COVID-19

3 Years, 39 Months, 1,196 Days, 28,703 Hours. That’s how long the COVID-19 Public Health Emergency (PHE) has been in effect. Can you believe it? Over three years ago today the initial COVID-19 PHE provided the first of many flexibilities to health centers to boost their response on the front lines of a new global pandemic. Under both the Trump and Biden Administration, the PHE has been extended 12 times. Today, the running streak of the PHE officially ends (May 11, 2023), due to the Biden Administration concluding the PHE at 11:59 PM.

The Path to the End: How Did We Get Here?

The COVID-19 Public Health Emergency was first declared by the U.S. Department of Health and Human Services (HHS) on January 31, 2020. The declaration allowed the HHS Secretary of to provide flexibility to state and local health departments in their pandemic response.

As the COVID-19 virus continued to spread, then President Donald Trump declared the COVID-19 National Emergency on March 31, 2020. The move directed the HHS Secretary to temporarily waive or modify requirements related to Medicare, Medicaid, and State Children’s Health Insurance Programs (CHIP) and HIPPA. Under the authority of the National Emergency, HHS issued blanket waivers for federal Medicaid & Medicare requirements with a particular focus on:

Waiving certain Medicare provider enrollment requirements.
Waiving requirements for in-person meetings between providers and patients.
Waiving requirements for out-of-state Medicare and Medicaid providers to be licensed in the state where they were providing services.

States were also allowed to request time-limited flexibility for their Medicaid and CHIP programs through 1135 Waivers. Many 1135 waivers will terminate at the end of the COVID-19 PHE. To find your state specific waivers please visit the following link.

What Will Happen to the Flexibilities Provided to Health Centers?

Telehealth: Throughout the pandemic, health center Medicare patients were able to access telehealth services in any geographic area in the United States. The pandemic policy flexibilities allowed patients with Medicare to stay in their homes for telehealth visits, rather than traveling to a health care facility. These pandemic flexibilities have been extended through December 31, 2024. For patients with Medicaid or CHIP, coverage will vary by state. The Centers for Medicare and Medicaid Services (CMS) encourages states to continue to cover Medicaid and CHIP services when they are delivered via telehealth. Lastly, telehealth coverage for patients with private health insurance will vary depending upon their plan specific details after the end of the PHE. When covered, private insurance may impose cost-sharing, prior authorization, or other forms of medical management on telehealth and other remote care services.

Behavioral Health Visits: Health centers can provide virtual mental health services to patients and receive their prospective payment system (PPS) encounter rate, without any geographic requirements for the patient or provider. This includes visits furnished using interactive, real-time telecommunications and audio-only technology. Starting in 2025, Medicare will require health centers to have an initial in-person visit within six months of a telehealth encounter and a 12-month subsequent in-person visit following the telehealth encounter, at the provider’s discretion.

Health centers were able to provide COVID-19-related services to non-established patients and were still covered for malpractice liability under the FTCA. This flexibility allowed health center employees to provide services in response to COVID-19 to both established and non-established patients of the health center, whether at the health center, or offsite, and whether in person or through telehealth. At the conclusion of the COVID-19 PHE (May 11, 2023) there is no clear end date for this flexibility.

Workforce Flexibilities: Health Centers had the ability to add temporary sites in response to the COVID-19 PHE. Additionally, the National Health Service Corps (NHSC) also provided flexibility for provider participants. Throughout the pandemic, the NHSC provided the following flexibility to participants:

Waiving the requirement of not being away from an approved service site for more than the allotted seven weeks per service year.
- Providing flexibility due to unemployment as a direct result of the COVID-19 outbreak.
- Allowing employer-directed care outside of an NHSC-approved health care facility.

When the PHE ends today both the temporary site location and NHSC flexibilities will conclude.

Administering the COVID-19 Vaccine: HHS amended the Public Readiness and Emergency Preparedness (PREP) Act to expand who could order and administer the COVID-19 vaccine. Dentists, Pharmacists, Midwives, Paramedics, EMTs, Physician Assistants, Respiratory Therapists, Podiatrists, Optometrists, and Veterinarians have been able to provide COVID-19 vaccines.

