Alvine Kapitako

In late 2019, the novel coronavirus (Sars coronavirus 2) started to gradually spread from Wuhan, China to the rest of the world. Before we knew it, the world was locked up and a global pandemic declared as more and more people were infected with the deadly virus every second of the day. The numbers of those who died were equally devastating. Slowly but surely every corner of the world felt the impact of this dreadful disease. With a number of vaccines in sight now, scientists and public health professionals are hopeful that life will eventually get back to normal with fewer hospitalizations and deaths, as a result. But, what did the pandemic teach us about humanity? Resilience? Yes, certainly. Telehealth, sometimes called telemedicine was definitely one of the lessons. During the pandemic, telehealth whether at Community Health Centers (CHCs) or hospitals was seen as an alternative to in-person health care service provision-all in an effort to curb the then ravaging pandemic.

Telehealth is defined as  “the use of electronic information and telecommunication technologies to provide care when a patient and doctor are not in the same place at the same time”.  Now that life is slowly getting back to normal, one of the biggest questions perhaps on everyone’s lips is whether telehealth will receive the same attention it did post COVID-19 pandemic.

Before the pandemic, there weren’t many providers using telehealth, said Dr. Eugenie Komives, a family physician who is also affiliated with the Wellcare Health Plan. Before the pandemic, Komives was exposed to telehealth but nothing compared to how much they used it when COVID hit. During the pandemic, the manner in which providers and patients viewed telehealth changed, primarily because of the need to provide services through telehealth to avoid possibly spreading the virus.

“I think we’ve learned that you’re able to provide safe care for a large number of conditions to patients who are either high risk or come into an office during a pandemic just having difficulty whether they’re literally afraid to come in and in doing so I think we’ve crossed over that digital divide around the use of telehealth and virtual healthcare and really looking forward to seeing how this continues to play out,” said Komives during a panel discussion of the North Carolina Community Health Center Association (NCCHCA)’s virtual Primary Care Conference in April 2021.

CHCs had to adapt to prevent the spread of COVID-19 within their settings. Changing the look of patient-provider interactions by modifying physical spaces, moving some appointments to telehealth and training staff and patients to use tele-devices are some of the changes CHCs had to implement, said Margaret Covington, the CEO of Stedman-Wade Health Services.

“The initial impression I had for telemedicine is that it’s a very underutilized tool for physician practices, said Dr. Michael Ogden of Healthy Blue NC. He said the uptake of telehealth was not immediate and before the COVID-19 pandemic “I felt like we were practicing fax machine medicine in the iPhone era”.

Also sharing his experience with the use of telehealth, Dr. George Cheely of the AmeriHealth Caritas insurance plan in North Carolina said that before the pandemic, there was potential for telehealth. However, it was viewed more as a modality that was often focused on night and weekend adjunct urgent care delivery often for people who could not afford to pay out of pocket for the services.

“I got a glimpse of positive and hopeful experiences working with neurology colleagues at Duke to help them expand their telestroke programs. It really gave me insight into how access to constrained services.  Some specialists could really be expanded statewide to deliver high quality care for stroke patients and I think that the pandemic has really built on that concept of expanding access,” he said.

Telehealth is now seen as a tool to break down barriers to access where people might have to drive to primary care more easily.  “People who are working shifts can step out on lunch and get their visit instead of missing work to get to visit a doctor,” said Dr. Cheely. Behavioral health, in particular, proved to be effective with telehealth, noted Dr. Cheely. “I think we’ve also really seen that where behavioral health providers may have had a 20 or 30 percent no show rate pre-telehealth with the deployment of telehealth those have dropped to almost 0.  Telehealth is an important way to augment access, provided it’s coordinated closely with primary care,” said Dr. Cheely.

But, as we know, telehealth is not entirely new. It has been around much longer than we probably had a formal definition of it. Dr. Michelle Bucknar of United Health Care shared her initial experience with telehealth. “My first experience with telehealth was actually in the mid to late 90s”, she told the panel. She had just finished her medical residency and moved to Kansas City. “The University of Kansas actually had school-based telehealth…” she related. Being “old school”, the idea of attending to patients without seeing them was not her idea of practicing pediatrics.

