COVID-19 Webinars

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Recorded in 2020, this webinar series is focused on immediate actions to avoid entering a vicious cycle of staffing shortages.

1. Expanding Scopes of Practice

This session focuses on emergency measures states can take to remove certain restrictions on the scope of practice of a variety of health professions, as a strategy to maximize the current workforce capacity.

The COVID-19 crisis makes the basic principle of having all personnel working at the top of their education and license especially urgent, both as a way to enhance efficiency and to reduce frustration among health care team members. Panelists review changes that should be considered and then discuss executive orders already issued by governors in ten states.

Relevant Resources:

Full Summary:

In anticipation of this growing demand for COVID-19 care, the federal government and states are rapidly enacting policies to expand and increase health workforce capacity, both by increasing the pipeline of healthcare workers and by shifting or expanding the ways the current workforce is utilized. This latter approach is often constrained by state scope of practice (SOP) regulations, which address how, where, and to whom healthcare workers can provide care.

Session #3 of the Fitzhugh Mullan Institute for Health Workforce Equity’s mini-webinar series Emergency Health Workforce Policies to Address COVID-19, describes opportunities and challenges with regard to emergency measures states can take to relax SOP restrictions as one way to maximize the current workforce capacity and efficiency.

Moderated by Dr. Patricia Pittman, Director of the Mullan Institute, the webinar features two national experts in health workforce policy, Dr. Joann Spetz and Dr. Bianca Frogner, as panelists. Both panelists are currently working with their respective state governments (CA and WA) on emergency workforce policies to address the COVID-19 pandemic.

Dr. Spetz (minute 02:42) explains that regulations are usually first established through legislation and then implemented by the appropriate state licensing board or agency. SOP regulations may dictate who can work in certain professions, the tasks they are permitted to undertake, and under what circumstances work is permitted to be performed. For example, SOP regulations may place restrictions on the extent to which certain health workers, like physicians’ assistants (PAs), are able to practice autonomously, as opposed to under the supervision of a physician.

While scope of practice restrictions has long been an issue for most of the health professions, in the current situation, they are particularly burdensome for subsets of health workers. Dr. Frogner provides insight (minute 04:30) on SOP implications for an often-overlooked group of front-line health care workers: paramedics. Typically limited in scope to providing transport to the ER, SOP waivers can be enacted allowing them to triage and screen patients for COVID-19 in additional care settings, such as skilled nursing facilities. Dr. Frogner also examines implications for PAs (minute 05:30). She explains that states are increasingly removing restrictions around supervisory requirements, ability to diagnose, and care delivery via telemedicine for this sector of the health workforce, pointing out that removal of these restrictions serves the dual purpose of increasing access to health care services while freeing up physicians to focus on the most severely ill patients.

Dr. Spetz, (minute 06:25) goes on to explain that SOP waivers at all levels of nursing – from those pertaining to licensed vocational nurses to advanced practice nurses like nurse practitioners (NPs) and nurse midwives – can be used to increase the provision of care and expand workforce capacity. For example, states can put waivers in place allowing vocational nurses and nursing assistants to deliver some medications, while waivers for nurses with advanced degrees may remove restrictions around physician supervision or provide them with hospital admitting privileges (the latter of which is especially relevant for certified nurse midwives, as the number of deliveries taking place in non-hospital settings is expected to increase during the pandemic). These provisions, among others, can contribute to the efficient use of scare workforce resources.

Dr. Frogner (minute 09:05) adds that SOP waivers can assist in keeping non-COVID patients out of the hospital during the pandemic. Pharmacists, for example, can divert patients from hospital settings by providing them with clinical consult, while laboratory technicians can perform diagnostic testing in the home care setting, when SOP waivers allow. Scope of practice for respiratory therapists can also be expanded by permitting them to provide non-COVID-19 care in the home setting.

States have taken varied approaches to addressing health worker SOP in the wake of COVID-19 in terms of type of the mechanism used to establish them (minute 12:30). Dr. Frogner explains that the most commonly used approach has been an executive order issued by governors. However, she notes that it is up to state boards to then make SOP changes a reality in practice. Dr. Spetz provides examples of two states using alternative measures to promulgate SOP waivers: emergency legislation (Ohio) and an executive proclamation authorizing state agencies to implement a waiver request and approval process (California). Dr. Frogner points out that payers, like CMS, must also authorize provisions allowing for reimbursement that aligns with SOP changes. “It has to be a simultaneous set of moves that are made to make sure that there is congruency between what state leaders expect and want and what our insurance payers are actually doing”, she states.

Currently, states are taking varied approaches to the types of SOP waivers being authorized, although replication across states is starting to be observed. Three states presented in the webinar: Indiana (EO 20-12, 20-05); New York (EO 202-10); and Pennsylvania (EO Waiver Under Disaster Declaration) have emerged as early leaders in SOP regulation in response to COVID-19 (minute 18:15). Although these states vary in terms of political climate, previous SOP regulations, and severity of COVID at this time, Dr. Spetz points out that they represent early enactors of SOP waivers that are both comprehensive in the provisions and professions they cover and responsive to workforce needs.