HHS Amended the PREP Act again last month to extend pharmacists, pharmacy interns, and pharmacy technicians’ ability to administer the COVID-19 vaccine and be protected from liability under the PREP Act through December 2024. These protections were extended regardless of whether vaccines are available on the commercial market or under emergency use authorization. The above groups will continue to be protected from liability claims as they administer COVID-19 and flu vaccines and tests to people ages 3 and older, consistent with other requirements, even after the public health emergency ends on May 11. Non-traditional vaccinators, like students and recently retired providers, will no longer be covered once the vaccines hit the commercial market.

NACHC Resources to Help Navigate a Post PHE Environment:

Health Center COVID-19 Flexibilities Tracker: To assist PCAs in tracking pandemic-related flexibilities, NACHC has developed a tracking document that breaks down all flexibilities that were provided to health centers throughout the pandemic. View the COVID-19 Flexibilities Tracker.

COVID-19 Vaccines, Testing, & Treatment: Curious about whether payers (private and public) will cover COVID-19 related services? NACHC’s blog post breaks down specifics into coverage for each payer group after the PHE. Additionally, CMS put out two fact sheets for patients to better understand how their coverage may change after today. Follow these links for the English and Spanish version of the factsheets.

Medicaid Redetermination Listening Sessions: NACHC continues to host monthly listening sessions on Medicaid redeterminations. We encourage PCA and health center staff to register, attend and share your insights on redeterminations in your state. We also use an online information hub, Noddlepod, to share the most recent information related to Medicaid redeterminations. To stay up to date, sign up for Noddlepod access here. As always, if you have feedback on topics to address in the next listening session, please email federalpolicy@nachc.org.

The White House recently unveiled a COVID-19 Winter Preparedness Plan to make vaccinations, testing and treatment even more widely available as cases surge. One feature of their plan jumpstarts a partnership with the U.S. Postal Service to mail free at-home COVID tests to households. The plan also calls for “additional resources to Community Health Centers and aging and disability networks to support COVID-19 vaccination efforts.”

Activities include building vaccine trust and vaccine adherence

The Biden Administration is concerned about a notable rise in COVID, flu and respiratory infections as winter sets in. The announcement comes on the heels of $350 million in one-time funding to health centers to boost COVID-19 vaccinations in their communities, with a specific focus on underserved populations. Health centers can use the funds to expand:

outreach and education
community engagement
coordinated events to increase COVID-19 vaccinations through mobile, drive-up, walk-up, or community-based vaccination events, including working with community and faith-based organizations

The funding will support vaccine administration of the updated COVID-19 vaccine, the COVID-19 primary series and/or other (e.g., influenza) vaccines. The expanded COVID funding allows health centers to continue efforts to form new or strengthen current on-the-ground partnerships with other entities to build vaccine trust and vaccine adherence. It is this particular aspect of health centers’ work that strengthens the public health infrastructure — filling health gaps, meeting people where they are and bringing preventive services to them.

View NACHC’s one-pager on this new COVID-19 funding

Deadline for health centers to submit information

Health centers have until Sunday, January 8, 2023, to submit information about planned activities and costs that the funding will support. There’s a technical assistance webpage for award submission guidance.

Health centers have played a pivotal role in fighting COVID-19 since the beginning of the pandemic. They have provided services to the nation’s most at-risk, medically underserved communities, administering more than 22 million vaccines, of which 70 percent have gone to patients who are racial and ethnic minorities.

Erica Weiss is the Senior Writer for NACHC’s Clinical Affairs Division.

Health centers have been seeing patients with long COVID symptoms, but they haven’t gotten strong guidance or resources to manage this condition. To start, we should define “Long COVID”:

Long COVID, or Post-Covid Conditions as defined by the Centers for Disease Control and Prevention (CDC), includes the wide range of cognitive and physical conditions present four (4) or more weeks after a COVID infection. The World Health Organization (WHO) considers symptoms that last longer than 12 weeks to be Long COVID (or post-acute sequelae of SARS-CoV-2 (PASC).

Whichever timeframe you pick, more patients than we realize are experiencing debilitating Long COVID symptoms after a severe, mild, or asymptomatic acute infection – and health centers, have found themselves caring for a large number of cases.

