One in 5 Americans utilizes federally qualified health center (FQHC) services for their primary care, preventive, and community health needs. Medicaid and FQHC programs have been partners at the forefront of addressing population health needs for more than 50 years. Although testing and contact tracing during the coronavirus disease 2019 (COVID-19) crisis are helping rural FQHC patients, there are other vital Medicaid services that are both available right now and ripe for enhancement to ensure the accessibility of services during and after the COVID-19 emergency. A primary example is nonemergency medical transportation (NEMT). Community health centers must focus on NEMT use to ensure access to care for rural patients as states reopen. This commentary defines NEMT and ways that FQHCs can enhance it as a Medicaid benefit as states reopen amid COVID-19.

Community health centers provide primary care to 1 of 5 Americans and are vital to patient access as states reopen amid the coronavirus disease 2019 (COVID-19) pandemic.

Federally qualified health centers must focus on the special Medicaid benefit of nonemergency medical transportation in the COVID-19 emergency.

Despite the news of states reopening, coronavirus disease 2019 (COVID-19) has had devastating impacts on the overall economy and population health in ways that will take years or even decades to overcome.

 Growing numbers of people are unemployed, under- or uninsured, or unable to pay for health care. Consequently, the largest safety net programs for coverage and care, Medicaid and community health centers/federally qualified health centers (FQHCs), have been under enormous and mounting pressure to fulfill their critically important roles in the response to the public health emergency.

Medicaid provides health and long-term care coverage for more than 70 million adults and children, or 1 in 5 Americans. States and the federal government fund the program jointly. Health centers serve as the primary care safety net for more than 29 million adults and children, including 1 in 5 of Medicaid beneficiaries.

 By mission and mandate, they provide health care and enabling services to individuals regardless of their ability to pay.

Medicaid financing ensures that health centers are able to provide high-quality care to vulnerable populations, including a state’s Medicaid enrollees. The Medicaid and health center programs have been partners at the forefront of addressing population health needs for more than 50 years. Although testing and contact tracing during the COVID-19 crisis are helping rural FQHC patients, there are other vital Medicaid services that are both available right now and ripe for enhancement to ensure the accessibility of services during and after the COVID-19 emergency. A primary example is nonemergency medical transportation (NEMT).

During the COVID-19 emergency, lack of transportation frustratingly reemerged as a barrier to care for low-income Americans. When the pandemic struck, some patients lost their personal vehicles due to financial difficulties. Many others avoided the risks of ridesharing or public transit options, which have been substantially reduced. Finally, technology barriers make the use of telehealth especially challenging. Taken together, health centers were among the many providers to experience a steep decline in patient visits.

Fortunately, the Medicaid program has long recognized lack of transportation as a barrier, which is why state Medicaid agencies are required to ensure necessary transportation to and from providers via NEMT. In addition to providing the benefit, states must describe how they will deliver the NEMT benefit in their Medicaid state plan. Some states choose to deliver NEMT directly, whereas others may deliver the benefits through a broker program or under contract with individuals or entities.

Ways to Enhance the Medicaid NEMT Benefit

Coverage is complex and access to care is highly dependent on one’s comprehension of the coverage labyrinth. The Medicaid NEMT benefit is often overlooked despite its demonstrable need and proven value.

 Some practical steps that health centers can take to help ensure the availability of NEMT services, working with their partners at state primary care associations and health center controlled networks, include:

reviewing the Medicaid state plan to understand how their state makes operational the NEMT assurance requirement

obtaining written guidance from the state on how Medicaid beneficiaries can access NEMT;

sharing up-to-date information about the Medicaid NEMT benefit on their FQHC’s website and ensuring that outreach and enabling services staff are equipped with and sharing that information;

working cooperatively with their state Medicaid agency to resolve NEMT access issues for FQHC users;

monitoring state proposals to waive NEMT through section 1115 waiver demonstrations and section 1135 COVID emergency state plan amendments

working with their state to determine NEMT flexibilities it would be willing to offer through a section 1115(a) waiver demonstration and/or section 1135 Medicaid Disaster Relief for the COVID-19 National Emergency State Plan Amendment.

Forging Ahead With Existing Tools and Space for Innovation

As safety net programs, FQHCs and providers continue to step up to address the mounting challenges before us, but it is critical that we first ensure that existing tools, such as NEMT, are fully maximized.

 Shasta Cascade Health Centers, Mount Shasta, CA.

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design; acquisition of data; drafting of the manuscript; and supervision.