Although SOP waivers can be an effective tool for expanding workforce capacity, they remain relatively scarce across the landscape of state legislative and executive responses to COVID-19 (minute 20:15). Drs. Frogner and Spetz provide context for this discrepancy, explaining that SOP has always been a politically contentious issue and an area not well understood by the public. Dr. Frogner emphasizes here is a popular misconception that SOP restrictions are in place to protect patient safety and, that by relaxing restrictions, patients will receive sub-par care. Studies, however, demonstrate this not to be the case. “When you relax SOP laws to allow people to work at the top of what they’re licensed to do…that does not provide any less quality of care to the patients”, she affirms.

Dr. Frogner (minute 21:40) indicates that an additional complexity inherent in SOP policy discussions is that SOP is not well defined for many allied health workers. Additionally, SOPs vary across states, and their implementation also varies across health care organizations. Dr. Frogner acknowledges that there is limited understanding of how many health workers are being used across settings and best practices for deploying them. These factors, she points out, make SOP legislation difficult.

Dr. Spetz (minute 23:00) notes the broader question is which SOP waivers states will make temporary as an emergency response to COVID-19 and which will be sustained in the long-term through codified legislation. She points out that some states, such as California, already had SOP legislation in the pipeline prior to the US being hit by COVID-19, and only time will tell if these temporary waivers will complicate or facilitate their passage. When it comes to the lasting policy implications of emergency SOP waivers, “It’s too early to say how this is going to play out”, concludes Dr. Spetz.

2. Federal and State Preparations - Focus on 1135 Waivers

Section 1135 of the Social Security Act allows CMS to waive certain Medicare, Medicaid, and CHIP regulations to support state effort to address COVID-19. This session examines the status of 1135 waivers and shares Washington State’s efforts to address critical health workforce needs.

Relevant Resources:

Centers for Medicare & Medicaid Services:
George Washington University:
- Using Medicaid Waivers to Help States Manage the COVID-19 Public Health Crisis

3. Increasing Supply by Tapping Retirees and Other Health Practitioners

Lauren Block of the National Governors Association discusses policy strategies that states are using to increase workforce capacity. Jean Moore, director of the Center for Health Workforce Studies in Albany, reports on New York State’s efforts, including the use of retirees and other volunteers, and provides advice to other states as they prepare for the surge from COVID-19.

Relevant Resources:

Full Summary:

As cases of COVID-19 continue to rise around the United States, health care leaders are struggling to assure that the nation has the capacity of caregivers to treat those in need. Increasing Supply by Tapping Retirees and Other Health Practitioners provides a broad framework of state policies to increase workforce capacity and takes a closer look at the New York State experience. Moderated by Edward Salsberg, Director of Health Workforce Studies at the Mullan Institute, this webinar’s speakers include Lauren Block, Program Director for the National Governors Association (NGA) Center for Best Practices’ Health Division, and Jean Moore, Director of the Health Workforce Technical Assistance Center.

Since the onset of the COVID-19 pandemic, states have taken a variety of approaches to expand the workforce through executive action, Ms. Block explains (minute 03:30). These actions include easing licensure requirements, expanding telehealth within and across state lines, and authorizing temporary scope of practice. Also included among these actions is reactivating licenses for retired clinicians. Ms. Block also notes that in addition to expanding the workforce, states are also prioritizing personal protective equipment for workers. “In order for health care workers to do their jobs, they need those protections,” she adds. Memos summarizing these key priority areas are available from the NGA.

With respect to licensure, Ms. Block points to increased reciprocity with other states and expedited licensing as actions states can prioritize (minute 19:38). Some states also participate in interstate compacts allowing nurses to practice across state lines. Similarly, the Emergency Medicine Assistance Compact (EMAC) enables states to share resources, including health workers, through license reciprocity and also provides protection for those personnel. EMAC is state law in all 50 states, the District of Columbia and U.S. territories but requires activation by the governor during times of emergency.

As the epicenter for the outbreak in the U.S., Governor Cuomo in New York State placed the call early for additional health professionals to supplement current workforce capacity (minute 10:55). According to Dr. Moore, outreach first began with retirees and those with inactive licenses, then expanded to all actively licensed individuals and to professional associations. As of April 3rd, over 80,000 individuals had responded with vetting and deployment of these healthcare workers currently underway. The state has also been mindful of the increased risk posed to older individuals and has identified other supportive roles allowing them to assist without being on the front lines (minute 16:00).

New York State is also experiencing regional variation with the New York City metropolitan area experiencing a high volume of cases while upstate New York is seeing significantly fewer cases (minute 24:50). This has led to furloughing of some health care workers who could potentially get deployed to high-needs areas though this is still being explored. As the pandemic is expected to peak in different areas at different times, Ms. Block adds that actions being done by executive order now such as cross-state licensing could help to facilitate movement of health workers across state lines (minute 27:35).
Based on the experience so far in New York State, Dr. Moore advises other states to have a plan for collaboration across state agencies (minute 26:10). “We put down our turf issues and worked collaboratively to figure out a way to get this done as rapidly as possible because we just don’t have the time to do otherwise,” she says.

When surveying potential health workers, she recommends collecting a variety of information in addition to the health profession the applicant represents (minute 18:30). This includes status of license, last date of practice, availability, prior experience in infectious disease, emergency medicine, or intensive care, and prior experience with respirators. She also notes that logistical information such as need for childcare, transportation and lodging are helpful when deploying individuals to high needs hospitals.

As other states prepare for the pandemic and continue to build workforce capacity, Ms. Block recommends creating new administrative flexibility and removing barriers to allow providers to participate in the critical areas (minute 29:40). Similarly, understanding current inventory and needs is also important.