Community Health Center patients disproportionately represent essential workers and people who have been heavily impacted by COVID-19. Health center patients in NACHC’s large (>1 million patients) sample, had a positivity rate for COVID that was 16.7%. This rate is far higher than the national average. More COVID = More post-COVID syndromes.

With federal COVID insurance ending, uninsured health center patients no longer have access to care outside health centers, meaning they generally can’t access specialists and allied health professionals necessary for post-COVID care. Health center patients without insurance represent, on average, 25% of patients.

The scope of the Long COVID problem

It’s been a real challenge for health center care teams (all providers, really) to recognize post-COVID symptoms since conditions like fatigue or sleep disturbance are also common with aging, disabilities, or other illnesses.

The good news is that Long COVID symptoms are often treatable if providers make a conscious effort to ask patients if/when they had COVID-19 when they come with new, returning, or ongoing physical or cognitive symptoms. It also helps to tell patients with an acute COVID infection that they should come back for care if a symptom persists.

The CDC estimates 1 in 5 adults (1 in 4 older adults) who had COVID-19– at least 6 million people in the U.S. – report Long COVID symptoms. Women are more likely to experience symptoms, as are people with disabilities.

The most common post COVID symptoms are fatigue, sleep disturbance, shortness of breath and exercise intolerance, “brain fog”, cough, and chest pain. View a broader list of symptoms from the CDC.

“Designing our health care delivery services with EMPATHY is powerful for patients, especially when there is so much unknown about this condition. There’s a lot of anxiety, fear, anger, jealousy, sadness, and many other emotions we feel as patients,” said Fred Rachman, MD, Chief Executive Officer, AllianceChicago – and a Long COVID patient.

What is NACHC doing about Long COVID?

The National Association of Community Health Centers (NACHC) is advocating intensely to generate resources and clear guidance for health center care teams and patients. NACHC leaders presented at the CHI meeting in August, participate in the Working Group on Health Equity, consult with the White House COVID-19 task force, coordinate with the CDC, and participate in the National COVID Cohort Collaborative (N3C) and the American Academy of Physical Medicine and Rehabilitation (AAPM&R), among others.

Long COVID conditions have an unknown duration and can heavily impact a patient’s wellbeing. Patients experiencing any Long COVID symptoms are at high risk for co-occurring anxiety and depression. Because Long COVID is a new condition with constantly emerging evidence, health center Care Team members need training and resources to recognize symptoms and treat them as high-risk life events that impact physical and mental health.

What can health center care team members do?

If we’re not diagnosing Long COVID at health centers, then we’re probably not asking the right questions. It’s important to:

Inform patients with acute COVID about the potential for long-term symptoms. Ask them to reach out if they experience a symptom that seems like Long COVID.
Ask about symptoms. Recognize a pattern. If a patient comes in with one or two symptoms, especially if they are new to the patient (severe fatigue, physical weakness, brain fog, shortness of breath, cough, exercise intolerance, dizziness, heart palpitations, chronic pain, headaches, chronic tingling, mood disorders, changes in menstrual cycle…)– these signs could be Long COVID
Ask if symptoms began after a COVID infection or the vaccine. And ask how long after.
Avoid unnecessary tests and regularly reevaluate symptoms. Use testing to rule out other medical and mental health causes of symptoms. If there is no clear cause, consider symptoms to be Long COVID. Try to avoid extra, anxiety-provoking tests.
Ask what medications a patient is currently taking, take their medical history, and ask how their symptoms affect their life.
Schedule more touchpoints during the active phase of Long COVID symptoms. Patients benefit from a longitudinal and supportive care relationship.
Treat the symptoms you can treat. Offer supportive treatments and use allied health and behavioral health professionals to support symptom management. New research and guidelines show that there are evidence-based therapies for many Long COVID symptoms.

“Managing Long COVID requires consistent, long-term engagement with patients and continued collaboration with a range of care team specialists,” said Julia Skapik, MD, MPH, FAMIA, Chief Medical Information Officer, NACHC.

Are there Long COVID evidence-based guidelines for care team members?

