As awareness dawned about COVID-19’s virulence and ease of transmission, care providers had to make quick decisions about human safety and care delivery before anyone knew how the virus worked or how to treat it — and without any vaccine to ward against infection. They rapidly deployed safety protocols for staff and closed their doors to visitors to prevent in-facility transmission; navigated necessary but disruptive curtailments to planned procedures; addressed how to allocate finite resources; and shifted to telehealth for select service offerings so patients could have a different channel of access. Still, the surge in cases created enormous capacity problems. Rapid action resulted in positive outcomes and challenges, both of which generated insights for the current crisis and future emergencies.
President and CEO, health system: “Healthcare will never be the same. The fundamental operations of healthcare systems have changed.”
KEY FINDINGS
Telehealth has solidified its value in care delivery.
Care providers found themselves facing an influx of severely ill COVID-19 patients while still needing to care for patients with other urgent and emergent needs. Their remarkably fast pivot to telehealth, empowered by expanded payment, freed essential inpatient space to help meet those needs and to maintain access to primary, behavioral health, and other types of care in a way that was safe for patients and staff. Clinicians who had contracted COVID-19 themselves or had to quarantine often went beyond the call of duty to offer telehealth visits from a remote location. Other virtual modalities, like remote monitoring and hospital-at-home models, also helped acute care hospitals address capacity problems.
Emergency response is a cross-continuum challenge.
Lockdowns, spurred by the severity and contagiousness of the virus, quickly stalled patient transfers between the various players along the healthcare continuum — a clear indication that what happens in one segment of the healthcare system affects the entire system. The breakdown exacerbated patient capacity problems and severely strained emergency departments. Cer-tain care specialties, such as pediatrics, behavioral health, post-acute treatment and home care, didn’t get the attention they needed early on. The often-siloed nature of the care continuum was not ideal for the sharing of ideas and resources. Only when coordination began to span across provider types did the situation improve, showing that cross-continuum collaboration plays an essential role in ensuring people can access care in the right place at the right time.
The downstream impacts of the crisis were important to anticipate.
Healthcare organizations learned that they must anticipate and quickly plan for the downstream and secondary effects public health emergencies can have on the community, such as behavioral health, health inequities, and deferred care. Providers witnessed that large-scale medical crises cause proportional emotional crises, and that the deferral of medical care has significant clinical consequences. The secondary impact of public health emergencies is especially difficult to plan for when dealing with persistent, longitudinal crises like COVID-19. These impacts further strain healthcare facilities, which are often still addressing the primary effects of the same crisis.
Government flexibility is a pillar of effective emergency response.
Provider organizations’ successful response to the pandemic relied on the ability to secure significant, timely waivers and regulatory flexibilities from the state and legislature. This included waiving a number of regulations that posed barriers to opening up bed capacity and ensured patients were able to receive care in the right setting. Payment parity for telehealth visits and the expansion of covered services and modalities empowered providers to rapidly make that shift to virtual care. The suspension of strict credentialing and licensing rules expanded the pool of caregivers as caseloads surged, and waivers granted providers more freedom around capacity and transitions from acute to post-acute care, again opening inpatient beds.
Surge capacity creation was central to Massachusetts’ response.
Many healthcare organizations in Massachusetts were able to create surge spaces and capacity that equaled or exceeded their expectations. This was partially enabled by collaborations between facilities to address capacity constraints regionally. Despite this general success, the provision of healthcare services was often limited due to capacity, equipment, and staffing constraints. In some cases, equipment was available but the requisite room infrastructure was not. In others, the right room was available but specialized setup to treat pediatric or behavioral health patients was lacking. While healthcare surge capacity will continue to be most limited by staffing, physical plants also play an important role.
RECOMMENDATIONS
Encourage continued telehealth adoption and investments.
Signs are emerging that some payers may want to move away from payment parity and other solutions that enabled remote care. Healthcare leaders urge the continuation of payment parity and other proven measures, through legislation if necessary. Audio-only visits, when appropriate, are often preferred and should be considered equal to video visits from a reimbursement and regulatory leniency perspective, as they are especially critical to behavioral health, rural, and marginalized populations. The broadband infrastructure for virtual care delivery should continue to be expanded, and strategies should be deployed to promote widespread physician adoption, including the refinement and dissemination of new workflows. The telehealth delivery model should continue to improve, and its effect on care quality should be closely monitored.
Address digital equity with a cross-sector response.
Telehealth relies on people’s digital literacy and access to digital devices and connectivity — both of which are lacking among those who were hit hardest by COVID-19. The digital divide must be addressed for telehealth to reach its full potential and avoid worsening existing care inequities among minority and underserved populations. For pediatric patients, school-based virtual health programs should be funded and offered, especially in communities where digital inequities and barriers to care are the most severe.
Expand surge capacity and facility flexibility across the continuum.
State and healthcare leaders should work together to codify best practices and workflows related to the enablement and rapid deployment of sustainable surge capacity across the healthcare ecosystem. This means identifying and ensuring alternative healthcare facilities are ready for temporary mixed use, including critical care outside of ICUs, and non-acute, sub-acute, behavioral health, and post-acute care. In addition, healthcare leaders should consider a range of future disaster needs in new facility construction and upgrades to accommodate the needs of patient isolation, climate impacts (e.g., flooding, wind, heat, etc.), security threats, and community-based care.
Incorporate behavioral health into emergency planning.
Even before the pandemic, the healthcare system lacked the capacity and workforce to address the commonwealth’s behavioral health needs, which have been systemically underfunded. Although telehealth helped to expand access, the COVID-19 crisis sparked a delayed bolus of demand, as well as a striking demand in acuity, for which the system and its regulatory agencies did not have an effective solution. Moving forward, better coordination between DPH and DMH is needed to ensure that guidance is specific enough to different patient populations and care settings, and considers the unique needs of behavioral health patients.
Additional resources are necessary to build capacity and incentivize entry into the behavioral healthcare workforce to address the mental health pandemic. Furthermore, sustainable funding and reimbursement for care is required, much like the state-run plans offered during the pandemic, including payment for patients as they board in hospitals.
Leverage the use of waivers and regulatory flexibility.
The capacity crisis remains due to continued workforce shortages and patient demand for care that was put on hold during the pandemic’s worst phases. Yet several waivers that gave healthcare organizations the flexibility they needed for care delivery, staffing, and patient transitions are set to expire. The long-term utility of these waivers should be closely evaluated, and those that are relevant should be extended permanently, such as those related to minimizing administrative barriers and encouraging administrative redesign.
Waivers should be organized and saved in a centralized repository so they are ready at a moment’s notice for future emergencies. Considering the broad spectrum of possible public health emergencies, it is important to define the circumstances under which each waiver would be deployed. In parallel, relationships between providers and payers need to tackle the inefficiencies around pre-authorization and reporting that contribute to care continuum bottlenecks.