May 2020
Project Spotlight
Sheps Leads Survey of Provider Needs
The Sheps IT team worked with Jacqueline Halladay, MD, MPH, and the Mountain Area Health Education Center (MAHEC) in Asheville to build a web-based platform to support data collection and outreach efforts to understand the needs of primary care practices dealing with the COVID-19 pandemic. Within days, a survey and data collection systems were developed and deployed to hundreds of practices in the MAHEC region.

Medical students and other volunteers from both MAHEC and UNC/Sheps called primary care practices to inquire about training needs, transition to telephone and telehealth visits, shortages of equipment and supplies, managing staff shortages, and understanding how to support specific patient populations. Additionally, the effort connected primary care practice staff and providers to experienced practice support coaches who provided direct support and daily video conference sessions. 

More than 100 practices have responded so far to this MAHEC-funded initiative. Practices are immediately being provided with resources and practice coaches who continue to check on the practices weekly. Currently about 40% of responding practices can offer COVID-19 testing, and 60% said they had enough N95 respirators for the next two weeks —although that number decreases when asked about four weeks from now. All of the data, including interactive maps, can be found at the MAHEC website: .

The MAHEC Needs Assessment Survey was the impetus for a similar, larger, effort that is being deployed statewide by Sheps in partnership with the NCDHHS Office of Rural Health and NC AHEC. 
Sheps Collects Data on Practices Statewide
The Sheps Center, in coordination with NC AHEC and the NCDHHS Office of Rural Health, created and implemented a data collection system and survey focused on workforce and supply needs of primary care practices across the state of North Carolina. With Brian Cass at the helm, the system was issued as a “Call to Action” by Governor Roy Cooper and NCDHHS Secretary Mandy Cohen.

Sheps is the perfect place to house this data; it has the advantage of being a neutral entity with the IT acumen and research infrastructure to execute such a project. The collaboration has yielded a large database of COVID-19 survey response data from seven different partners. By compiling these surveys and making aggregate data available to stakeholders, North Carolina will better be able to maximize its response to needs of its healthcare practices. Efforts are also underway on an interactive map of North Carolina counties showing broadband access, telehealth uptake, and supply needs. 

The project’s greatest challenge has been the collection of practice information. The team has successfully compiled 1,000 accurate practice contacts, but this is likely only one quarter of all North Carolina primary care practices. Every day practices are added, clinic personnel complete surveys, and Sheps continues to build the data system.

This effort was also made possible by the generous contributions of NC TraCS. 
Research News
Sheps Director Participates in State Modeling Group
Mark Holmes, PhD, director of the Cecil G. Sheps Center for Health Service Research, was part of a group of North Carolina experts, including researchers from UNC Chapel Hill, Duke University, and RTI International, who performed modeling to help the state respond to COVID-19. The group briefed Governor Roy Cooper, NCDHHS Secretary Mandy Cohen, legislators, and the media on their findings.

The group released a composite modeling forecast looking at how COVID-19 could affect North Carolina in the coming months.

The group also collaborated on a brief analyzing data to inform North Carolina’s reopening strategy. The analysis showed that reopening fully by relaxing all social distancing policies prematurely would markedly increase the probability that hospitals and healthcare workers could face an unsustainable influx of patients in a compressed time period. The experts proposed a gradual, “dimmer switch” approach to reopening, supported by a plan including
rapid testing and contact tracing along with careful monitoring of hospital capacity and the safety and supply of our healthcare workforce.

The reports have received a great deal of local media attention ( WRAL ,   WUNC , and   N&O). The experts are continuing to run models using information from other states and countries and intend to release further data as it becomes available. Check their website for updates.
Support the Sheps Center
Give UNC was rescheduled to June 16 due to the pandemic. Stay tuned for more details, but you can support the Sheps Center online by following the link and searching for Cecil G. Sheps Center. Your support will help ensure that critical projects like these continue, supporting health policy, capacity and workforce here in North Carolina.
Primary Care Perspective
Dan Jonas, MD, MPH, is an associate professor and section chief for research in the General Medicine and Clinical Epidemiology department of the UNC School of Medicine. He is the deputy director for research and director of the medical practice and prevention program at the Sheps Center. Dr. Jonas gave a first-hand account of the challenges faced by primary care providers during the pandemic .