“There are no universal treatments for Long COVID, so you’ll have to tailor palliative care for each person. Know that while there are a lot of symptoms out there, there are several similar strategies that help treat most cognitive and physical symptoms. The AAPM&R guidelines are helpful.” said Benjamin Abramoff, MD, MS, Asst. Prof. Clinical Psychical Medicine and Rehab., Co-Founder and Co-Director of COVID Recovery Clinic, Dept. of Physical Medicine and Rehab.; Dir. Post-COVID Assessment and Recovery Clinic, Univ. of PA.

AAPM&R offers the following resources based on groupings of the main Long COVID symptoms seen:

Fatigue (train patients in the energy-conserving 4 P’s (Prioritize, Plan, Pace, and Position))
Cognitive symptoms (including Cognitive Behavioral Therapy, compensatory tools, other techniques)
Breathing discomfort (including inhalers, respiratory therapy, physical therapy for structured breathing)

Cardiovascular complications (including pacing and energy conservation tips plus lab and imaging tests)
Autonomic guidance statement (coming soon)

“Expectant management is important. Patients should feel like they have continuity of care, rather than feel pushed from specialist to specialist. Be a point of contact and check in. That alone is therapeutic for patients. Teach patients self-management tools and recognize that their symptoms are interconnected. Most patients ultimately feel better; still, some will have serious health consequences,” said Abramoff.

Because Long COVID is still being studied with evolving definitions and guidance, it’s important for us to stay aware of updates and be clear that millions of people are struggling. Our health centers are, once again, serving on the front line.

NACHC is working hard to collect and clarify guidance for health center staff, and advocate for resources to help. We will continue to provide information as we learn it. NACHC’s COVID-19 Resources for Community Health Centers can be found here: https://www.nachc.org/coronavirus/

Related Long COVID Resources

American Academy of Physical Medicine and Rehabilitation (AAPM&R) Long COVID Consensus Guidelines

Andrea Lyons is Vice President of Marketing and Communications at Neighborhood Family Practice. PHOTO: Neighborhood Family Practice participates in a regional networking meeting. Credit: Consulado de México.

Neighborhood Family Practice (NFP) in Cleveland has a long-standing dedication and commitment to serving the Latinx/Hispanic community. Earlier this year, we decided to deepen that commitment by establishing a program to better serve and engage our Hispanic neighbors. The COVID-19 pandemic helped our staff and leadership realize there was potential to further our outreach through partnerships.

More than 40 years providing care in Cleveland, Ohio

_{Julia de Burgos is one of NFP’s community partners}

NFP started in 1980 as a response to the lack of care options for a high number of residents who lived in poverty on the west side of Cleveland. In 2000, NFP gained official status as a federally qualified health center and has grown to seven locations serving a very diverse mix of residents.

Many of our Hispanic neighbors are from Puerto Rico. However, many come from outside of the country, too, including from El Salvador, Guatemala, Mexico, Dominican Republic, and Costa Rica.

The Hispanic community in NFP’s service area is large and continues to grow. During the 2020 census, there were over 45,000 people who identified as Hispanic. Our patient base is about 30% as well, making us a vital part of the community.

Lessons learned during the COVID-19 pandemic about serving Hispanic community

NFP’s experience during the pandemic made us aware of the need to better serve our Hispanic community and support health, wellness, and a connection to care and access. During the pandemic, we developed a collaborative of numerous Hispanic community leaders, partners, social service, faith-based and education organizations.

We met on an ongoing basis to connect the Hispanic community to accurate health education information on COVID. As a trusted partner, NFP developed in-language educational tools, small business outreach and support (e.g., COVID kits), presentations and much more to support the community.

When the vaccine became available, we worked closely with our partners, as a credible source of information, to help the community access the vaccine. We focused particularly on high-risk and high-need populations in underserved communities in the service area.

Supporting Latinx/Hispanic patients beyond the pandemic crisis

With ongoing support from partners, NFP recognized we needed to further support the Hispanic community. We created the Hispanic Engagement Coordinator position to demonstrate our commitment to serving our neighbors. In developing the position, we kept in mind that our goal is to lift the voices of our patients in a culturally appropriate and relevant manner.

Our Hispanic Engagement Coordinator, Jennifer Castellano, is a new point of contact and a recognized community leader. Partners and residents are confident in reaching out to connect with her. It is important for NFP to provide ongoing support and to offer access to care in a way that respects the culture of each patient.

