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Rural hospitals are under siege from COVID-19 – here’s what doctors are facing, in their own words

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Physician, Associate Professor of Family Medicine, University of Colorado Anschutz Medical Campus
Family Physician, Assistant Dean for Rural Health at the University of Kansas Medical Center, University of Kansas
Lauren Hughes receives funding from the Zoma Foundation. She is a member of the Rural Health Redesign Center Organization Board of Directors.
Jennifer Bacani McKenney does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
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It’s difficult to put into words how hard COVID-19 is hitting rural America’s hospitals. North Dakota has so many cases, it’s allowing asymptomatic COVID-19-positive nurses to continue caring for patients to keep the hospitals staffed. Iowa and South Dakota have teetered on the edge of running out of hospital capacity.
Yet in many communities, the initial cooperation and goodwill seen early in the pandemic have given way to COVID-19 fatigue and anger, making it hard to implement and enforce public health measures, like wearing face masks, that can reduce the disease’s spread.
Rural health care systems entered the pandemic in already precarious financial positions. Over the years, shifting demographics, declining revenue and increasing operating expenses have made it harder for rural hospitals to stay in business. The pandemic has made it even more difficult. In mid-March, most rural hospitals halted elective procedures to slow the spread of the virus, cutting their revenue further, and many have faced price gouging for supplies given extreme shortages.
I work with rural doctors and hospital administrators across the country as a researcher, and I see the stress they’re under from the pandemic. Here is what two of them – Konnie Martin, chief executive officer at San Luis Valley Health in Alamosa, Colorado, and Dr. Jennifer Bacani McKenney, who practices family medicine in Fredonia, Kansas – are facing. Their experiences reflect what others are going through and how rural communities are innovating under extraordinary pressure.
I’ll let them explain in their own words.
COVID-19 fatigue is real. It’s wearing on people. Everyone wishes we were past this. I read the other day about health care workers being the “keeper of fears.” During COVID-19, patients have disproportionately placed their fears on clinicians, many of whom experience the same fears themselves. I focus on building resilience, but it’s hard.
My hospital currently has seven patients with COVID-19 and can make room for as many as 12. Back in the spring, we converted a visiting specialist center into a temporary respiratory clinic to keep potentially infectious patients separate and reduce pressure on our emergency department.
It’s all about making sure we have enough staff and hospital capacity.
There isn’t any hospital that isn’t under siege, which means that getting patients to the right level of care can be a challenge. In the past few days, we have accepted three transfers from facilities that are on the front range. We’ve never had to do this before. With six ICU beds and 10 ventilators, we are trying to help others.
Influenza hasn’t arrived yet in our community, and I worry about when it comes. We have nearly 40 staff out right now on isolation or quarantine, a staggering number for a small facility. We are having to shift staffing coverage in half-day increments to keep up.
We are not at a point where we are even contemplating bringing COVID-19-positive staff back to work, like the governor of North Dakota suggested. I hope we never get there. We are, however, considering high-risk versus low-risk exposures. If a clinician is exposed to COVID-19 during an aerosolizing medical procedure, that’s high risk. If a clinician is exposed in a classroom of 50 people who were all socially distanced and wearing masks, that’s low risk. If we face critical workforce needs, we may bring back health care workers that have had low-risk exposures.
We have gained a lot of knowledge this year, and we all feel wiser now, but definitely older, too.
We chose to live in a rural community because we look out for one another. Our one grocery store will deliver to your home. Our sheriff’s department will drive medications outside of city limits. If we could return to our rural values of caring for and protecting one another we would be in a better position. Somewhere along the way, these values took a back seat to politics and fear.
Wilson County, where I practice in Southeast Kansas, didn’t see its first COVID-19 case until April 15. By August, you could still count the number of cases on two hands. But by mid-November, the total was over 215 cases in a county with a population of about 8,500 – meaning about one out of every 40 residents has been infected.