Looking at the use of telehealth beyond COVID-19.

“I really wasn’t in favor of the school-based telehealth clinics but at that time, I was also working at a pediatrics academic center that was mostly evolving into a telehealth program and by the time I moved to North Carolina they had a robust telehealth program predominantly the specialty visits,” she related. This early experience was very helpful during the pandemic, she notes. “I feel like I’ve come full circle and I embrace telehealth. I think the important thing is to not disrupt that primary care relationship.  Even though I’ve come a long way, I want to preserve that primary care relationship and because of that I really want primary care to offer these services and I think COVID has really pushed us forward. While COVID is just awful and has really disrupted our lives, I think there are some good that’s going to come out of that and I hope telehealth is one of those,” said Dr. Cheely.

The future of telehealth

Dr. Ogden believes that telehealth is an underused adjunct to a face-to-face relationship of providing healthcare.  “The balance of using that platform to be an augmenting factor in that relationship is really where I see the future of telemedicine being in North Carolina and beyond. I do think telemedicine is an important modality and from a [Blue Cross Blue Shield North Carolina’s Medicaid Insurance Program] Healthy Blue perspective we would want to preserve that modality of access as an adjunct and not a replacement for the primary care relationship,” said Dr. Ogden.

While telehealth has proved effective during the pandemic, concerns raised during the panel discussion are the challenges of access and affordability.  For example, not everyone owns a cellphone or broadband connection in America, which can make video telehealth visits harder if not impossible to accomplish.

“Anything we can do to lower the barriers to having that access will be a big advantage as long as it results and benefits to the patient,” said Dr.Ogden.  Additionally, confidentiality and protecting patient information is important, noted Dr. Ogden.  Looking at the future of telehealth would also require being clear on what is not telehealth, said Dr. Ogden.  “Telephone only consultations as a definition of telemedicine probably ought to be softened a little bit. I don’t think it’s the same thing as a telehealth visit unfortunately and right now it’s covered at a certain percentage but that’s one of those things that we feel is probably not the same thing and shouldn’t be covered at the same rate as a telehealth visit,” Dr. Ogden said. Another challenge is finding ways to prevent financial exploitation of telehealth claims, the panelists noted.

“To prevent fraud we would need to watch the data over time and ensure that when we see deviations from the norm we ask the questions rather than make assumptions,” Dr. Ogden said.  Blue Cross and Blue Shield of North Carolina announced in April that it would keep its pandemic telehealth policies through 2021. The use of telehealth by Blue Cross’ 3.9 million members grew by more than 7,500 in 2020, according to a report published by The News & Observer. Read more about it here: https://www.newsobserver.com/news/local/article251718023.html.

When the Covid-19 pandemic hit 13 months ago every aspect of life changed. In addition to people dying in great numbers from the novel coronavirus SARS Cov-2, the pandemic also revealed wider economic gaps, racial injustices, and climate crises. It no longer had to be business as usual because many spheres of life were disrupted and systems, as well as individuals, had to adapt to these challenges and find new ways of leveraging existing resources to remain resilient despite the trying times. The recently concluded North Carolina Community Health Center Association (NCCHCA) virtual conference held a session focused on assessing the role of Federally Qualified Health Centers (FQHCs) in mitigating the effects of this global pandemic.

 “The pandemic hit our poorest and most vulnerable communities the hardest and community health centers were uniquely positioned for purpose to be an answer and voice of our most impoverished and vulnerable communities,” said Chris Shank, the NCCHCA President, and CEO during a panel discussion on the role of FQHCs in the public space during the pandemic. The panelists represented the public health sector in government and non-profit organizations.

Ben Money, the Deputy Secretary for Health Services at North Carolina Department of Health and Human Services said community health centers have demonstrated speed and the ability to act unilaterally. Also, FQHCs have deep ties with the communities that they serve, making their role even more important, noted Money.  “Community health centers have patient governed boards and that’s critical. Community health centers work very closely with HRSA, state, and county government but they can act in ways that in many instances government entities cannot. And, they’re also able to hire quickly and deploy staff rapidly. So, that was critical in our covid response,” explained Money.