Gaining an understanding of what Latinx/Hispanic patients need from Neighborhood Family Practice

In the early months after joining NFP, Castellano has focused on learning about the needs of patients the best way we can: by going directly to the source. She is conducting one-on-one listening sessions with staff who work directly with the Hispanic population, as well as shadowing our Spanish-speaking providers. Additionally, we are assessing patient needs from a survey that was conducted in Spanish.

New partnerships with the Latinx/Hispanic community

While NFP established important partnerships with Hispanic organizations during the pandemic, Castellano is now developing new relationships with partners, organizations and businesses serving the Hispanic community to connect them to care.

The goal is to position NFP as a trusted source of health education and information in the community.

How NFP practices cultural competency

“Cultural competency” is a term used frequently in our field. At NFP, we believe that cultural competency is achieved when you engage with communities to hear their voice, listen to their concerns, and support the solutions that they provide. The answers to community-based issues can be found with those who are closest to the problems. The role of NFP is to listen, learn, and lift up community perspectives.

We are fortunate to have a talented team that consists of passionate and engaged staff who talk with the community, know the community, and live in the community.

The Hispanic community appreciates a setting where they see people they can relate to and speak to in a relatable manner. As soon as a patient notices that our teammates speak Spanish, they are comfortable with raising questions and engaging on topics that can lead to breaking down barriers.

Celebrating Hispanic Heritage Month

This year, NFP will celebrate Hispanic Heritage Month with renewed energy. The focus, while on health and well-being, is also a celebration of culture and community. As part of our celebration, we are investing in marketing through La Mega, which is Cleveland’s Hispanic radio station. Key partners include the Spanish American Council, Step Forward, Julia de Burgos, and Esperanza.

Beyond getting people connected to care, this is about engaging the community we serve in the most impactful way.

This summer marked a major milestone in COVID-19 prevention strategies for our youngest pediatric patients. In June, the FDA and CDC approved emergency use authorization (EUA) for Pfizer and Moderna COVID-19 vaccines for children ages six months to five years old. Moderna also received EUA approval for its COVID-19 vaccines for children ages 6 to 11 years old and 12 to 17 years old.

“People who have children in this age group have waited a longtime…Now we have a vaccine for six months and older. It is a time to be hopeful,” said Lisa M. Costello, MD, MPH, FAAP, Associate Professor, Department of Pediatrics, West Virginia University School of Medicine and Immediate Past President, American Academy of Pediatrics, West Virginia Chapter when speaking during a recent NACHC webinar on these new pediatric vaccines. “We want to do what is best to protect your child. Vaccination is our strongest tool.” Dr. Costello added that COVID-19 is now one of the leading causes of death in children.

Watch our webinar: “Educating Nurses and Pediatric Staff About COVID-19 Vaccines”

With these latest pediatric COVID-19 vaccines now available, Dr. Costello recommends that health care providers at health centers review their policies and procedures for administering the new vaccines, carefully read the EUs for each product, and become very familiar with specific differences between the products such as dosing schedules, need for dilution, appropriate age range for different formularies, cleaning, and storage. Given the potential for confusion between the different products for different pediatric age groups, Dr. Costello advises health centers display product wall charts with product and label information and dosing schedules in areas where immunization staff can read and reference them. To learn more about each of the new pediatric vaccine products and key clinical considerations for administration, click on these short videos that feature Dr. Costello’s overview of each one.

Strategies for Effectively Communicating with Parents About COVID-19 Vaccines for their Children

Health center staff care for patients and parents with a range of vaccine confidence, particularly the COVID-19 vaccine. Dr. Costello shared several approaches she finds very helpful in building vaccine confidence, and others she recommends staff to avoid.

Pediatric COVID-19 Resources for Health Care Providers

For health center care teams who want to provide educational resources on the new pediatric vaccines for staff as well as patients, Dr. Costello recommends the following:

HHS We Can Do This is a national initiative which includes a new toolkit for pediatricians and other health care providers to have access to parent education materials on all the pediatric COVID-19 vaccines.

CDC Resources to Promote COVID-19 Vaccines for Children & Teens offers a suite of digital and downloadable resources to help promote COVID-19 vaccination for children and teens.