It’s a challenging time to be a primary care physician as we aim to provide excellent health care for our patients while also shifting a large portion of our focus toward the novel coronavirus. Care delivery models and systems are changing rapidly, to quickly integrate processes to deliver care by telephone and video visits, aiming to avoid in-person visits unless absolutely necessary. 

Hospital preparations also impact primary care providers. Redesign of inpatient hospital care teams and systems to prepare for potential/expected surges of COVID-19 patients involves planning to bring primary care providers into hospitalist roles if needed. Therefore, many primary care providers are spending a lot of additional time re-learning (or newly learning) care standards for common inpatient medicine problems (e.g., GI bleed, chest pain). For me, it has been 15 years since I’ve taken care of patients in the hospital.

There are many meetings and numerous emails every week dedicated to COVID-19. Like all working adults, many primary care providers are challenged with caring for their children who are now always home, the additional “home schooling,” and all while continuing with a busy work schedule. 

One silver lining in all the changes: none of my kids could ride a bike prior to all of this, and now we have two little bike riders in the house!
Workforce Research
Erin Fraher, PhD, director of the Carolina Health Workforce Research Center, joined six other directors of health workforce research centers to highlight state strategies to ensure and sustain the health workforce to meet patient needs during the COVID-19 pandemic. Their article,  “Ensuring and Sustaining a Pandemic Workforce,”  was published recently in the New England Journal of Medicine. 

As state and health system leaders seek to quickly ramp up their health workforce to meet the surge of patient demand from COVID-19, removing bureaucratic barriers and adapting regulations are necessities. As a result of the state of emergency, the Centers for Medicare & Medicaid Services (CMS) has waived certain regulations, expanded telehealth coverage and broadened payment flexibility.

States can make additional requests under Section 1135 of the Social Security Act for greater flexibility in the deployment of health care workers. Another strategy is working with licensing boards to reinstate recently expired licenses through temporary extensions to encourage retired health professionals to re-enter the workforce.

The authors also recognized efforts by health professional societies, health care educators, and accreditors to find education and training solutions to bolster the health workforce. These include:
  • accelerating education programs for essential workers, such as respiratory therapists;
  • retraining health care workers who have seen reduced clinical volume – like physical therapists – to provide needed care;
  • redeploying health professional students to assist in medical tasks to free up other clinicians; and
  • engaging social workers and community health workers to address social needs.

The authors call on leaders to take swift action to expand and sustain the health workforce to help our country meet the needs of patients during this COVID-19 pandemic, and to evaluate these changes to inform any future response to pandemics. 

Sheps Health Workforce NC COVID-19 Blogs
As North Carolina prepares for a rising number of COVID-19 cases, the Program on Health Workforce Research and Policy is providing data on the availability of needed health professionals. Continue to check our website for additional blogs and resources.

North Carolina's Respiratory Care Board has acted swiftly to surge the state’s respiratory therapist (RT) workforce. However, according to a recent survey, RT coordinators and managers at hospital and health facilities suggested the need for at least 765 additional RTs. This is more than the currently available pool of unemployed RTs in the state.

North Carolina needs a trained and accessible nursing workforce to care for the high influx of critically ill patients. To increase the existing workforce and support the anticipated surge of critically ill COVID-19 patients, places in North Carolina with few ICU nurses may need to encourage and recruit RNs to relocate to these areas or cross-train existing staff to take on critical nursing tasks.

Many people in rural areas of North Carolina lack adequate access to primary care practitioners (physicians, nurse practitioners, physician assistants and certified nurse midwives). Seven counties have a particularly low supply of primary care clinicians: Anson, Northampton, Franklin, Warren, Gates, Tyrrell and Camden. Camden County has a population of just over 10,000 and no primary care providers.