While still very early in the pandemic, both speakers recognize the opportunity to learn from this experience and to share lessons across state lines. “It’s clear to me that we have no choice but to learn from this experience and build strategies and approaches that allow us to respond to something like this a whole lot more quickly [and] a whole lot more efficiently,” Dr. Moore says.

4. Is There a Right to Not Work During COVID-19?

This session builds on a prior webinar entitled Why Occupational Standards Matter and focuses on the question of whether health personnel have the right NOT to work when they feel their health or their family’s health, or life, is in danger.

The WHO affirms that employers must “allow workers to exercise the right to remove themselves from a work situation that they have reasonable justification to believe presents an imminent and serious danger to their life or health …” without undue consequences.

Panelists from three professions – medicine, nursing and home care – discuss the different ways in which they are experiencing tensions between the social mission of their work, on the one hand, and its limits when employers have not provided adequate worker protection, on the other. They also discuss policies and practices that would help alleviate this tension, including child care, housing, and hazard pay.

Relevant Resources:

Full Summary:

In the current pandemic, weakened guidance, a lack of personal protective equipment, and high infection rates among health care workers have exacerbated the tension between front line health care workers’ professional duty to serve and their personal duty to keep their families safe. The webinar Emergency Health Workforce Policies to Address COVID-19, explores this topic and asks whether health personnel have the right NOT to work when they feel their health or their family’s health, or life, is in danger.

Moderator Dr. Patricia (Polly) Pittman of the Mullan Institute is joined by three panelists from different parts of the country, institutional settings and professions: Dr. Sonal Batra is an Assistant Professor of Emergency Medicine at the George Washington University and a member of the Mullan Institute; Dr. Cheryl Taylor chairs Graduate Nursing Programs at Southern University and A&M College; and Angelina Del Rio Drake is the COO of PHI, an organization that advocates for the direct care workforce.

Dr. Batra works in one of the most precarious health care settings during this pandemic: the emergency department. Despite this, she asserts that times of crisis do not morph her overall approach to being a doctor, which is deeply rooted in promoting health equity (minute 03:48). The challenges patients face day-to-day persist during a crisis, maintains Dr. Batra, and although the way she addresses them may change, her resolve to do so does not. Despite Dr. Batra’s commitment to health equity and her patients, she warns that the obligation of physicians is not infinite, nor unconditional (minute 30:55). “There is a reciprocal obligation of employers and society as a whole to make sure that we are adequately protected,” states Dr. Batra, adding that how this balance plays out during COVID-19 will set a precedent for future crises.

Angelina Del Rio Drake is an advocate for a sector of the health workforce she describes as invisible to many: direct care workers. Despite the critical role these 4.5 million workers play in long-term care, they are underpaid, undervalued, and underutilized (minute 06:45). Direct care workers, like personal care assistants and home health aides, often make poverty wages, lack employer benefits and paid leave, have little job support, and receive minimal training. Further, these workers are often racially and ethnically discriminated against, compounding the economic and professional challenges they face.

For these reasons, Ms. Drake emphasizes that deciding whether or not to work during a crisis like COVID-19 is especially difficult for direct care workers (minute 26:15). “Every risk bearing factor that goes into making an assessment about whether to work right now is magnified when you’re making low hourly wages,” she states. Workers’ economic vulnerability and a sense of obligation to the clients who rely upon them make it hard for direct care workers to turn down cases. For those who choose not to work, little if any guidance is available on how to do so without falling into economic ruin or compromising the well-being of their clients. “We’ve heard from direct care workers across this country that they feel like they’re on their own,” states Ms. Drake. She points out that the widespread lack of support and guidance in direct care puts workers, their families, and their clients at risk.

Dr. Taylor has equally fervent concerns around the rights and well-being of nurses during COVID-19, while acknowledging the strong demand and need for their services (minute 13:20). A resident of Louisiana, she sees the same response from nurses to this crisis that she witnessed after Hurricane Katrina: a rush to care for others, often at the expense of their own self-care. She appeals to employers and nurse managers to remember that ‘health care worker’ is a label nurses have willingly taken on, but they are first and foremost human beings with their own health needs and families, and they deserve to be cared for.

Demand for nurses, coupled with the sense of guilt they may feel for not going to work, puts vulnerable members of this workforce in harm’s way, and this, in turn, makes solving workforce shortages all the more difficult. This is particularly true in nursing, where one-fifth of the workforce is over the age of 55. Ms. Taylor believes this risk can be mitigated to some extent by implementing supportive management and deployment practices (minute 21:25), for example by assigning nurses to tasks or units based on what they are fit and able to do, as opposed to automatically reassigning all nurses from one unit to another.

The policies and resources needed to support domestic care workers and nurses – both in their decision to and not to work – vary, but Ms. Drake and Dr. Taylor both call for an immediate response that is integrated across systems, collaborative, and inclusive. Ms. Drake says the public and policy makers must first recognize the critical contribution direct care workers make in ‘flattening the curve’ by keeping long-term care patients out of acute care settings (minute 08:10). Direct care workers can be supported by federal provisions that explicitly designate them as members of the essential health care workforce, which would allow them access to relief and assistance, as well as through paid leave policies and access to social support services, community aid, and unemployment benefits (minute 10:45). Local health departments should provide clear guidance to workers and their employers that is contextualized to the home care setting. To establish these provisions, it is crucial to include direct care workers in conversations around worker protections and integrate them more systemically in health care delivery (minute 26:20).