In addition, CHCs were in a position to test populations in harder to reach areas for Covid. “The need for community health centers to have community health workers and other individuals from the communities that they serve employed to engage these populations is also a critical feature that many health centers have embarked upon” explained Money. In addition to providing comprehensive health care services, community health centers provided crucial patient education that focused on preventing Covid-19 in the early phases of the pandemic.  They distributed PPE and now they’re equally active during the vaccination efforts.  “I think the advent of the federal vaccine effort through HRSA where allocations are provided directly to FQHCs is really making a huge impact in terms of being able to get more vaccines into the state,” Money said.

Additionally, the CEO of South Carolina Primary Health Care Association and Chair of the National Association of Community Health Centers Board, Lathran Woodard, observed that FQHCs in North Carolina were more actively involved in mitigating the effects of the pandemic from the start of the pandemic.  Different states prioritized CHCs differently in the COVID response, explained Woodard. In addition, testing for their workforce was hard. 

“We went from mass testing for volumes to realize that there were population groups and communities of color that were not being reached because they don’t have the transportation to come to these big football field testing sites,” said Woodard. One of the most important roles that FQHCs played during this pandemic was to address the challenge of vaccine hesitancy, which was also prevalent among workers, said Woodard. They did this by using trusted community leaders and community health center staff to address the hesitancy.

“We in the south and southeast don’t have deep pockets but we have a lot of patients who need the care.  We had health crises before and if you look prior to Covid we still were dealing with the opioid issues, hypertension issues, infant mortality, and all of that, and then this goes on top of it. We know how to reach the community, we know how to reach those who are vulnerable populations and who trust us but we need the backing and resources to do it,” said Woodard.

Going forward, FQHCs will need to have a population focus looking at their patient panels and service areas, added Money. “Covid has allowed us to address some of the cultural inhibiting factors that exist across our state system,” explained Money.  In addition, he noted that North Carolina has a decentralized public health structure with only a few exceptions. “Local health departments are county governed. But the capacity of local health departments is largely dependent upon the level of county investment and so more economically distressed counties are less able to adequately fund their local public health infrastructure,” said Money.  While Money covered things from a state health perspective, there was also a panelist from HRSA to cover the national view.

Angela Powell, a Director in the Office of Health Center Program Monitoring of the Bureau of Primary Health Care also noted the crucial role community health centers play in the country, adding that FQHCs have always ‘been high profile and they receive a lot of recognition’. For example, when the Affordable Care Act was enacted in 2010, health centers were at the forefront. “It certainly was no surprise that health centers were called to the forefront once again during the response to Covid19,” she said. The challenge now is to ensure that FQHCs not only get to reach many people but that the outcomes of the services they provide will be worth every dollar injected into FQHC programs. 

“The good work that we do with that ensures that the funding will keep coming and that when the next crisis hits, folks will know that the return on investment in the health center program is one that yields a good outcome,” said Powell. Echoing similar sentiments, Brian Toomey, the CEO of Piedmont Health said: “Financial challenges have been the father of creativity for health centers. That’s a challenge to us but we have to make the best investment of those dollars to show that we really are everything that we said that we are and everything that we can be”. On addressing future public health challenges, Money concluded: “I envision a future in which some necessary public health resources are for core public health services such as the accessibility to data scientists and epidemiologists that are going to be so critical to mitigating future pandemics. 

The NCCHCA Communications and Emergency Preparedness Coordinator, Leslie Wolcott agrees that the pandemic indeed revealed the important role CHCs play in the community.

“This has been a year for Community Health Centers to shine, but all the attention to their work will also bring more scrutiny. Whatever role CHCs play in the future of public health, they will continue to deliver great care for a great value—and do extensive and detailed data reporting and collection as they go. CHCs must continue to reach underserved populations moving forward from COVID, in order to best prepare their patients for the health challenges of the future,” said Wolcott. The theme for this year’s virtual conference was “Positioned for purpose: mission and service in 2021”.

NCCHCA President and CEO Chris Shank, far right, with Piedmont Health Staff in 2019.

