Health Centers on the Frontlines: Mary's Center on Virtual Enabling Services, Internal Communication, and Finances during COVID-19

At Mary’s Center, a large Washington, DC and Maryland-based community health center with five clinical sites, two senior service centers, and 23 school-based mental health sites in partnership with DC public schools, Seiji Hayashi, MD, MPH, Chief Transformation Officer, is taking it one day at a time. As COVID-19 and the accompanying economic crisis -- resulting in a national trend of fewer primary care visits and a swift end to face-to-face outreach -- has shaken health centers’ funding streams and business models, many health centers have been forced to lay off staff, especially in the enabling services, but not Mary’s Center.  “We have maintained our entire workforce -- for now,” he tensely noted. “It’s super, super challenging.” 

The roughly 700 people on Mary’s Center staff, like the rest of the country, quickly migrated to online platforms to provide televideo and televoice appointments at the start of the pandemic. Three clinics remain open for in-person care, one in Washington, DC and two in Maryland; for those clinics, patients are screened at the door for respiratory symptoms and fever, and those with symptoms are sent to a separate section of the clinic. “We are doing a rotation with one week in the regular clinic -- no respiratory patients -- [followed by] one week in the respiratory clinic, and four weeks virtual,” Dr. Hayashi explained. “This allows our staff to recover from the high-risk environment in the respiratory clinic and ensure that they have not been infected.”

About 85 to 90 percent of Mary’s Center services are now provided virtually.  “It took about a week, maybe two, to try to get the workflows ironed out -- it was crazy,” he admitted during a recent lunch break. “Seven hundred people, trying to align shifts, and who does registration, and virtual nurses and MAs doing intake, on the phone and video.” All enabling services are now virtual, with a virtual warm handoff to behavioral health, social services, and nutrition services.

The staff use Microsoft Teams for interstaff communication and check-ins. While they initially used Zoom for patient contact, they quickly found it didn’t work well for many of their patients. “We’ve been doing... telehealth for about three years using Zoom. Our telehealth program had an MA go to the patient’s house, connect to the computer, use an electronic stethoscope [and other tools] so you can do almost anything you could do in the clinic,” Dr. Hayashi noted. As the pandemic hit, Mary’s Center suspended the program to protect the health of the MA. Without the staff member to assist in establishing the initial internet connection, patients struggled to download the Zoom app and to open the link to start the telehealth session. Despite years of experience in telehealth, the group found themselves starting from scratch: looking for a program that would be easier for patients to use. They settled on Doxy, a video platform designed for telemedicine. The scramble to develop working systems has proven largely successful, Dr. Hayashi claims, and he credits the clinicians.

“Our clinicians have been wonderful. Everybody has stepped up,” Dr. Hayashi said. Even as new systems have rolled out and been adjusted, the pace continues to be fast, and the work is shifting day to day. The medical directors of each center are meeting nightly at 8:30pm, “because there’s no time during the day,” to review the day and plan for the following day, he said. For all staff, the learning curve of new systems and processes is overlayed by the stress and fear of exposure when working with patients in-person. Many clinicians, Dr. Hayashi notes, have young families, and are additionally juggling family needs and home stress. Dr. Hayashi, because of his work with COVID-19-positive patients, has himself been self-quarantining in his basement for several weeks -- he understands and shares the tremendous stress and fear that Mary’s Center clinicians are battling. It’s the same stress and fear that patients are also experiencing.

Dr. Hayashi recognizes the health center’s critical role in serving a low-income, primarily immigrant population that, before the pandemic, already struggled to access sufficient care and had fear over accessing health services. “Our patients, we know, are less likely to call for help, less likely to go to the hospital, to engage in the health care system if our health center isn’t open -- and that could lead to people dying,” he said. The health center’s role, at this time, is to serve as many people as possible to ensure that the emergency services aren’t overwhelmed. “If we acted like a private practice that shut their doors and did everything virtually, that means the burden shifts to ambulance drivers and emergency services,” Dr. Hayashi asserted.

Dr. Hayashi admits that Mary’s Center is in a unique position to maintain full staffing, in part because Washington, DC has permitted health centers to bill at the full rate for tele-video and tele-voice services. Many other places have not extended the same reimbursement options, and will not reimburse wraparound services provided virtually, which puts health centers in a financial bind. But, he says, enabling services are more essential than ever.

“People are losing their jobs, and they don’t know how to navigate these systems,” to get the social and health services they need, he said. Dr. Hayashi anticipates a higher demand for behavioral health services, in particular: “We are beginning to see regular patients who have mental health issues and needed care, that, now, because of the stress, are needing more care.”  And, the demand for the virtual services, including for enabling services remains high: “Our schedules are packed,” he said, with virtual care providers seeing three to four patients or more per hour.

Day to day, Mary’s Center’s primary focus continues to be on boosting clinician well-being in part by promoting and delivering open communication about the difficult and rapidly changing times. “Our CEO holds an all-hands townhall meeting every Tuesday during lunch, to update everybody on what’s going on,” he said. Even with the recently announced injection of funds from HRSA and the payments for virtual services, the health center will have lost a significant number of encounters that they may never be able to recapture, he said, complicating the financial picture for months to come. The CEO is upfront about the tenuous financial position that the health center will be in for months to come, Dr. Hayashi said. “She’s completely honest that the financial issues are real: How do we sustain our operations?” 

On top of financial strain is the possibility of infection. Several staff members have tested positive to COVID-19. “Everybody is scared, and it’s so important to communicate well, tell everybody what’s going on,” he continued. He asserts that, in such times of disaster and heightened stress, the message needs to be clear -- and deeply rooted in the health center mission.

“It’s not just about individual patients. When we think about disasters in the past -- Hurricane Katrina, fires, earthquakes -- health centers are always there to make sure the most vulnerable people are cared for,” Dr. Hayashi said. “Sending that message to staff and reminding them really helps our staff get refocused, aligned, and energized to do the work that needs to get done.” 

“It’s about communication and transparency,” Dr. Hayashi added. “We’ve done a good job of that. When it’s chaotic, it’s hard for people to hear the messages. Speaking in one voice is important.”

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