As the state of Washington cautiously eases restrictions on the types of medical procedures that can be performed in hospitals, health care providers are encouraging people not to put off the care they need to stay healthy.
“If you need care, seek care,” said Alan Fisher, CEO of Mid-Valley Hospital in Omak. “We’re starting a campaign urging people not to be frightened” about coming to the hospital or clinic for care despite the coronavirus pandemic.
Under orders from Gov. Jay Inslee, hospitals around the state stopped performing non-urgent and elective medical and dental procedures on March 19. Now, with a new statement from the governor last week clarifying the order, hospitals have a little more flexibility in conducting surgeries or other procedures that are not emergencies, but are needed to prevent pain or dysfunction in patients.
The ban on elective surgeries and non-urgent care was put in place to ensure that there would be enough hospital beds and adequate protective gear for medical workers in case of a deluge of patients with COVID-19 (the disease caused by the coronavirus). Most hospitals in Washington have avoided being overwhelmed with COVID-19 patients as “stay home, stay healthy” orders and social distancing measures have slowed the spread of the virus in this state.
But hospitals – especially rural hospitals like Mid-Valley in Omak and Three Rivers Hospital in Brewster – have been hit hard financially by the loss of patients seeking care for health conditions unrelated to the COVID-19 outbreak.
“Hospitals and health care providers across the state are reporting abnormally low volumes of patients seeking routine medical care,” the Washington State Hospital Association (WSHA) said in a statement last week. “Patients who have arrived at the hospital seeking care have been more severely ill. People are waiting to seek medical attention – and endangering themselves as a result,” the hospital association said.
Mid-Valley Hospital recently posted a video on its website urging community members not to delay treatment for chronic or urgent conditions.
Don’t delay care
“We are distressed and disheartened to see that people are waiting for long periods of time, because of either fear or an erroneous message that they could not come to the hospital because of the concern about COVID-19,” Jennifer Thill, an emergency department doctor at Mid-Valley Hospital, said in the video.
“We are seeing people who are much sicker than they have been on presentation previously. We don’t want you to wait and we don’t want you to delay care. We want you to come in and be seen,” Thill said.
“If you are positive for Covid-19 … we are here for you,” Thill said. “We have precautions in place to be able to adequately take care of you and to protect you and to protect us … we do not want you to stay at home if you feel you are getting sicker.”
Jules Sleiman, a family practice physician at Mid-Valley Clinic, also urged patients not to delay care. “We’ve made lots of changes in order to cope with the COVID pandemic, including more telehealth visits and video visits. We’ve also made changes to our walk-in clinic including a separate entrance for patients who may be presenting with COVID symptoms … to protect our patients and our community,” Sleiman said.
“We are distressed and disheartened to see that people are waiting for long periods of time, because of either fear or an erroneous message that they could not come to the hospital because of the concern about COVID-19…
We don’t want you to wait and we don’t want you to delay care. We want you to come in and be seen.”
Jennifer Thill, an emergency department doctor at Mid-Valley Hospital
Concern about possible exposure to coronavirus may be keeping people away from hospitals and clinics, but rumors and misinformation have also played a part, said Jennifer Best, the business development coordinator at Three Rivers Hospital.
“I actually heard from a community member that we [Three Rivers Hospital] were only open to treat COVID patients and not other patients,” Best said. “Our emergency room is open 24/7. Our laboratory and pharmacy are open. Our clinic next door is still open, mostly doing appointments by telemedicine and seeing patients on site as needed,” she said.
Hospitals and clinics throughout Washington have developed procedures to protect patients and staff, such as screening all patients before they enter a facility, doing extra cleanings and sanitizing of exam rooms, physically distancing patients, masking patients and providers, and not having people wait for their appointments in a waiting room, according to the state hospital association.
The loosening of restrictions on non-urgent or elective procedures may begin to ease the financial crisis faced by Mid-Valley and Three Rivers hospitals, which have received state and federal emergency funding in recent weeks. Mid-Valley has about 30 days of cash to support operations, Fisher said this week. Three Rivers has about 50 days of cash on hand, Best said.
For small rural hospitals, “elective surgery is our bread and butter,” said Fisher. “We have had a 48% decrease in surgeries” since the governor’s March 19 order restricting medical procedures. “If we take a look at where we are typically in the month of April, we saw about $1 million difference in revenue,” he said.
The ban on non-urgent procedures applied to those that would not “cause harm to the patient” if they were delayed for three months. Examples include most joint replacements, cataract and lens surgeries, non-urgent cardiac procedures, cosmetic procedures, some endoscopy and interventional radiology services.