Universal healthcare for all Americans, a comprehensive Covid-19 relief program, and raising the minimum wage ‘to a living wage’ are some of the basic necessities that advocate for poor people, Reverend Dr. William J. Barber II, called for during the recent virtual conference of the North Carolina Community Health Center Association (NCCHCA). Rev. Dr. Barber, the President of Repairers of the Breach and Co-Chair of the Poor People’s Campaign delivered keynote remarks at the closing session of the NCCHCA conference.

“We must fight to guarantee healthcare for all. This must become a battle. We cannot continue to be a nation that does not provide some form of universal healthcare for all of its citizens and that includes covering pre-existing conditions,” said Rev Dr. Barber, who adopted quotes from Dr. Martin Luther King’s famous ‘I have a dream’ speech.  Rev. Dr. Barber spoke passionately about injustices affecting minorities and poor people in America, ranging from the rights of indigenous people, undocumented migrants, LGBTI rights, migrants, and equal fair taxes. At least 87 million people in American are uninsured or underinsured, Rev. Dr. Barber said.

The United States [of America] is the only country out of the 25 wealthiest nations in the world that does not provide some form of universal healthcare insurance “where healthcare is connected to a person’s humanity and not their job”. He was also disturbed that not a single bill from Congress provided universal healthcare since the start of the pandemic. Yet, corporations have made over two trillion dollars during the pandemic while people have lost billions of dollars and millions of jobs. He was further saddened by the fact that over one million people in North Carolina do not have healthcare insurance even during this pandemic. “Now 500,000 of them could have had healthcare if the Republican legislature had agreed to just expand Medicaid,” he said. Rev. Dr. Barber had a hard time fathoming why even in the midst of a pandemic 32 percent of the North Carolina population cannot afford to pay for clean water.

“In a time where we talk about this need to wash hands and stay clean, we have this ecological issue that we’re facing in this country even prior to the pandemic. Nothing would be more tragic than for us to stop now,” remarked Rev. Dr. Barber.

Spending nearly $800 billion in the war economy is unjustifiable because if that money were cut in half, for example, $350 billion the U.S would still be spending more on war economy compared to China, North Korea, Iran, Iraq, and Russia combined, he said. “If we took 20 percent of that money and put it in our healthcare and education infrastructure, we could fund everything we basically need in the midst of the Covid pandemic. The truth of the matter is we’re putting more money in the war economy to kill than we are money to live,” he said. And still, so many veterans live with low wages and in poverty.

“We have a sickness in society and nothing will be more tragic than for us to stop now,” he said before expressing concern for religious philosophies that encourage only prayer and shouting and those that overlook societal injustices against minorities such as women, and the LGBTI community. He ended his address on a positive note stating that these challenges can be addressed if people unite for a common purpose.

“The issue is not scarcity. We have the resources. It’s the scarcity of will. We cannot continue to be a nation that does not provide some form of universal healthcare for all of its citizens and that includes covering pre-existing conditions. We must raise the minimum wage to a living wage. We have not raised the minimum wage in nine years in this nation.  No, no no; there’s no way in the world that corporations are making two trillion dollars in the midst of a pandemic and people are suffering. We must raise the minimum wage. We’re saying to a minimum of $15 an hour initially. That’s what Dr. King asked for and others in 1963. We’re 57 years late. We can do this. It will bolster the economy,” he concluded.  The NCCHCA virtual conference took place on April 7, 8, and 9. This year’s theme was “Positioned for purpose: mission and service in 2021”.

Rev. Dr. William J. Barber II giving a keynote speech during NCCHCA’s 2021 PCA virtual conference.

Renowned Duke University professor of psychiatry and behavioral sciences, Dr. Bryan Sexton was the first official speaker at the North Carolina Community Health Center (NCCHCA)’s opening of the Virtual Primary Care Conference on Wednesday, sharing research findings on work-life balance and burnout in healthcare settings.

Clinical staff such as nurses, physicians, and pharmacists have a 40 – 45 percent burnout rate when measuring just emotional exhaustion alone. Burnout is also associated with lower patient satisfaction, higher infection rates, medication errors, and even higher standardized mortality ratios said Dr. Sexton.