Nurses can be supported by employee health departments through the provision of child care and temporary housing, which could mitigate the risk of family members becoming infected (minute 21:25). Further, nurses’ emotional well-being must be cared for by providing grief counseling, especially in the wake of COVID-19 when nurses are witnessing a potentially overwhelming among of death. Ms. Taylor also stresses that at a time when many standards are being relaxed, it is imperative for managers to protect workers by maintaining the integrity of their intention, noting that standards are developed based on what we know works (minute 29:00).

Dr. Batra believes physicians can play a role in supporting their colleagues during this time (minute 18:05). As highly visible (by comparison) health care workers, she points out that physicians have an especially important podium during this pandemic, and it should be used to advocate for all health care workers. Other health care settings contribute to people ending up in the hospital, she points out. For this reason, and out of respect for all health care workers, advocacy efforts need to extend beyond those that work in acute care.

5. Mobilizing Health Professions Students

Jo Wiederhorn, MSW, of the Associated Medical Schools of New York (AMSNY) discusses the early graduation of fourth year medical students in New York State and the proposed roles these new physicians would have in the COVID-19 response. Garrett Chan, PhD, RN, of HealthImpact outlines potential strategies for nursing students in California to aid in the pandemic while also maintaining academic and practice partnerships.

Relevant Resources:

Full Summary:

As state and local leaders develop and implement policies to expand health workforce capacity, some health leaders are looking at how health professions students could be utilized in the pandemic response. Mobilizing Health Professions Students takes a closer look at how students, particularly those near to graduation, can be mobilized to meet the increased demand for health workers. Moderator Sara Westergaard of the Mullan Institute is joined by Garrett Chan, President of HealthImpact, California’s nursing workforce and policy center, and Jo Wiederhorn, President of the Associated Medical Schools of New York (AMSNY).

Deans from medical schools in New York City’s metropolitan area expressed early interest in graduating students early as a possible avenue to help build health worker capacity, Ms. Wiederhorn begins (minute 03:30). By March of their final year of medical school, most fourth-year medical students have completed all requirements in anticipation of graduation in May. Together with AMSNY, Deans of various medical schools within New York State began to mobilize a plan.

Initial steps involved approval from the Liaison Committee on Medical Education (LCME) which provided a set of guiding principles for determining which students would be eligible for early graduation. Additional support from the State Board of Education came after some pressure from the Governor’s office, who had gotten word of the proposed plan. Per Ms. Wiederhorn, the State Board of Education has sent each school an attestation from to complete indicating that students were meeting LCME requirements for early graduation. Lastly, an executive order from Governor Cuomo waiving certain requirements in the education law and in the health law would allow these new graduates to work in the hospital.

At the same time, the Accreditation Council for Graduate Medical Education (ACGME) has also provided guidance for students and early graduates and AMSNY has been working with the medical schools and hospitals to define roles for these new graduates (minute 10:37). The new graduates would have a title of “COVID-19 specialist physician” and will be supervised by attending physicians not resident physicians as per the guidance from ACGME. These new graduates would be hired by the hospital and receive payment and benefits from the hospital including health and liability insurance. This role would end two to four weeks prior to the start of residency to allow the new graduates to quarantine if necessary and relocate to their new setting.

Ms. Wiederhorn also notes that while there is regional variation of COVID-19 prevalence in New York State, there are not currently any formal plans between schools to allow students from lower burden areas to relocate to higher needs areas. However, students who have matched in a program in the metropolitan area may relocate to that area early. “This is all voluntary on the part of the students,” she stresses. “Nobody is forcing the students to do this.”

As for nursing, Dr. Chan describes several potential roles for nursing students in the COVID-19 response (minute 16:25). Like other health professions students, the education and clinical rotations of many nursing students has been interrupted by COVID-19. Nursing leaders across the US have called for the mobilization and utilization of nursing students in the response. Dr. Chan states students can be utilized by providing both psychosocial and nursing care to patients, families, and community members at various levels of acuity.

Nursing leaders have also advocated for increased flexibility and creativity in clinical experiences for nursing students (minute 26:03) and Dr. Chan notes several waivers among state nursing boards to help move nursing students forward to maintain the educational pipeline. He reports these waivers fall into three main categories: allowing more latitude in clinical experience, increasing the amount of simulation, and suspending or creating new licensure experience.

Dr. Chan goes on to describe the work being done in California to mobilize nursing students which involves the preparation of students, faculty, and practice settings and addresses potential state and regulatory issues. In this preparation, Dr. Chan points out the importance of obtaining informed consent from the students and clearly articulating the risks, benefits, burdens, and alternatives if a student chooses to participate in the pandemic response. He also argues for the autonomy of students. “We have to recognize that students are free agents,” he says. “They have will and agency to make decisions for themselves.”

Similarly, medical schools are also developing strategies for current medical students who still have clinical rotations to complete though this is still evolving according to Ms. Wiederhorn (minute 36:40). She also notes that students in all years want to get involved to help with the response. “The students have really done some remarkable things,” she says noting that student in the metropolitan area have started a consortium of sorts to raise money for PPE and volunteer to help on phone lines. “Everyone is getting involved in their own way.”