Our 25-bed critical-access hospital doesn’t have dedicated ICU beds, and it has only two ventilators. Emergency department calls are split among the five physicians in Fredonia. In addition to dealing with COVID-19 cases, we’re managing every other illness and injury that walks through the door, including strokes, heart attacks, traumatic injuries and rattlesnake bites.
We have sectioned off a hallway of rooms for suspected COVID-19 cases. Without an ICU, however, we have to rely on other hospitals. Recently, my partner had to transfer a patient who had a gastrointestinal bleed. She had to call 11 different hospitals to find one that could take the patient.
I feel lucky to have on-site testing in the hospital lab. But like many of my rural peers, getting enough face masks and other personal protective equipment early on was tough.
The community is tired, frustrated and stubborn. Politicians talk about relying on personal responsibility to end the pandemic, but I don’t see a majority of people wearing masks in public spaces despite pleas from health professionals. Some people are scared. Others act as if COVID-19 doesn’t exist.
Politics is making things harder. I have been Wilson County’s health officer for the past eight years. This year, county commissioners gained more control over COVID-19 health decisions.
When I proposed a mask mandate early in the pandemic, one county commissioner argued it would violate his rights. Another commissioner balked at one of my reports, saying I had no right to tell schools how to evaluate kids before they can return to sports, despite the health risks.
I recently proposed a new mask mandate given our rising numbers. I explained that masks would not only save lives, they would help businesses stay open and keep employees at work. The commissioners voted it down 3-0.
We live in an interconnected world where commerce and people cross state and national borders, and with that comes the risk of new diseases. America will face another pandemic in the future.
Rural health care delivery systems can leverage lessons from COVID-19 to prepare. Among other things, their emergency preparedness “tabletop exercises” can include planning for infectious disease outbreaks, in addition to fire and floods; mass casualty incidents; and chemical spills.
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They can permanently diversify supply chain options from other industries, such as construction and agriculture, to help ensure access to needed supplies. To avoid staff and supply shortages, they can create regional rural health care networks for swapping staff, conducting testing and acquiring supplies.
Meanwhile, rural doctors and health care administrators are being as flexible and resourceful as they can in the face of adversity.
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We’re building a vaccine corps of medical and nursing students – they could transform how we reach underserved areas

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Chancellor and Professor of Population & Quantitative Health Sciences and Medicine, University of Massachusetts Medical School
Michael F. Collins does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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The U.S. faces one of the most consequential public health campaigns in history right now: to vaccinate the population against COVID-19 and, especially, to get shots into the arms of people who cannot easily navigate getting vaccinated on their own.
Time is of the essence. As new, potentially more dangerous variants of this coronavirus spread to new regions, widespread vaccination is one of the most powerful and effective ways to slow, if not stop, the virus’s spread.
Mobilizing large “vaccine corps” could help to meet this urgent need.
We’re testing that concept right now at the University of Massachusetts Medical School, where I am the chancellor. So far, 500 of our students and hundreds of community members have volunteered for vaccine corps roles. Our graduate nursing and medical students, under the direction of local public health leaders, have already been vaccinating first responders and vulnerable populations, demonstrating that a vaccine corps can be a force multiplier for resource-strained departments of public health.
On Feb. 16, we will help to launch a large-scale vaccination site in Worcester, where as many as 2,000 people could be inoculated per day.
Importantly, a large vaccination corps that includes local medical and public health students could help reach residents who might be missed by public campaigns and hospital outreach efforts. Students often represent their region’s races, ethnicities and backgrounds, which can make it easier for them to connect with communities that are hard to reach and might not trust vaccination.
The problem of getting people vaccinated quickly isn’t just about supply – it’s also about having enough people to carry out vaccinations, particularly in hard-to-reach communities.
If quickly mobilized on a large scale, a vaccine corps could directly meet three important challenges: accelerating the nationwide rollout of COVID-19 vaccines, ensuring that doses are distributed equitably to all and delivering on the promise that all Americans are able to benefit from major medical and public health advances.