The global Covid19 pandemic has revealed a lot about individuals, he noted. Before the pandemic, at least 1/3 of health care workers were burned out before the pandemic “and now that number is closer to two out of three,” he explained.

His presentation, titled ‘Thriving vs. surviving during times of change: The science of enhancing resilience’ focused on studies in the field of psychology to explain burn-out and work-life balance as well as interventions to mitigate the challenges posed by both burnout and poor work-life balance.

Citing data from a five-year study that looked at healthcare workers’ well-being, Dr. Sexton said: “We ran a series of randomized controlled trials to show that we can cause wellbeing to improve. We can cause burnout to go down. We can cause sleep quality and sleep quantity to improve.” Predictors of an individual’s work-life balance include how often in the past week an individual might have skipped a meal, ate a poorly balanced diet, worked through a day shift without any breaks, arrived home late from work, or changed personal or family plans for work.

“The answers to these questions cluster together in an interesting way and they give us an idea of your work-life balance behaviors (infractions) or how often you make decisions that put work-life above your personal life and drain your battery and that tells us a picture of where your wellbeing will be like in the future,” said Dr. Sexton. Furthermore, he said one sure way to guess an individual’s work-life balance is to ask the two closest people they work with, further adding that work settings and people within an organization are very likely to influence each others’ work-life balance.

“We never thought that work-life balance was a group norm but there’s a social contagion to work-life balance that makes it so that whether you know it or not, what other people are doing for their work-life balance is related to the decisions that you make about your work-life balance and vice versa,” said Dr. Sexton.  Physicians and nurses were found to be the worst offenders on work-life balance, highlighted Dr. Sexton.  Other predictors of work-life balance include the amount of time an employee has been working on their job. “If you’ve been working for less than 6 months you’ve got a pretty good work-life balance” but it takes six months to be like everyone else, he said.

Dr.Sexton also referenced a Michigan study that found that 26 percent of one individual’s burnout was predicted by the people they worked with. “A quarter of your wellbeing is simply who’s to the left of you and who’s to the right of you on any given day at work. That is completely independent of your marital satisfaction, your spiritual existential crisis. That is not something that we knew going into this study,” said Dr. Sexton.

Burnout is a big driver of the way individuals behave, he said. In work settings where burnout is high there was found to be more bullying, publicly humiliating colleagues, turning one’s back, and even hanging up the phone before the conversation was over, said Dr. Sexton.  Just like burnout is contagious, so is well-being, he said, adding that an individual’s focus determines their perceptions and view of the world around them.  “Your focus determines your reality,” he emphasized.

But how do you make positive emotions more accessible when the negative ones are so prevalent?  Dr. Sexton introduced conference-goers to one very simple intervention, called “3 good things.”  Writing down three things that went well in a day helps make those emotions accessible, said Dr. Sexton, citing another study that found that people who wrote down three good things that happened in a day were happier and less depressed six months into this practice despite their environment.

Conference-goers learned about the effects of burnout on individuals working in clinical settings.

It’s been nearly two years since the North Carolina Community Health Center Association (NCCHCA) took on the mandate to bridge health disparities in the state by enrolling medically uninsured children into the Children’s Health Program (CHIP) through the Connecting Kids to Coverage grant.

The Connecting Kids to Coverage Program assists families, children, and pregnant women who are below the Federal Poverty Level (FPL). The FPL is a measure of income issued annually by the Department of Health and Human Services. It is used to determine an individual’s eligibility for certain programs and benefits, including savings on marketplace health insurance, Medicaid, and CHIP coverage.

“Health insurance coverage varies dramatically by race. In North Carolina, 36 percent of all uninsured children are Latino,” explains Tamara Jones, the NCCHCA former Coordinator for Connecting Kids to Coverage program in a recent interview. In addition, more than 30 percent of Medicaid eligible parents are uninsured in North Carolina, she says.