 Miku Sodhi, MBBS, MHA, Shasta Cascade Health Centers, 1632 Christian Way, Mount Shasta, CA 96067-9202. Email: miku_sodhi@hotmail.com.

1. Health centers on the front lines of COVID-19: $7.6 billion in lost revenue and devastating impact on patients and staff. National Association of Community Health Centers. April 2020. Accessed June 20, 2020. https://www.nachc.org/wp-content/uploads/2020/04/Financial-Loss-Fact-Sheet.pdf

2. National findings on health centers’ response to COVID-19. National Association of Community Health Centers. May 2020. Accessed June 20, 2020. https://www.nachc.org/wp-content/uploads/2020/05/Health-Center-Response-to-COVID-19-Infographic-2pg-5.1.pdf

3. Community health center chartbook 2020. National Association of Community Health Centers. 2020. Accessed June 20, 2020. https://www.nachc.org/wp-content/uploads/2020/01/Chartbook-2020-Final.pdf

4. Cost-benefit analysis of providing non-emergency medical transportation. Transportation Research Board. Updated March 23, 2016. Accessed June 20, 2020. http://www.trb.org/Publications/Blurbs/156625.aspx

5. Medicaid state plan amendments. Medicaid.gov. Accessed June 20, 2020. https://www.medicaid.gov/medicaid/medicaid-state-plan-amendments/index.html

6. Medicaid waiver tracker: approved and pending section 1115 waivers by state. Kaiser Family Foundation. July 13, 2020. Accessed June 20, 2020. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/

Articles

COMMENTARY

Federally qualified health centers (FQHCs) must focus on enhancing the nonemergency medical transportation Medicaid benefit to improve patient access during the coronavirus disease 2019 (COVID-19) emergency as states reopen.

Ensuring Access to Health Care by FQHCs as States Reopen Amid COVID-19

Coronavirus disease 2019 (COVID-19) is a pandemic disease that has had a major impact on the world health care system and has brought catastrophic damage to the world and seriously affected normal life. Although the incidence of COVID-19 has slowed in China, new COVID-19 cases have been reported in hospitals there. China gradually realized that hospitals with concentrated personnel may become a potential danger area for new outbreaks because 

outpatient hemodialysis can go back and forth between the hospital and their own residences every day. They may become the group who will be most easily infected with severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19. We introduce a mobile phone app that may effectively prevent and manage COVID-19 in 

outpatient hemodialysis in Sichuan Province.

Coronavirus disease 2019 (COVID-19) is a pandemic disease that has had a major impact on the world health care system.

 As of June 1, 2020, 6,096,628 confirmed cases and 369,456 deaths had been reported worldwide. The pandemic has wreaked catastrophic damage internationally and has seriously affected the normal lives of people everywhere.

The incidence of COVID-19 in China, which has had a great impact on the country, especially its tourism and catering industries, has slowed; most new cases are in foreign patients and there are no more than 100 cases. However, COVID-19 cases have recently been reported in hospitals in many cities of Heilongjiang Province. Authorities gradually realized that hospitals may become a potential danger area for new outbreaks. Health administration departments all over China have imposed stricter control requirements on hospitals, including nucleic acid testing for newly admitted patients and those who accompany them, temperature testing, and epidemiological history registration for all outpatients.

However, outpatient hemodialysis patients may become the group who will be most easily infected with severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19.

 Unlike inpatients, who can be managed in a closed environment, outpatient hemodialysis patients can go back and forth between the hospital and their own residences every day. Additionally, they differ from sporadic outpatients in that outpatients on hemodialysis will go to the hospital very frequently and gather together for a long time (4 hours or longer). It is very easy for a COVID-19 outbreak to occur among outpatient hemodialysis patients.

 Then, once patients are infected, it is hard to find an alternate place where 

so many patients can be properly arranged. Therefore, methods to carry out effective prevention and control of COVID-19 for outpatients on hemodialysis are worth exploring. Here, we introduce a mobile phone app, Sichuan Health Pass, which is widely used in Sichuan Province, China.

This app can be embedded in WeChat, the most widely used social platform software in China (

]). After clicking this app in WeChat to register with one’s real name, it is automatically filled in with all information on the registrant’s identification card and their mobile phone contact information. After logging in, a health QR code is displayed, which refreshes dynamically every day (

). When the registrant enters the hospital or high-risk gathering area, the security personnel require the registrant to show their health QR code before being allowed inside.