6. Telehealth to Support Primary Care During COVID-19

Sanjeev Arora, MD, discusses how the Project ECHO model is being applied to support primary care providers during this pandemic. Bob Phillips, MD reports on how primary care practitioners are applying emerging telehealth policies and the tough choices practices are making to maintain financial viability with dramatically reduced in-person visits.

Relevant Resources:

Center for Connected Health Policy
- Telehealth Coverage Policies in the Time of COVID-19
- COVID-19 Related State Actions
Federation of State Medical Boards
- State Emergency Declarations and Licensing Waivers
CMS
- General Provider Telehealth and Telemedicine Toolkit (Updated to reflect COVID-19 related waivers)
American Board of Family Medicine
Virtually Perfect? Telemedicine for Covid-19

Full Summary

The emergence of COVID-19 has required an unprecedented and precipitous shift in how health care is delivered in the United States. Social distancing, fear of infection, and health care providers sidelined by mandatory quarantine present challenges to traditional clinical care at a time when the need for services is rapidly escalating. Recognizing these challenges, federal and state governments have recently issued waivers to support telehealth utilization, removing limitations and restrictions on service coverage, location, and modality.

Technology and telehealth may be particularly well-suited for use in primary care, where the need for services like chronic disease management and preventative medicine remain, but risk of infection or access issues related to COVID-19 have made office visits a diminishing option. As part of the webinar series Emergency Health Workforce Policies to Address COVID-19, the Fitzhugh Mullan Institute for Health Workforce Equity presents a webinar on how telehealth is being used to support primary care practice in the wake of COVID-19. Moderated by Dr. Guenevere Burke with the Mullan Institute, the webinar features Dr. Sanjeev Arora, Founder and Director of Project ECHO and Dr. Robert Phillips with the American Board of Family Medicine as panelists.

Founded in 2003, Project ECHO (ECHO) harnesses a hub and spoke model and innovative technology platform to build specialty care capacity in primary care settings. Dr. Arora explains how ECHO is leveraging its telementoring model to respond to provider training and education needs presented by the current pandemic, with sessions intended to amplify public health and clinical care preparedness and response (timestamp 08:50). Demand for the trainings has been unprecedented for ECHO: “In all of the history of ECHO we have trained about ninety-seven thousand mentees, but in the last two weeks, we have trained more than one hundred thousand additional physicians and nurses across the world…on COVID-19 best practices”, says Dr. Arora. Project ECHO Covid-19 best practices include:

How to adapt and enforce rigorous infection control practices?
How to cope with PPE shortages?
How to rapidly deploy telehealth services?
How to prioritize limited testing resources?
How to isolate homeless and unsheltered individuals with symptoms?
How to create a COVID-19 floor?
When to send someone to the ICU?

Dr. Robert Phillips provides a primary practice perspective, noting that the recent telehealth waivers to Medicare and Medicaid have resulted in rapid progress in advancing telehealth that practitioners and patients may not want to see halted after waivers expire. “After years of trying to get expansion of telehealth both for protections under HIPPA and for payment, it’s [going to] be hard to put this genie back in the bottle”, says Phillips. He goes on to describe the impact COVID-19 has had on primary care practice, particularly in FQHCs, which are seeing 50-70% reductions in office visits (timestamp 20:25). Phillips warns that the consequences of reduced service delivery, and the decrease in revenue that accompanies it, could spell disaster for primary care practices’ ability to remain in business just as the pandemic is ramping up.

While telehealth offers a potential solution to maintaining some level of health care delivery during the pandemic, Phillips notes that challenges to implementation remain (timestamp 22:30). For one, there is a lack of uniformity across federal, state, and private payer policies on telehealth, causing confusion among providers and billers. Patient access to and comprehension of telehealth platforms may further stifle its utility, and overhead costs related to telehealth can be too high for some providers to absorb. Phillips is hopeful that telehealth support included in the recently signed stimulus bill will offset some of these cost barriers.

The webinar concludes with Drs. Arora and Phillips take on innovation’s role in supporting vulnerable populations. Dr. Arora reiterates Project ECHO’s mission of democratizing best practices in clinical care and implementing them for underserved populations (timestamp 26:50). He notes that Medicaid patients and the uninsured have a particularly difficult time accessing specialty care, including infectious disease specialists. Many of these patients rely on FQHCs or other community clinics for all their health care needs, highlighting the need to scale up specialty care knowledge in these settings and the opportunity Project ECHO provides to do so. Dr. Phillips describes current efforts to enhance COVID-19 data tracking in rural and isolated communities where the pandemic’s tail is likely to be longer than in more heavily resourced urban settings. “We believe that if we can help CDC by sharing data with them about what’s happening in rural and underserved areas, that it may help focus their attention and resources on these areas, too”(timestamp 29:40).

Dr. Burke concludes the webinar with a quote from Mullan Institute founder, Dr. Fitzhugh Mullan, “Health workforce policy is increasingly a health equity battleground”. Other webinars in this series will explore actions that can be taken to support all members of our healthcare workforce as they serve on the front lines of the COVID-19 pandemic.

7. The Importance of Standards

This session asks whether national enforceable occupational standards matter, and if so, why the United States has no occupational safety standards for airborne pathogens.

The World Health Organization has issued guidance with a list of 13 health worker rights relevant to the COVD-19 pandemics, 8 of which refer to either the right to obtain training in infection control, or the right to appropriate protective gear. Panelists discuss why issuing a national safety standard is so important to ensuring those rights in the current situation. They also explore why employers and the Trump administration have opposed issuing an emergency standard.