Medical, nursing, pharmacy and other health students, as well as retired or unemployed clinicians, could deliver shots, monitor people who were just vaccinated or schedule the second doses that are required for the Pfizer and Moderna vaccines to be fully effective.
In particular, a large, well-organized vaccine corps could play a crucial role in reaching out to communities that are underserved, overlooked or hard to reach.
Corps members could staff phone banks to help people who lack internet or struggle to use online scheduling systems find vaccines in their areas and make appointments.
Our students in the vaccine corps have already helped administer vaccines in public housing complexes and homeless and domestic violence shelters. They could also provide transportation to vaccination sites or take doses directly to homebound elders who cannot safely venture out. In Alaska, for example, vaccine providers have been going out by plane and sled to remote villages to reach thousands of residents.
Members of a vaccination corps who share race or ethnicity with the community can also have an impact on overcoming people’s concerns about getting the vaccine. That’s important.
A poll released Feb. 10, conducted by the Associated Press and NORC Center for Public Affairs Research, found that only 57% of Black U.S. residents said they would definitely or probably get the COVID-19 vaccine, compared to 65% of Americans who identified as Hispanic and 68% as white. Fewer than half of Black Americans surveyed in a separate Kaiser Family Foundation poll in late January believed the needs of Black people were being taken into account.
Rural areas face similar concerns, as well as the geographical challenges of reaching people in remote areas. The Kaiser Family Foundation has found that people who live in rural areas are “among the most vaccine hesitant groups.” In mid-January, it found that 29% of rural Americans surveyed either definitely did not want to get the vaccine or said they would do so only if required.
If we extrapolate these vaccine hesitancy survey results, suggesting that as many as three or four out of every 10 Americans may avoid inoculation, public health officials’ hopes of reaching herd immunity will be in jeopardy.
The U.S. has a long history of creating health corps. After the Sept. 11 attacks, the federal government launched the volunteer Medical Reserve Corps to mobilize current and former medical professionals and others with needed health skills during emergencies. Several Medical Reserve Corps units around the country are now assisting vaccination efforts.
This concept could be expanded, including by partnering with universities, to have wider, game-changing reach. The model of service our students are testing opens up many possibilities, limited only by a lack of will and imagination.
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The US government’s $44 million vaccine rollout website was a predictable mess – here’s how to fix the broken process behind it

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Associate Professor of Operations Management & Business Analytics, Johns Hopkins Carey Business School, Johns Hopkins University School of Nursing
Tinglong Dai does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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The COVID-19 vaccine rollout has been a nightmare for many Americans as they struggle through multi-step registration and appointment systems.
The federal government had envisioned states using one national vaccine scheduling system, and it offered a contractor US$44 million to develop it. But that system turned out to be so poorly designed that all but nine states opted out before even trying to adopt it, even though it was being offered by the government for free.
The few states that do use the Vaccine Administration Management System, or VAMS, have reported random appointment cancellations and unreliable registrations. Some vaccinators have had to resort to creating records on paper because of system glitches, slowing down the pace of getting shots into people’s arms.
As troubled as the VAMS website may be, it is also a predictable result. We’ve seen this movie before.
HealthCare.gov, the federal healthcare exchange website that was launched to implement the Affordable Care Act, also known as Obamacare, cost taxpayers nearly $1 billion. When HealthCare.gov was launched on Oct. 1, 2013, only six people were able to sign up for health care on the first day. The Obama administration ended up having to enlist a team of engineers from Google, Amazon and Facebook to fix it.
The U.S. is among the most technologically advanced nations in the world, with some of the most powerful technology giants and the largest talent pool. So, why has the federal government repeatedly failed to deliver a functioning website essential to public health?
As an expert in health care operations management and contracting, I believe the complex federal contracting process bears much of the blame. The Biden administration has the power to fix it.