Normally, the QR code is green, indicating that the registrant has minimal risk of COVID-19 epidemiology. Once the registrant has 

had contact with patients infected with or suspected to have 

the virus or has recently visited the COVID-19 epidemic area, the health administration department will automatically report the registrant’s identification number to the software, and the registrant’s health QR code will turn orange. Once the registrant receives a diagnosis of suspected or confirmed COVID-19, the health QR code will turn red. An orange or red QR code will cause the registrant to be unable to enter the controlled area or be forced to isolate.

A nurse is on duty at the door of the hemodialysis center. Each patient who comes to the hemodialysis center is required to have their temperature checked and show their health QR code. If it is green, they can be treated normally. Patients with an orange code will be moved to the corner of the last shift of dialysis treatment; at the same time, the patient is required to take protective measures, such as wearing a mask, and nurses will take 3-tier prevention measures to treat all patients. If the code is red, they will be refused entry and asked to go to the designated hospital for isolation dialysis treatment.

Nearly 40,000 outpatients are receiving hemodialysis in Sichuan Province, China. After the application of this mobile phone software for COVID-19 prevention and control, the vast majority of hospitals reported that the screening work intensity and the pressure of prevention and control were greatly reduced. It is no longer necessary to fill in the form of epidemiological inquiry for dialysis patients every day, and it is no longer a concern that patients may hide possible epidemiological contacts. The operation of the whole hemodialysis center has gradually recovered to a calmer state. Most importantly, since the mobile phone software has been put into use, no new event of aggregated infection among outpatients with hemodialysis in Sichuan Province has occurred.

We will continue to discuss and analyze the role of the Health Pass program for early warning of COVID-19 in the future.

Yaqin Du and Jin Feng contributed equally to this work and are listed as co–first authors.

 Department of Nephrology (YD, YL, DH, QH, GL, LW, FD) and Department of Traditional Chinese Medicine (JF), Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China; Sichuan Center for Disease Control and Prevention (JD), Chengdu, China; Hemodialysis Center, Sichuan Center for Disease Control and Prevention (YX), Chengdu, China; Department of Nephrology, Chengdu Jinniu District People’s Hospital, Sichuan Provincial People’s Hospital, Jinniu Hospital (YD, FD), Chengdu, China.

 This work was supported by Sichuan Science and Technology Program (2019YFH0069), Sichuan Provincial People’s Hospital Clinical Research and Transformation Fund (2018LY12), and Primary Health Development Research Center of Sichuan Province Program (swfz18-Z-6).

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (YD, JF, FD); drafting of the manuscript (YD); critical revision of the manuscript for important intellectual content (JF, FD); provision of patients or study materials (JD, YL, YX, DH, QH, GL, LW); obtaining funding (FD); administrative, technical, or logistic support (JF, JD, YL, YX, DH, QH, GL, LW, FD); and supervision (YD, JF, JD, YL, YX, DH, QH, GL, LW, FD).

 Fei Deng, MS, Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China. Email: dengfei@med.uestc.edu.cn.

1. Alberici F, Delbarba E, Manenti C, et al; Brescia Renal COVID Task Force. Management of patients on dialysis and with kidney transplantation during SARS-CoV-2 (COVID-19) pandemic in Brescia, Italy. 

. 2020;5(5):580-585. doi:10.1016/j.ekir.2020.04.001

2. Tu H, Tu S, Gao S, Shao A, Sheng J. Current epidemiological and clinical features of COVID-19; a global perspective from China.

. 2020;81(1):1-9. doi:10.1016/j.jinf.2020.04.011

3. Rombolà G, Brunini F. COVID-19 and dialysis: why we should be worried.

. 2020;33(3):401-403. doi:10.1007/s40620-020-00737-w

4. Brioni E, Leopaldi D, Magnaghi C, et al. Covid-19 in patients on dialysis: infection prevention and control strategies. Article in Italian. 

WEB EXCLUSIVE

The authors introduce a mobile phone app that may effectively prevent and manage coronavirus disease 2019 (COVID-19) in outpatient hemodialysis patients in Sichuan Province, China.

