By Carter Wilson, Associate Director for the National Center, and Rebecca Koppel, Program Manager for Field Building & Resources

Individuals with complex health and social needs are particularly vulnerable during a pandemic like COVID-19. Many have compromised immune systems, crowded living conditions, and jobs that either require them to work out of the home or are early losses in the economic downturn. In the current epidemic, programs that serve these individuals have had to rapidly adapt their operations to meet the growing and changing needs of this population. A redesign of services is required to address the emerging needs that the pandemic has indirectly created. Existing operations needed to quickly pivot to dramatically reduce in-person interactions. And new collaborations are necessary to inform, support, and deliver these interventions.

Last year, the National Center launched a working group of 15 individuals tasked with defining the front-line competencies for the field of complex care. The group was diverse in profession, care setting, and geography, but all were actively working in programs supporting individuals with complex health and social needs. The National Center interviewed members of the core competency working group to learn the challenges they were seeing and how they were overcoming them. The result is a series of blog posts highlighting their stories. Parts two and three coming soon.

• Innovating and adapting to new services, populations, and opportunities
• Switching to virtual care delivery
• Finding and leveraging partnerships

Ensuring that the right quantity and combination of services are available to meet a community’s needs is always a challenge in complex care. When the pandemic hit, within a matter of days or weeks, needs in certain areas spiked, availability of many workflows and resources dropped, and the regulations and funds required began rapidly evolving. The providers we spoke to had to shift quickly to ensure they could provide the right care at the right time to those who needed it most.

Innovation opportunities and limitations in a Massachusetts community health center

Scune Carrington is the Director of Integrated Care at the Massachusetts League of Community Health Centers (the League), a statewide association that provides a wide range of technical assistance to its 52 community health center members. Scune’s role is to support health center clinical teams focused on integrating behavioral health and dental services into patients’ overall primary care. When the COVID-19 crisis hit, and resulting state directives either shut down or placed significant limitations on in-person care, community health centers were forced to drastically alter their operations. This included the rapid launch of telehealth services to ensure care continuity for their patients and to stem their massive revenue losses as a result of reduced patient visits. 

The League has well-established relationships with the state agencies that were instrumental in helping health centers make a largely smooth transition to telehealth. In particular, the state’s Medicaid agency, MassHealth, moved quickly to allow reimbursement of telehealth, including telephone-only appointments — a critically important component for serving the lower-income, under-resourced patients seen at health centers. At the federal level, reimbursement and regulatory obstacles were largely addressed through the Centers for Medicare & Medicaid Services, the Federal Communications Commission, and the US Congress, ultimately paving the way for federally-funded health centers to begin delivering care through the telehealth modality.  

The benefit of this new flexibility in services was greatest in behavioral health. The Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed some of their requirements, including newly allowing take-home methadone prescriptions for up to a month’s supply. Demand for behavioral health tele-appointments increased, no-show rates decreased, and the offering helped to address a significant  revenue spiral for the state’s community health centers.

Scune and the League’s clinical team are now focused on supporting a range of workforce issues, including worker burnout and ensuring that health centers have sufficient staff capacity for conducting ongoing COVID-19 testing and community tracing while also reinstating more in-person services as part of the Commonwealth’s reopening plan. 

This increase in service opportunity was not seen in dental care. Given the prevalence of aerosols and their risk of coronavirus transmission, paired with a shortage of personal protective equipment, routine dentistry halted. Private dental offices were closed, increasing the demand for emergency services at the state’s community health centers. In response, the health centers are beginning to incorporate telehealth services into the dental care they provide and, in addition, to reassess their overall clinical operations with the goal of improving health access and health outcomes in the communities they serve.

Maine social service agency looking to the future

Maine’s York County Community Action Corporation (YCCAC) is a rare pairing of a Community Action Agency and Federally Qualified Health Center. Their Executive Director, Barbara Crider, is navigating a dramatic decrease in revenue-generating visits to their clinic, operational limitations that threaten existing offerings, and a shifting of community needs. YCCAC has had some clear wins, including increased cooperation within their agency that resulted in bus drivers delivering food and medications with support from the Federal Transit Administration.

Other programs have struggled. The Head Start initiative that provides free high-quality, early childhood education and child care for income-qualified families was a high-cost program pre-COVID. It has moved to a telephonic model that YCCAC won’t know the effectiveness of for some time. When in-person offerings do return, class size will be reduced and social distancing measures will require increased space. Barbara worries that the investment will no longer be justified.

As Barbara and her team make the transition “from the sprint to the marathon,” she is asking herself, “What is the economy going to call us out to provide?” For the foreseeable future, this will be basic needs: food, housing, utilities. Employment services, including job training programs, are meaningless if there aren’t jobs to be had. However, these employment offerings will become essential and will need to be reimagined. As the economy recovers and a new model emerges, one that has learned the power of technology, service jobs may not return to pre-COVID levels. How can agencies like YCCAC prepare this workforce to meet an expected exponential growth in the use of technology?

As has always been the case for social service agencies, innovations and offerings will need to be developed at the community level. Meeting the needs of her community will require increased flexible funding streams, like the Community Service Block grants from the Office of Economic Opportunity, that allow communities to meet their local needs. For her own community, Barbara and her team are still in the early days of reimagining. “[We are] meeting and talking and thinking and reading and changing our minds in that cycle several times a week.”