The U.S. government is the largest buyer on Earth. It spends more than half a trillion dollars a year procuring a wide range of goods and services from the private sector.
While private buyers may have their own rules governing purchasing, the U.S. government has to follow a set of procurement regulations. These regulations are known as the Federal Acquisition Regulations, or FAR, and they have been in place since 1983. The rules dictate all aspects of the federal purchasing process, including the contracting process for building websites such as HealthCare.gov and VAMS.
The Federal Acquisition Regulations were created to uphold the federal government and taxpayers’ interests through a uniform set of rules. Despite its good intention, this process has three key problems.
First, with thousands of clauses that are difficult to navigate, the Federal Acquisition Regulations have created a complicated and time-consuming contracting process, and many of those clauses are nearly impossible to implement in practice. That restricts the government to using a small group of vendors who are experienced in the game of contracting but are not necessarily the best choices for delivering products.
When the government announced the HealthCare.gov project, the tech giants that were eventually called in to fix it did not even participate in the bidding process, because the process favors past vendors such as CGI Federal, which specialized in federal contracting.
Second, in many cases, the complicated nature of the rules enables vendors to be selected without competition. In choosing a vendor for developing VAMS, the Centers for Disease Control and Prevention determined that Deloitte was the only contractor that met the project requirements. The reason: The CDC believed VAMS required GovConnect, which is Deloitte’s propriety platform. The GovConnect platform was launched in June 2020 and has had some problems. It is not clear why a vaccine rollout platform had to be built on GovConnect.
Third, the contracting process discourages communications and interactions between vendors and contracting officers. For websites like HealthCare.gov and VAMS that have many stakeholders, the needs of those stakeholders typically evolve during the development process. Companies such as Google, Amazon and Facebook use an “agile” method designed for changes during development. The current federal acquisition process naturally supports a traditional “waterfall” model that largely specifies all requirements at the beginning and allows little room for change.
How can the federal contracting process be fixed? Repealing the Federal Acquisition Regulations would likely cause chaos, but fixing it is doable. The executive branch of the U.S. government can modify the Federal Acquisition Regulations on its own, so it is up to the Biden administration to make changes.
Next, the federal contracting process must value results, not only the process itself or the vendors’ history of winning federal contracts. Deloitte and CGI Federal both continue to win federal contracts worth billions of dollars despite past failures.
VAMS has sparked far less public outcry than HealthCare.gov, but its failure is no less consequential, because a rapid vaccine rollout is the key to ending the ongoing COVID-19 pandemic. Deloitte spokesman Austin Price told Bloomberg News the company “continues to enhance the system based on feedback and priorities of VAMS users.”
The Obama administration started some reforms of the federal contracting system, particularly moving it away from the “waterfall” approach to allow more changes during development. The Biden administration could continue that work as it rethinks the tangle of federal contracting rules.
Unless it fixes the outdated federal contracting process, the U.S. will almost certainly repeat the same disaster again and again.
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How can I get the COVID-19 vaccine? Here’s what you need to know and which state strategies are working

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Associate Dean for Clinical Affairs, University of Southern California
Steven W. Chen receives funding from the Los Angeles County Department of Public Health in partnership with the Centers for Disease Control and Prevention 1817 Wellness Grant.

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For many people, trying to get the COVID-19 vaccine has been a lesson in frustration. The vaccine supply is limited in many areas, creating confusion over who can get a first and sometimes second dose of vaccine. Even when given the green light because of their age or occupation, many Americans have no idea how to go about getting vaccinated.
Nationwide, 6 in 10 older adults reported in a recent survey that they didn’t have enough information to know when or where they could get the vaccine. Those that do locate appointment systems are often finding them hard to use, and some have faced cancellations.
The Biden administration has promised to help alleviate some of the underlying problems, particularly vaccine shortages in some areas and inconsistent deliveries that have upended appointment scheduling. But the federal government doesn’t control the vaccination process within states or communication about it, and many states have pushed those decisions to understaffed counties. Currently, fewer than two-thirds of all vaccine doses distributed to the states have been administered, suggesting the problems go beyond supply shortages.
