in the community. For example, the health system used virtual visits to expand capacity in its palliative care and home-based primary care programs. MedStar also mobilized community health workers (who typically screen patients for health-related social needs and provide links to community resources) and transitional care clinicians (who provide postdischarge clinical support) to create COVID-19 care transition teams. The teams ensured that COVID-19 patients received education, clinical and social referrals, and follow-up care. Over a four-month period, transitional care teams reached out to more than 2,000 patients and provided services to 960, including help obtaining food, medications, and home health services. “Prior to the virus we had been focused on the needs of patients and communities, thinking about care not just in the hospital but more holistically,” says Meena Seshamani, M.D., Ph.D., MedStar Health’s vice president for clinical care transformation. “That has come full circle because you can’t fully address a public health crisis within the four walls of the hospital.”
MedStar Health also partnered with 33 skilled nursing facilities (SNFs) to help them cohort COVID-19-positive patients, support testing needs, and offer virtual consultations with geriatricians and palliative care specialists. Some of the collaboration preceded an executive order that Maryland’s governor, Larry Hogan, issued in early April directing hospitals to partner with the National Guard, local and state health department representatives, and emergency response providers to support testing and triage of nursing home residents. Maryland is one of several states that have deployed these “strike teams” to nursing homes, and bills pending in the U.S. Senate and House of Representatives would allocate federal funding to all states to deploy the teams to manage COVID-19 outbreaks in nursing homes.
Expanding use of telehealth during the pandemic has offered some unexpected benefits, including enabling patients who, because of work, childcare commitments, and/or transportation barriers, struggle to make it to in-person visits. Martin Luther King, Jr. Community Hospital saw its no-show rates for ambulatory care appointments — previously hovering around 50 percent — drop to just 7 percent after shifting to virtual visits.
As these snapshots suggest, hospitals serving populations disproportionately affected by COVID-19 have an important role to play during the pandemic. Given their slim operating margins, these facilities will need additional support to do so. In early June, the U.S. Department of Health and Human Services (HHS) announced $10 billion in funding for safety-net hospitals that have an operating margin of 3 percent or less and meet other criteria related to the uncompensated care they provide. Safety-net hospitals are expected to receive between $5 million and $50 million each. HHS also announced that it would provide an additional $10 billion to hospitals in COVID-19 hotspots, with distributions based on the number of COVID-19 hospital admissions.
The new rounds of funding aim to rectify the uneven distribution of CARES Act funding to hospitals, which was initially tied to the volume of Medicare billing. This approach disadvantaged safety-net hospitals that are more dependent on Medicaid than on Medicare.
The federal government has also increased its spending on hospital preparedness, offering an additional $350 million to hospitals to train workforces, procure supplies, and coordinate the COVID-19 response across regions. This funding doesn’t make up for shortfalls in previous years when hospitals received less than $100,000 annually for disaster planning, says Irwin Redlener, M.D., founding director of the National Center for Disaster Preparedness at Columbia University’s Earth Institute. “We need to move away from the concept that any individual hospital is shouldering this burden on its own,” he says. “We also need a smarter way of distributing funding. What New York needs is not what North Dakota or Alaska needs.”
New policies may also be needed to promote cooperation among wealthy and less wealthy institutions to avoid what happened this spring in New York City, where some hospitals were overrun and others had untapped capacity — a phenomenon evident even within well-resourced networks. In response to COVID-19, Seattle’s Harborview Medical Center created the Regional Care Coordination Center to coordinate transfers among hospitals as needed to ensure that COVID-19 patients had timely access to care and that no single hospital was overburdened or received a COVID-19 patient it was not equipped to handle. (The center was also a resource for long-term care facilities, homeless shelters, and jails.) Washington State also relied on the Washington Healthcare Emergency and Logistics Tracking Hub, developed in collaboration with Microsoft to help the state monitor hospitals’ capacity and PPE supplies.
Such coordination is sorely lacking in many states, due in part to competition among providers, a problem Nicole Lurie, M.D., M.S.P.H., who was President Obama’s assistant secretary for preparedness and response, witnessed in the wake of Hurricane Sandy in 2012. “When push comes to shove, it is very much the impulse that a health system or nursing facility wants to send patients to some other part of their system, even 150 miles away, rather than a few blocks to a competitor — even during a disaster,” she says. This suggests more clear federal guidance, if not a mandate, may be needed to ensure hospitals coordinate their efforts during disaster responses.
As was made clear this summer, preparedness plans must also anticipate the possibility of weather-related disasters like wildfires and hurricanes, on top of pandemics. These events have complicated sheltering-in-place and social distancing efforts and are becoming more common with a warming climate. A bad flu season or another disease outbreak would make things even worse. “My board asked me if the situation we were looking at in March was the worst-case scenario,” says Akram Boutros, M.D., MetroHealth’s president and CEO. “I said, ‘No. The worse health care scenario is we haven’t gotten out of this and a new virus comes on top of it.’ Imagine Ebola on top of coronavirus.” That prospect doesn’t seem outlandish to him. “The time period between global epidemics is shrinking rather quickly,” he says. “It’s no longer 50 years, or 10 years, or four years.”
Ultimately, one of the most effective solutions to the current crisis, and future ones, may be a population health strategy. “The best protection against the coronavirus is being a healthy human being,” says Boutros. “As hospitals, we need to focus on keeping people healthy and well, instead of treating illness.”
Given their deep roots in disadvantaged communities, safety-net hospitals are in a unique position to promote health, provided they have the resources to expand community outreach, health education programs, and patient engagement strategies. Lurie hopes the opportunity presented by the pandemic won’t be squandered. “Before we have a vaccine, there is going to be this intense period of testing and contact-tracing. It’s important not to do this in a stovepipe. We can use this moment to offer H.I.V. tests, depression screenings, and other services that people need.”