“So, the Connecting Kids to Coverage program aims to help bridge those disparities by reaching out to the sub-groups and children that have lower than average coverage rates such as children in rural areas, teens, native Americans, and Hispanics,” she adds. The program also targets hard-to-reach populations, including the homeless. “NCCHCA also provides training focused on reaching these hard-to-reach populations by trying to bridge those health disparity coverage gaps that we’re finding in these sub-groups,” Jones explains.

About 300 families have benefitted from the Connecting Kids to Coverage program. Jones believes this number could be higher because CHCs have on countless occasions assisted people outside of the program’s target population.  Still, not everyone who needs to benefit from the program has benefitted from it either. This is primarily because of the Medicaid and CHIP program requirements. For example, the threshold for working parents in North Carolina is 47 percent of the FPL.

“A parent with two children who earns $ 12,000 makes too much for Medicaid in North Carolina So, you have to have a very low income to be eligible for Medicaid in North Carolina. This makes it very difficult to find eligible parents that meet the requirements for Medicaid and so we found that a lot of them are in that coverage gap,” explains Jones.

This essentially means that most families have an income that’s too high for Medicaid but still too low to even seek health insurance subsidies in the health insurance marketplace. “To receive health insurance subsidies from the marketplace they would have to earn $25,100 to even get assistance so that is what we’re running to a lot with the parents and children that we’re trying to assist,” explains Jones.

To date, 39 states (including DC) have adopted the Medicaid expansion and 11 states have are yet to adopt the expansion. North Carolina is one of 11 states that have not expanded Medicaid. Other states that have not expanded Medicaid include Florida, Georgia, and Tennessee. “ We know that parents who are covered are more likely to have their children covered,” responded Jones when asked if she thinks the Connecting Kids to Coverage program would achieve higher coverage rates if more parents were covered with Medicaid.

A provider sharing information with a parent and her daughter.

Black women are known to have played significant roles in the history that shaped America and its values. Today, more women of color continue to dedicate their lives to the development of this great nation, and as we zoom into the health sector and the significant roles Community Health Centers play, we’d like to introduce you to a long-time leader in North Carolina’s Community Health Center movement, Margaret Covington.

Covington is the CEO of Stedman-Wade Health Services and has dedicated her life to serving communities through healthcare service provision. While not directly working with patients, her leadership roles have certainly contributed to what Stedman-Wade is today, and by extension the health sector in North Carolina.

“I was born in North Carolina and moved to Washington, DC in October 1966. I finished college, then I returned back to NC in 1978 which is when I started to work for a Community Health Center in Jones County,” says Covington. In 1981, she went to work for Stedman-Wade as an office manager. “I later became CEO in 1994 and the rest is history,” she related with a sense of pride.

Community Health Centers  (CHCs)are perhaps not entirely recognized for their role in health care service provision and especially for those individuals who are medically uninsured. We asked Covington to highlight the significant impact Stedman-Wade has had in Fayetteville and North Carolina at large, considering that it is the largest safety net provider for medically uninsured and indigent populations in Cumberland County.

“Stedman-Wade provides access to care to patients that can’t afford to get care elsewhere. Our patients get comprehensive primary medical, dental and behavioral health services,” she explains. Stedman-Wade has been joint commission accredited since 2000. “All our sites are Patient Centered Medical Homes (PCMH),” she says. She further adds: “The care Stedman-Wade gives this community has been far reaching and the patients are so grateful. It is rewarding when patients know that you care about their health” she adds. But being considered a trusted provider has its challenges, notes Covington. “Maintaining provider staff has been a challenge, especially dentists. But, striving to keep our staff and patients safe has been our biggest challenge,” she admits.

As we know, the global COVID-19 pandemic has made its impact felt in all spheres of our lives and in March of 2020, CHCs had to adapt to prevent the spread of COVID-19 within their settings. Changing the look of patient-provider interactions by modifying physical spaces, moving some appointments to telehealth and training staff and patients to use tele-devices are some of the changes CHCs had to implement. And, as the head of Stedman-Wade, Covington had to cope with these changes even when not knowing what the next day will bring. She’s transferred the same energy to her staff and patients, assuring them that “the organization will be there for them”.

Stedman-Wade staff stand with Congressional staff during a visit.