Relevant Resources:

Full Summary:

Personal protective equipment (PPE) – and its lack thereof – has been at the forefront of discussions around healthcare worker safety throughout the pandemic. Dr. LaPuma describes the fundamentals of PPE to explain why standards in this area matter (minute 02:25) noting that not all PPE offers the wearer the same protection. N95 masks should be the minimum PPE standard for patient-facing health care workers during COVID-19, he contends. They meet stringent performance requirements and can filter out small virus particles, like that which causes COVID-19; surgical masks cannot. He adds that actions must be taken to stop the pilfering, hoarding and price gouging causing their depletion.

The situation around the physical shortage of PPE should provide all the more reason to immediately enact a national occupational safety standard that will protect health care workers, states Dr. Perry, (minute 08:25). She points to the success of the federal bloodborne pathogen standard, established during the HIV/AIDS epidemic, as an example of the kind of response that is now needed for airborne pathogens. Despite initial resistance to the standard from some employers and even health care workers, the 1991 standard resulted in a significant decrease in hepatitis B transmission and needle sticks to healthcare workers. “A standard right now would have a tremendous impact on ensuring that health care workers are getting the proper protection that they need”, states Dr. Perry. She emphasizes that OSHA had made progress in this area, until anti regulation efforts by the current administration brought it to a halt in 2017.

This lack of regulatory muscle has resulted in perilous working conditions for health care workers on the front line of the COVID-19 response, states Kelly Trautner (minute 12:10). She points to weakened infectious control guidance from the CDC and the suspension of N95 fit test requirements from OSHA as two examples. “What’s most unsettling about these changes”, Ms. Trautner points out, “is that they were made based on supply chain, not science.” She argues that when the government does not enact strong occupational standards to keep workers safe, the results are devastating, and “we’re seeing them now as health care workers increasingly take up hospital beds and spread the virus they aimed to treat.” Some workers have gone to great lengths to report these dangers to the public, even risking their jobs to do so (minute 22:30). Ms. Trautner urges the public and policy makers to pay attention to the plight of health care workers and protect their right to speak out against untenable and hazardous working conditions. She emphasizes that a collective voice is the most powerful vehicle clinicians have right now in their push for worker protections and that the need for health care worker representation has never been more critical or relevant.

Many had hoped that emergency national occupational safety standards would have materialized by this point in the COVID-19 crisis. When asked why it hasn’t, Dr. Perry notes that occupational standards have always been resisted by employers based on perceived difficulty in enforcing them and cost (minute 18:35). She argues, however, that when standards have been introduced in the past, companies do not go out of business, but instead adapted to them, again pointing to the bloodborne pathogen standard as a good example. She says she is optimistic that the attention the pandemic has shed on occupational safety and health care workers’ rights may finally result in a national standard that will protect health care, and other workers, and hold employers accountable for their safety.

Dr. Perry has a parting message for health care workers: you are not alone (minute 26:35). She urges them to continue to document their experiences to build awareness and a sense of urgency that will catalyze a national push to invoke an emergency temporary standard. “Let this be a pivotal time for occupational health and the united necessity of protecting health care workers and all workers,” she concludes. Dr LaPuma reiterates this message of solidarity, stating “The health and safety of the health care workers is paramount. We absolutely have to protect the health care workers at all costs” (minute 27:35).

8. Unique Challenges Facing the Abortion Provider Workforce

Alice Mark, Medical Director for the National Abortion Federation, discusses underlying challenges facing abortion providers and how these have been exacerbated by the COVID19 crisis. Heather Shumaker, Senior Counsel for Reproductive Rights and Health at the National Women’s Law Center, explains current state policies and litigation affecting the abortion provider workforce. Jen Villavicencio, OB/GYN and Clinical Lecturer at the University of Michigan, talks about the impact of abortion care policies in Michigan and changes that providers are making to reduce risks of exposure.

Relevant Resources:

9. Ensuring Access to Behavioral Health

Joe Parks, M.D, Medical Director, National Council for Behavioral Health discusses federal and state policies that enable ongoing access to behavioral health during the COVID19 crisis. and outlines additional policies that are needed to further support patients and providers during the pandemic. Amelia Roeschlein, DSW, MA, LMFT, and Consultant, Trauma Informed Services discusses resilience techniques and how to support health care providers during the pandemic. The session concludes with a discussion on how we can prepare for a likely surge in behavioral health needs in the coming months.