Some states are doing better than others, and they can offer lessons for the rest. And another Biden administration proposal could also soon connect more people with the vaccine and improve communication: activating more pharmacies to help.
As a pharmacy professor, I have been following developments in the U.S. vaccination effort. Here’s what you need to know.
Unfortunately, there isn’t one satisfying answer to this question right now. The federal government recommended priorities based primarily on age, preexisting health conditions and jobs that create a greater risk of exposure, like medical personnel. But states are following through in different ways.
To find your state’s information, you can check the Centers for Disease Control and Prevention’s list of state links. Or enter the name of your state and “COVID vaccine” in your favorite search engine to find out whether your state has a centralized process or whether each county or city maintains its own priority system.
States that centralize their COVID-19 vaccination procedures generally match registrants with available vaccine providers, as New Mexico and California do. If your state does not centralize vaccination procedures, you’ll need to look up the details for your county or city. Even within the same state, who is allowed to receive vaccinations and how to get one can vary widely.
A few states that have done well with vaccinations can offer lessons for the rest.
West Virginia vaccinated all of its long-term care residents and staff who wanted the vaccine within three weeks and started on second doses before other states had finished the first round. It had been the only state to opt out of the federal vaccination partnership with CVS and Walgreens for long-term care residents, instead relying primarily on a network of independent pharmacies.
The state also centralized vaccine decisions, coordination and registration at the state level rather than having West Virginia counties and localities come up with their own rules and processes. This eliminated a lot of the confusing messages and conflicting priority lists. Not everything was perfect. There were still problems with canceled appointments, particularly for groups using a troubled new appointment management system created for the CDC called the Vaccine Administration Management System.

North Dakota, which has had one of the highest COVID-19 case rates in the nation, expanded its priority list early to include anyone 65 and older, as well as adults with at least two high-risk medical conditions and front-line school or child care workers. It maintained its own warehouse to store and manage vaccine supplies, which allowed it to more easily send vaccine to providers across the state instead of only hospitals and health systems, as most other states were doing. It also deployed independent pharmacies to vaccinate people in long-term care facilities.
New Mexico credits its success in large part to a website that matches registrants with providers who have available vaccine and arranges appointments accordingly.
These three states have small populations, making the logistics somewhat simpler than in more populous states, but their approaches to vaccinating residents have worked.
Looking outside the U.S., Israel leads the world by far in vaccination rates, having vaccinated over half of its 9 million citizens. A strong public health system that treated vaccination efforts as a national security issue was key. Early preparation including aggressive acquisition of vaccines and allowing anyone over 60 to be vaccinated were also important strategies.
In many states, local pharmacies remain an untapped community resource for vaccination information.
With about 67,000 sites across the U.S., community pharmacies are highly accessible and experienced at administering vaccines due to their long history of providing vaccinations for flu and other preventable illnesses.
They also have established relationships with the communities they serve, often with staff who reflect the community’s ethnicities. This is critically important for improving the low vaccination rates among minorities.
And they have had continuing contact with people during the pandemic. Many patients have been unable or unwilling to see their medical providers as often during the pandemic, but they still pick up their medications and interact with their pharmacies.
States and counties can leverage this relationship to reach patients with information about when and how they can be vaccinated. Pharmacists have access to older and underserved patients who may have difficulty accessing and navigating websites. They can also help address questions about the vaccines from people who may be concerned after hearing rumors and misinformation. If people aren’t getting vaccinated, that could put herd immunity and a return to normal in jeopardy.
Vaccination is critical to slow the spread of new and more contagious virus variants and hopefully prevent the development of vaccine-resistant mutations. The president’s plan includes securing enough Pfizer and Moderna vaccines for everyone in the U.S. to receive both doses by the end of summer, provided the doses are distributed effectively.
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