American Academy of Pediatrics COVID-19 Campaign Toolkit contains articles, videos and social media messages to help families understand the science behind the vaccine and make informed decisions about protecting their children with the COVID-19 vaccine.

In addition, NACHC’s COVID-19 resources web page provides a communication toolkit, webinar recordings that address misinformation, COVID-19 vaccine developments, guidance on talking to parents etc.

As we begin 2022 and enter the third year of the COVID-19 pandemic, care teams are responding to the pandemic amid cases of the new Omicron variant surging, flu cases rising, and millions of people still unvaccinated. Health center teams who may have been stressed, strained, and burned out before, are now experiencing emotional exhaustion. They are also experiencing moral injury and distress. These are emotions and bodily changes that accompany a disconnect between what you believe is right and good, and what you are able to do or what you see happening around you.

Resources Delivered to Your Inbox

“At this point in the pandemic we are tired, not even physically tired, but we are mentally exhausted, so trying to give our employees an outlet to be verbal about what they are experiencing with that burden is critical,” says Ronda Arline, Director of Nursing, Albany Area Primary Health Care, Albany, GA. “With this pandemic, our employees have lost parents, siblings, and even children so in order to help them, you have to consider their personal lives on top of things constantly changing in the clinics which are busy outside of COVID.”

NACHC is addressing moral injury and distress with health centers to strengthen their workplace culture. In the NACHC presentation, “A Path to Healing for the Workforce,” Senior Fellows Jennie McLaurin, MD, MPH, FAAP, Wanda Montalvo, PhD, RN, FAAN, and Grace Wang, MD, MPH, FAAFP discussed the impact and trauma on the workforce resulting from the pandemic. The presentation illustrated staff resources to assist healing, including poetry exercises, and examples of grief walking methods.

“As our health care teams continue to push through this pandemic response, we must acknowledge and meet our provider teams where they are.”
Dr. Wanda Montalvo, Phd, RN, FAAN

The Therapeutic Power of Poetry

Functional MRI studies show poetry composition provides an opportunity to rest the parts of the brain that are used for planning and priority setting. Research also shows writing poetry increases activity in areas of the brain associated with motivation, drive, and intentional self-generated action. According to Dr. Wang, “Poetryis a narrative medicine tool that helps staff process and channel intense emotions, give perspective to their worries and foster a sense of calm and peace.”

Writing short poems like Haikus are ways that care teams can gather to express their reality and their hopes for the future.

Haiku Poetry Technique	Examples
Contains 17 syllables, arranged in 3 lines Lines 1 and 3 – 5 syllables Line 2 – 7 syllables Does not rhyme or have titles Is not a reflective or finished poem The verb “to be” shouldn’t be included, it is already implied Should be kept simple Tends to include a reference to nature or to the current season	Too many thoughts abound I long for peace and quiet Too much to be done Toward better health Respect for healthcare workers Listen to the science

Reflecting on Loss Through Grief Walking

Health center staff are experiencing griefs both large and small. One intervention that safely assists staff to collectively process and validate their grief is Grief Walking, developed by Joanna Macy, PhD, author, teacher, and Buddhist scholar. “This structured, safe and short (1 hour) method helps people share and process “small griefs” that compound greater griefs. It’s perfect for the many pandemic losses felt in the workplace,” says Dr. McLaurin.

Creating a Forum for Open Communication and Connection with a Nurse Leaders Boot Camp

Creating opportunities for care teams to come together to help share and connect about the burnout and stress they are experience personally can also assist with their individual healing process and build resilience. Rhonda Arline of Albany Area Primary Health Care recently led her nurse leaders from different clinic locations through a half-day “Nurse Leaders Boot Camp.”

Held at a partner’s auditorium (donated space), the session gave nurse leaders the opportunity to decompress and have open communication with each other and leadership about their experiences of stress and burnout. They were given the opportunity to share what is and is not working in their clinics and what leadership can do to better support them. The opportunity to come together helped forge connections and new support systems among these nurse leaders who all worked at different clinic locations.

Discussion topics and role play activities focused on a range of stress, burnout and communication issues including:

compassion fatigue
putting the fun back into the workplace
adapting to change
conflict resolution
crucial conversations
generational diversity
mindfulness and self-care

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