In 2018, 211 North Carolina physicians reported that infectious disease was their primary area of practice. Many are associated with academic health centers and may do research or work in public health in addition to seeing patients.
NCIOM Helps Draft Statewide Pandemic Protocol
As the COVID-19 pandemic has increased in intensity, the North Carolina Institute of Medicine (NCIOM), the North Carolina Medical Society (NCMS) and the North Carolina Healthcare Association (NCHA) were asked by the North Carolina Department of Health and Human Services to work with stakeholders to develop a new statewide protocol for the allocation of scarce critical care resources during a Governor’s declared state of emergency (NCGS §166A) due to a pandemic and when demand for critical care resources exceeds supply. This work continues work on a Pandemic Influenza Task Force conducted by the NCIOM in 2006-2007.

On March 26, the organizations convened a Scarce Resource Allocation Protocol advisory group to solicit feedback on a revised draft protocol from stakeholders. The advisory group included representatives from a number of clinical specialties, nursing, spiritual care, ethics, law, and public health, as well as community and advocacy groups. On March 31, NCIOM, NCMS and NCHA convened an additional group – the health care stakeholder group – comprised of clinical, legal, and ethics experts from the health system, to review the draft.

Following additional revisions and feedback from both groups, the draft North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic was provided for consideration to the Secretary of Health and Human Services on April 6.
In addition, NCIOM has published brief blog posts about the ways that Task Force recommendations and other stakeholder work are impacted by COVID-19. Examples include:

Upcoming blog posts will address emerging data on COVID-19 and food insecurity and implications for rural North Carolina. NCIOM has also published, in partnership with the South Carolina Institute for Medicine and Public Health, an issue brief on federal COVID-19 legislation and assistance for North and South Carolina residents affected by the pandemic.  
Sheps Center Briefs
Domino Assists NC Medicaid During COVID-19

As one of the largest sources of health insurance coverage in North Carolina, the Medicaid program has implemented a number of emergency provisions in response to the coronavirus pandemic. Dr. Marisa Domino, director of the Program on Mental Health and Substance Abuse Systems and Services Research and professor in the Department of Health Policy and Management in the Gillings School of Global Public Health, is working with a team at the N.C. Division of Health Benefits to examine the use of emergency provisions and monitor the impact of policies such as transitioning office visits to telemedicine, extending supplies of pharmaceuticals, and offering testing reimbursement for Medicaid enrollees and providers.
Support Continues for Providers Treating Opioid Use Disorder

UNC ECHO for MAT, which helps primary care providers offering medication assisted treatment (MAT) to those with opioid use disorders, is continuing to thrive during the COVID-19 pandemic with a few adjustments. The team has discussed issues related to COVID-19 with participating providers and shared information, educational sessions, and additional resources to help them and their practices. 

Some scheduled clinic topics have been modified to address telemedicine, distance communication, and COVID-19 in general. Topics have included caring for patients in isolation, providing behavioral care for patients dealing with an increase in stress and anxiety, managing testing during the pandemic, and improving provider self-care. 

Leaders have been contacted by clinicians and colleagues from all over the continent who are interested in the clinics because they don’t have anything like this where they are living and working. 
Sheps Center Library Responds to COVID-19 Challenges

Sheps Center Library, programming, and RTI-UNC Evidence-based Practice Center (EPC) staff have worked on a contract with AcademyHealth and the National Library of Medicine (NLM) since the early 1990s to educate the health services research (HSR) community about NLM resources and to curate and maintain a freely available database of ongoing HSR at NLM, HSRProj (Health Services Research Research-In-Progress) , led by PI Christiane Voisin, Associate Director for Library and Information Services at Sheps. 

In response to a request from NLM, Sheps Center Library/HSRProj staff have implemented strategies to meet new information demands related to the COVID-19 pandemic. In conjunction with our partners at AcademyHealth, our approach includes: (1) engaging with key current contributors to the HSRProj database to identify new funding opportunities, which will be tracked until awarded; (2) identifying new funders and activities that can be included in the HSRProj database; and 3) reviewing key HSR information sources to identify existing studies that are adding a COVID-19 component. This new work aims to help researchers in our field separate what is HSR from the firehose of new COVID information being produced. We expect these endeavors to 1) help speed addition of COVID-19 research to the publicly available portal HSRProj; and 2) identify and report potential novel funding streams and performing organizations that are responding rapidly to the pandemic.