Effective Prevention and Management of COVID-19 in Outpatient Hemodialysis Patients

Elderly, homebound individuals comprise a vulnerable segment of society who have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic through a myriad of unique challenges. There is a significant amount of fear of acquiring COVID-19 by seeking health care services, which has adversely affected patients by worsening fixable situations. Another challenge is the decrease in diagnostic support for evaluating patients compared with a pre–COVID-19 world. Agencies providing at-home phlebotomy, portable radiology, and support services have had to limit their home visits due to an inability to access personal protective equipment. This loss of diagnostic and therapeutic support has had an emotional toll on patients and their caregivers. COVID-19 has had a tremendous impact on the health and finances of home health aides and their patients. Loss of long-term home health aides has adversely affected younger patients with ailments like Down syndrome as well as older patients with dementia. COVID-19 has also increased pressure on end-of-life decision making. Patients and their families are increasingly opting for palliative care and hospice programming to avoid separation. Families are being forced to consider advance directives under an increased emotional strain as patients become “persons under investigation” for COVID-19. Technology has allowed for the provision of services through telehealth, and changes to policy by CMS have aided widespread implementation of telemedicine. We anticipate continuing to be nimble in the face of challenge and to provide timely and meaningful care for those who depend on our efforts.

A greater awareness of the unique challenges faced by home health programs in the coronavirus disease 2019 (COVID-19) era will allow decision makers to take a holistic approach to patient management.

Fear of encountering COVID-19 precipitates poor decision-making.

Inadequate supplies of timely diagnostics for COVID-19 adversely affect services for homebound patients.

A lack of personal protective equipment also diminished services by vendors such as visiting nurses and physical therapists.

COVID-19 triggered altered end-of-life decisions by those afraid to be without loved ones in the hospital.

Home visit medical care benefited from a boom in the use of telehealth services.

A vulnerable segment of society is composed of elderly homebound individuals who can no longer care for themselves. We have witnessed bravery by families who embrace their elders with respect and love. Homes are redesigned to incorporate safety and creative design to facilitate accessibility for those with disabilities. Unfortunately, there also are those who suffer neglect by family and social isolation. We care for those who experience financial abuse, poverty, and burdens of chronic disease.

Our medical home visit program is embedded in the Division of Geriatrics at Staten Island University Hospital in New York. We provide ongoing medical visits for 325 families with a professional staff of geriatricians, family practice physicians, a physician assistant, nurse practitioners, a social worker, and a clinical pharmacist. Our office staff facilitates every imaginable need of this population. We have seen our share of natural disasters. While our hospital was being evacuated for Hurricane Irene in 2011, we approached Incident Command with our plan of contacting each family to assess needs. In 2012, while preparing for the impact of Superstorm Sandy, we had some homebound individuals transferred by ambulance to shelters. Staff members purchased and delivered food, and processes were coordinated with oxygen companies, visiting nurse agencies, and Meals on Wheels to predeliver goods. After each disaster, we assisted patients in recovery and safe relocation. The needs emerging from our current emergency are unlike those from any of our past crises. During the coronavirus disease 2019 (COVID-19) pandemic, we have experienced a myriad of unique challenges.

There is an exceptional amount of fear on the part of patients and families to access the health system with concern of coming in contact with COVID-19. This fear impairs good judgment. For instance, a patient taking Coumadin developed black diarrhea and light-headedness yet refused to go to the hospital for decreasing serial measurements of hematocrit. He said, “Hospitals are full of coronavirus and I won’t go there.” There is a fear of isolation because hospitals will not allow visitors, which also leads to poor decision-making. A patient with an acute cerebrovascular accident, with new-onset oropharyngeal dysphagia and the pocketing of food, progressed to fatal aspiration pneumonia because the caregiver could not bear the thought of sending their loved one to the hospital alone.

Another challenge is the decrease in diagnostic support for patient evaluation compared with a pre–COVID-19 world. Vendors have been limiting their home visits, and as a result, our program has had less diagnostic support. Our portable radiology vendor went on hiatus. Previously reliable laboratories for home phlebotomy offered fewer rounds, and patients lost the benefit of urgent testing from home. Testing for COVID-19 by both polymerase chain reaction and antibody identification has been relatively nonexistent for the first few months of this pandemic for the homebound.

The inability to access personal protective equipment (PPE) placed severe limitations on our visiting nurse partners. They were unable to visit patients because they did not have PPE to protect themselves and not all the agencies were prepared to conduct telehealth services. Without these community agencies, support services such as physical therapy, occupational therapy, and speech therapy came to a staggering halt.

Another burden with the loss of diagnostic and therapeutic agencies is the emotional toll of losing the reassurance that these providers gave to patients. Regular contact by nurses and therapists plays an integral role in providing emotional support to overstressed caregivers. Positive reinforcements from these service providers ensure validation for families that they are providing appropriate care. Such reassurance is invaluable in supporting caregiver efforts.