Relevant Resources:
- Resources
- Relief Funds
  - Summary of financial relief included in CARES: National Council summary
  - Small Business Administration
    - COVID-19 Economic Injury Disaster Loan Application
    - Paycheck Protection Program
  - SAMHSA: Emergency Grants to Address Mental and Substance Use Disorders During COVID-19
  - FCC: COVID19 Telehealth Program
- Resilience Resources
  - Compassion Resilience
  - Professional Quality of Life Measure
Full Summary:
COVID-19 has heightened the behavioral health (BH) needs of both of patients and the providers who care for them, necessitating a national response to ensure expanded and ongoing access to care. This session of the Fitzhugh Mullan Institute for Health Workforce Equity’s webinar series, Emergency Health Workforce Policies to Address COVID-19, co-hosted by the Beyond Flexner Alliance (now Social Mission Alliance), discusses the changing BH policy landscape, the BH needs of providers, and how health systems can adapt to meet the BH needs of the public and health care providers moving forward. Moderator Dr. Isabel Chen is joined by two experts with the National Council for Behavioral Health, Dr. Joe Parks and Dr. Amelia Roeschlein.
Policies to facilitate access to BH services in the wake of COVID-19 are being enacted at a rapid pace (minute 03:40), reports Dr. Parks. Federal changes enacted by CMS include loosening restrictions on eligible telehealth services and modalities and allowing for the provision of services across state lines. HIPPA requirements are also being relaxed, as are prescribing restrictions for substance use disorders, which now temporarily allow for increased take-home dosing. States, meanwhile, are using the 1135 emergency declaration waiver process to enact a variety of policy changes that protect and facilitate access to BH services during the current national public health crisis.
Dr. Parks cautions that these policy changes, while welcomed by the mental and behavioral health professionals who have long advocated for them, do not come without challenges (minute 06:20). Telehealth has the potential to increase access to services, but it often relies upon patients having access to smart phones, enough data plans, and internet, posing an access barrier for many, especially those in rural settings. And even for those with access to the necessary technology and services, navigating telehealth platforms can be a challenge.
Behavioral health service barriers also exist on the provider side. Many agencies do not have the needed equipment to go mobile, and the cost to secure it can be prohibitive. Behavioral health providers may also need training to adapt their services, like group therapy, for telehealth. Dr. Parks notes that financial and training resources are available to help providers navigate these challenges, and that many of them are now available through The National Council for Behavioral Health’s coronavirus resources library (minute 07:35).
Financial assistance is an especially urgent need given the scale of the COVID-19’s financial impact on BH providers (minute 12:25). Dr. Parks cites a recent survey conducted by the National Council for Behavioral Health finding that two-thirds of the 600 organizations surveyed do not have enough money to stay in business more than three months. He warns that if payers don’t act quickly, there will not be enough behavioral health providers left during the latter stages of the pandemic and beyond, emphasizing the need for retainer payments which will allow providers and treatment centers to keep their doors open and prevent a permanent loss of BH service capacity.
This financial strain is just one of many added pressures health care providers face during the current crisis. Dr. Roeschlein points out that COVID-19 has exacerbated the stress already inherent in health care providers’ work and shed new light on the BH needs of the health workforce (minute 18:50). She asserts that now more than ever, providers need to be encouraged to engage in the self-care and stress management practices they teach to their patients, noting that much like when on a flight, providers should be reminded to put their masks on first during times of crisis. By tending to their own BH needs, Dr. Roeschlein points out, senior-level providers are also modeling vulnerability, authenticity, and healthy self-care strategies for their trainees, thus contributing to the resiliency of the next generation of healers. A variety of innovative, on demand tools like health care worker self-care cards and resilience apps are emerging, giving providers immediate access to mental and behavioral health support (minute 22:35).
Drs. Parks and Roeschlein agree that despite the current crisis, the path forward presents an opportunity to better prepare for the future BH needs of the public and health care providers, stressing that pre-COVID-19 practice guidelines and policies should not ultimately define future strategies (minute 26:10). Health systems need to be flexible and adapt based on an assessment of patients’ needs and what is both feasible and sustainable for the provider, recognizing that providers cannot always give all of themselves. Moving forward, Dr. Roeschlein says health systems should focus on creating safe and compassionate work environments that promote the psychological and social safety of their staff and clients (minute 24:00). Health systems can work toward this by providing resources like ongoing resilience and compassion satisfaction training, implementing trauma-informed supervision, and prioritizing collaboration and mutuality in staffing dynamics.
Dr. Parks concludes the webinar with two parting messages (minute 28:00). First, he emphasizes that not all stress leads to trauma; it can instead lead to strength, resiliency, and newfound skills. “The one thing that victims and heroes have in common is that both have been wounded,” he states. “We could end up heroes instead of victims.” Secondly, Dr. Parks challenges people to critically assess their fears and the amount of time they spend focusing on the pandemic, explaining that just as you don’t want someone recovering from a chronic disease to become all about their illness, we shouldn’t become just about the COVID-19 crisis. He notes that a balance exists in the moment-to-moment decisions we will make in response to the crisis, saying that if there is something you can do to help the situation, do it, but once you’ve done everything you can, you must get on with living your life.

10. Contact Tracing to Ease Social Distancing

Dr. Michael Fraser, Chief Executive Officer of the Association of State and Territorial Health Officials (ASTHO) provides an overview of the need for contact tracing in the COVID-19 pandemic and discusses the opportunity to build the capacity of the future public health workforce. Dr. Nilesh Kalyanaraman, Health Officer of the Anne Arundel County Department of Health, outlines the county level approach to contact tracing in Anne Arundel County and presents unique challenges and opportunities of the experience to date.

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11. Social Mission of Health Professions Schools

Lawrence Deyton, MSPH, MD, of the George Washington University School of Medicine and Health Sciences discusses the clinical public health curriculum work at GW and how these principles are being deployed in response to COVID-19. David Edelman, MD, of Columbia University Vagelos College of Physicians and Surgeons provides a student’s perspective, noting especially how interprofessional students can build on existing structures and relationships to mobilize in a crisis. Veronica Thierry Mallett, MD, MMM, of Meharry Medical College shares community strategies and approaches Meharry has undertaken to improve health equity during the pandemic and future recommendations for health care providers and policy makers.