The governor’s proclamation did not define “harm,” and the clarification issued last week leaves assessment of harm up to individual clinicians. To assess harm, the clinicians should consider if a patient’s illness or injury is causing significant pain or dysfunction in daily life, or is progressing or at risk of progressing. Among the criteria for considering harm is whether leaving a condition untreated would make the patient more vulnerable to COVID-19.
At Three Rivers Hospital, Best said, “we have a couple of procedures on the schedule this week, but they’re not elective. We’re hoping to start accommodating more surgeries soon that fit the criteria of Gov. Inslee’s proclamation and interpretive statement.”
Procedures that are likely to be resumed include cancer lesion removals, some joint replacements, and certain laparoscopic procedures such as gallbladder removal, Best said. “But it all depends on the patient’s situation and the provider’s discretion. We’re looking forward to hopefully helping some patients who have been waiting longer than they would ordinarily to get their health issues addressed,” she said.
“First though, we’re creating policies … to keep our patients, staff and surgeons safe. This includes some changes to pre-op screening and intubation processes, as well as PPE [personal protective equipment] guidelines,” Best said.
“If anyone is experiencing severe pain or illness, whether they’re waiting for a surgery date or not, they should go to the emergency room or call their primary care doctor for guidance,” Best added. “We still ask that patients call us ahead of showing up if they have any COVID-19 symptoms or if they’ve been exposed to someone who does, just so our staff can be prepared. We have implemented infection control measures to keep patients safe.”
Twisp dental clinic closed
The ban on non-urgent medical and dental care has also impacted community health centers across the state. A recent economic impact analysis by a national accounting firm predicted severe funding shortfalls for the state’s community health centers, including Family Health Centers, headquartered in Okanogan.
“The biggest impact has been in the dental side of things,” said Jesus Hernandez, CEO of Family Health Centers. “We’re limited to doing emergency dental work.”
With the temporary ban on routine dental care, Family Health Centers has taken measures to cut costs, including closing its dental clinic in Twisp that saw patients two days a week. The clinic on Second Avenue was closed when the March 19 ban on non-emergency dentistry went into effect, and Family Health Centers has decided not to reopen it when the restrictions are lifted, which is expected to occur on May 18.
Hernandez said Family Health Centers will continue to provide dental care in the Methow Valley, however, with a mobile dental clinic. The Twisp dental clinic was staffed by a dentist and dental assistants from Okanogan, and they will staff the mobile clinic.
Closing the Twisp clinic “is a cost-saving measure – it reduces the overhead of the lease,” Hernandez said. He said the Twisp dental clinic has also faced staffing issues, because Family Health Centers had difficulty recruiting local providers.
Other dental clinics operated by Family Health Centers in Okanogan, Brewster, and Oroville have reduced hours and a Bridgeport clinic is temporarily closed, Hernandez said.
Family Health Centers’ medical clinics, including the Twisp clinic on Second Avenue, are faring better than many other community health centers, Hernandez said. That’s largely because Family Health Centers was able to transition quickly to telemedicine, which has become essential while limiting face-to-face medical visits during the coronavirus pandemic.
Virtual health care
“We had built in a lot of IT infrastructure so we were able to stand up virtual health care rather quickly. We were fortunate that we made some investments that fit the current situation,” Hernandez said.
“We have amazing staff that were willing to jump on this. As soon as Medicare and Medicaid announced they would pay for telemedicine, they were ready to go,” Hernandez said. As a result of the quick shift to virtual care, he said, “we are one of the less threatened community health centers” in Washington. (Community health centers are private nonprofit organizations that receive some federal funding and provide care regardless of ability to pay.)
“We are re-educating the public that access to health care has not gone away, it’s just different,” Hernandez said. “Call us and schedule a virtual encounter. If needed, follow safety protocols so people can come in person.”
Revenues are down to about 60-70% of normal for Family Health Centers, largely due to the loss of dental business. But a federal Paycheck Protection Plan loan of $3 million will provide operating funds for at least three months and allow Family Health Centers to avoid laying off staff, Hernandez said.
Like hospitals in the region, Family Health Centers is reaching out to the public using social media and direct contact to emphasize the need for continuity of health care despite the pandemic. “Our providers did a lot of calling patients to follow up, depending on morbidities,” Hernandez said. Ongoing care is essential for people with conditions like diabetes and hypertension, or obstetric patients, he said.
Hernandez said he recently learned that community health centers around the country will receive funding through the CARES COVID-19 relief act to build up the capacity to test for COVID-19. “We have been getting a good amount of testing supplies from public health and the lab system we contract with. In the next month or two we expect to be doing more tests,” he said.