COVID-19 has had a tremendous health and financial impact on home health aides. Some of these dedicated professionals have contracted the disease themselves. While ill and convalescing, they are unable to work, and this has taken a financial toll on this force. Conversely, when a long-serving aide is taken out of rotation for a patient with advanced dementia, there is an increased risk of the patient developing delirium. Continuity of care providers is one key to success in care of adults with dementia. Additionally, there is the risk that aides may bring COVID-19 to patients either by having mild illness or as asymptomatic carriers. Our program has seen this tragically affect younger patients who are compromised by congenital ailments such as Down syndrome and older patients with dementia.

Another impact of COVID-19 on the homebound community is the pressure it brings to end-of-life decision-making. Even in patients who are chronically ill with a high degree of disease burden, some patients and families refuse to address issues relating to assigning someone as a health care proxy, establishing advanced directives such as Medical Orders for Life Sustaining Treatment, and considering palliative care and hospice programming. As patients become “persons under investigation” for COVID-19, their families have been forced to consider these issues under scenarios of increased emotional strain. An increased number of patients have transferred to hospice whose families previously would not consider it. The driving force in most of these situations was that the family did not want to be separated from the patient as they were dying. Most of these cases should have been on hospice already, but pre–COVID-19, there was a significant amount of familial resistance.

Technology has assisted in our provision of services. Families have embraced telehealth and have been very supportive and understanding of the strains on our professional and support staff during this crisis. They express appreciation for telehealth visits and to staff for their assistance in day-to-day operations. Patients have benefited in ways that would not have been earlier imagined. For instance, a patient had fallen and, after being lifted into a chair, was afraid to move for fear of hip fracture. When we were called, we had the family extend her legs with underlying support so we could see whether there was leg shortening or outward rotation of the foot. Upon seeing neither, we were able to coax the patient to ambulate with direct visualization. Other assessments have included shingles, bed bugs, olecranon bursitis, cellulitis, and exacerbations of congestive heart failure and chronic obstructive pulmonary disease—all handled with minimal exposure to the patient and with gratitude from the family. We have trained families to assist in meaningful data collection activities like tracking temperatures, measuring heart rate, and performing pulse oximeter checks so that we could identify patterns of concern. Additionally, we have embarked on a program to have medical students provide “social calls.” They check on how patients are doing, and if a need is identified, including the need for psychological services, then appropriate referrals can be made.

We have been grateful for actions the federal government has taken to help ease transitions from the community to a skilled nursing facility when needed—for example, for the urgent care of a patient with dementia who could no longer be handled at home. CMS rescinded the “3-day rule,” which required a hospitalization for 3 days before Medicare allowed for payments in a skilled nursing facility.

 Further federal and state allowances to decrease regulation and support payment for telehealth visits have provided needed fiscal support of programs that virtually bring medical professionals into the home to direct care.

 We anticipate continuing to be nimble in the face of challenge and to provide timely and meaningful care for those who depend on our efforts.

 Division of Geriatrics, Northwell Staten Island University Hospital (DS, AS, JRM, ZS), Staten Island, NY.

 Dr Seminara is a part-time employee of Staten Island University Hospital, and one of her responsibilities is as medical leader of the home visit program. Dr Szerszen is employed as a home visit program physician. Dr Maese’s wife is a part-time employee of the home visit program at Staten Island University Hospital. Dr Shah reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (DS, AS, JRM, ZS); acquisition of data (DS, JRM, ZS); analysis and interpretation of data (DS, JRM, ZS); drafting of the manuscript (DS, AS, JRM, ZS); critical revision of the manuscript for important intellectual content (DS, AS, JRM, ZS); provision of patients or study materials (DS, JRM); administrative, technical, or logistic support (DS, JRM, ZS); and supervision (DS, JRM, ZS).

 Zeel Shah, MD, Division of Geriatrics, Northwell Staten Island University Hospital, 420 Lyndale Ave, Staten Island, NY 10312. Email: zeelshah8994@gmail.com.

1. Medicare Shared Savings Program: skilled nursing facility 3-day rule waiver. CMS. April 2020. Accessed April 26, 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/SNF-Waiver-Guidance.pdf

2. Medicare telemedicine health care provider fact sheet. CMS. March 17, 2020. Accessed April 24, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

This report highlights the unique challenges faced by home health programs in addition to discussing how technology and policy changes have helped the elderly homebound during the coronavirus disease 2019 (COVID-19) pandemic.

November 2020

Ensuring Access to Health Care by FQHCs as States Reopen Amid COVID-19

Effective Prevention and Management of COVID-19 in Outpatient Hemodialysis Patients

Medical Home Visit Programs During COVID-19 State of Emergency