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12. An Opportunity to Build the Public Health Workforce

Moderated by Lynn Goldman, Dean of the George Washington University Milken Institute School of Public Health, this session highlights the importance of public health’s role in building stronger communities and considerations for scaling-up contact tracing. Jeffrey Levi, PhD, of the George Washington University Milken Institute School of Public Health provides a national historical overview of public health workforce spending decline and the potential investments needed to rebuild the public health infrastructure. Amanda D. Castel, MD, MPH, of the George Washington University Milken Institute School of Public Health shares her observations as a volunteer of the DC Health Department, providing an in-depth look into the on-the-ground work by public health workers and the implications of COVID-19 response on other preventative health services. Alan E. Greenberg, MD, MPH, of the George Washington University Milken Institute School of Public Health and School of Medicine and Health Sciences describes past experiences from the HIV/AIDS epidemic that may help inform the pandemic response.

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13. Data Tool to Calculate Contact Tracer Workforce Need

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14. Ensuring Access to Oral Health Care

This Webinar examines the implications of COVID-19 for the oral health workforce. Speakers address the impact of COVID-19 on dental practices, share innovations – including teledentistry and integrated oral health, primary care, and public health – and discuss implications and policy needs for future practice to ensure oral health care access.

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15. The Ins and Outs of Hazard Pay for Healthcare Workers

Full Summary:

Essential health care workers are putting their lives on the line as they treat and attempt to control the spread of COVID-19. This webinar examines the concept of Hazard Pay, defined by the U.S. Department of Labor as “additional pay for performing hazardous duties or physical hardship.” Dr. Natalie Kirilichin, an emergency physician, moderates. Panelists include Dr. Michael Strain, Arthur F. Burns Scholar in Political Economy and Director of Economic Policy Studies at the American Enterprise Institute (AEI); Dr. Sarah Nolan, Deputy Policy Director for Healthcare at Service Employees International Union (SEIU); and Ms. Laura Wooster, Associate Executive Director of Public Affairs at the American College of Emergency Physicians (ACEP).

SEIU and ACEP are two organizations that traditionally represent low and high wage essential health workers, respectively. Dr. Sarah Nolan describes how SEIU represents one million health care workers, including personal care attendants, nurses, and nursing home workers (3:27). She discusses the challenges facing workers predate the pandemic and includes issues related to low wages, lack of benefits, few opportunities for professional development, and historical exclusion of home care providers—the majority of whom are women of color—from labor protections. These challenges are exacerbated by fewer available jobs or hours as consumers become fearful of workers entering their homes. Dr. Nolan emphasizes that the pandemic has exposed the cracks in our health care system, and pay policy must include long term structural solutions (8:29).

Ms. Wooster provides an overview of ACEP, a professional organization representing 40,000 emergency physicians from across the country and the 150 million patients they serve (12:04). She points out that in addition to those practicing in COVID-19 hot spots, resident physicians in training are particularly vulnerable to COVID-19 given their extended contact with patients during 80-hour work weeks. She also explains the counterintuitive downward pressure on front line physician salaries and benefits occurring as a result of curtailed care-seeking behavior leading to lower E.R. volumes and diminished profitability.

Dr. Michael Strain explains the importance of clarifying the goals of hazard pay before developing policy (17:22). Hazard pay may be a uniform supplement if intended as a gesture of gratitude; incremental based upon hours worked if intended to mirror potential exposure, or periodic over time to discourage attrition. He believes the purpose of hazard pay has been ill-defined at the Federal level.

(19:35) When asked what factors might govern hazard pay eligibility for health care workers, both Dr. Nolan and Ms. Wooster agreed that type and duration of exposure and the availability of PPE should all be considerations. They point out that even with adequate PPE, there are clear points of exposure risk during donning and doffing.

Ms. Wooster explains current policy proposals for hazard pay across sectors (22:43). She reflects on how certain private companies like Amazon and Walmart have temporarily increased pay at a flat rate for grocery workers. There are many similar proposals at the state and local levels, but few actual laws. At the Federal level, House and Senate Democrats have recently called for legislation including hazard pay differentials. She cites the following examples: Rep. Torres’ “Dear Colleague” Letter; The “Heroes Fund”; Senator Romney’s “Patriot Pay” proposal, and HEROES Act provisions. Ms. Wooster also emphasizes ACEP’s advocacy efforts to direct hazard pay towards individual workers as opposed to their employers. (29:08).

When thinking about the proposed policies, Dr. Strain reiterates the lack of clear goals from these proposals and identifies two approaches depending on the intended outcome of hazard pay. Stemming attrition with an income threshold payment, particularly for low wage workers, or encouraging retention within the profession by way of ongoing hazard payment are possible scenarios (31:10).

Dr. Nolan considers the potential limitations of hazard pay (37:07). She explains how short-sighted hazard pay policy may act as a patch but may fail to address the longstanding injustices marginalized health workers like home care workers face. Dr. Nolan suggests retention pay as a longer-term benefit for low wage workers after a finite period of hazard pay.

Dr. Strain examines potentially sustainable alternatives to hazard pay (42:34). He emphasizes the importance of programs that support workers with reduced hours, like partial unemployment. Of note, 27 states and D.C. have allowed employees who’s hours have been cut to receive partial unemployment benefits. He believes all states should embrace such a policy. Dr. Strain closes the discussion with how measures of health care worker morbidity and mortality in work settings may also provide objective criteria for hazard pay (45:25).