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Preparing for COVID-19 surge has left local health clinics with a strange problem: not enough patients.

COURTESY PHOTO: ST. CHARLES - Madras Emergency Department coordinator Labree Tolman demonstrates work in the department's tent with Shayla Jones, an admitting representative at St. Charles Madras.In the midst of the biggest public health crisis in 100 years, local health care providers are ailing. Social distancing has been effective so far in preventing an unmanageable surge of COVID-19 cases but has left St. Charles Madras and Jefferson County health clinics grappling with an ironic problem: not enough customers.

Several factors have combined to dramatically reduce the volume of patients seeking care at St. Charles Madras. The most direct factor is Gov. Kate Brown's March 19 order that health care providers postpone all elective surgeries and nonemergency procedures to conserve face masks and other personal protective equipment.

Indirectly, the governor's stay-at-home order for the general population has lowered the number of accidents requiring medical care and caused a steep decline in people seeking care for infectious diseases like colds and flu.

The hospital is seeing about half of the number of outpatients it normally would see at this time of year because treatments like physical therapy and occupational therapy, as well as routine screenings like mammograms, have been put on hold.

People are probably also staying away from the hospital because of fear they will come into contact with others infected with COVID-19.

Visits to the emergency room are down about 50%, according to St. Charles Madras Administrator David Golda, who stressed that the hospital has taken steps to ensure safety for patients and staff.

"You're still going to get safe, high-quality care. We want to make sure people aren't staying away when they really need to be here," Golda said. "We've seen a couple instances when people probably should have come in earlier, but we were still able to help them."

Under the new protocols, a triage nurse meets incoming ER patients in the parking lot for an initial screening that includes a temperature reading and questions about symptoms such as a cough and shortness of breath. Suspected COVID-19 patients will be directed to the ambulance entrance and taken to a separate part of the hospital for further examination.

The hospital has a large tent set up in its northwest parking area to handle a potential surge in patients with respiratory illness. So far, the hospital has not needed to use it.

In addition to those precautions, everybody entering the hospital, including staff, goes through the screening process. Staff are restricted from traveling out of state or on an airplane to ensure that they don't inadvertently spread the coronavirus.

The loss of business has created financial difficulties for the hospital system.

"It's something we're trying to mitigate through the financial assistance we're getting from the federal and state governments," Golda said. St. Charles Health System has received about $14 million of the $30 billion of CARES act funds that have been allocated to hospitals.

Golda says the Madras hospital's shortfall is partially offset by current St. Charles policy, which calls for the hospital in Bend to take on COVID-19 patients while sending less-acute patients to be cared for in Madras, Prineville and Redmond.

"Because of that, our inpatient census is at or above normal," Golda said. "On the inpatient side, we're staying busy."

COURTESY PHOTO: ST. CHARLES - St. Charles Madras Emergency Department coordinator Labree Tolman demonstrates caregiving on Shayla Jones, a hospital admitting representative.

Health care clinics

Like the hospital, local health care clinics have experienced a sharp drop in patient visits and a corresponding drop in revenue.

"We've got the stay-at-home order, so people are trying to be respectful of that, and from our perspective, that impacts our income. If we're not seeing patients, we're not making money," said Bob Jones, administrator of Madras Medical Group.

Some staff members have had to take time off for maternity leave and for child care issues related to school closures, but so far, Madras Medical has not had to lay off any staff.

"With the CARES act that just passed in the last three weeks, it looks like we're going to get some funding that will help mitigate the need to do that. And we had a busy couple of months in December, January and February that I think were enough that we're going to be able to squeak by without needing to do anything extreme," said Jones.

In order to generate more income and to ensure the safety of staff and patients, the clinics have implemented significant changes in the way they serve their clientele.

All three clinics -- Madras Medical Group, Mosaic Medical and St. Charles -- have introduced telemedicine so that patients can consult with care providers without leaving their own homes.

Madras Medical Group uses the video chat program Zoom in a password-protected, secure format that maintains patient privacy in compliance with HIPAA regulations.

"It's moderately popular," Jones said. "It's such a new idea that it's challenging for some people. They have to get an app on the phone, they have to have a smartphone or a computer with a video camera."

Mosaic Medical Clinic Physician Assistant Joy Light works from home four days a week, talking with patients over the phone or via video for ailments such as rashes, allergies and chronic conditions.

Light says her patients have been understanding about the need to meet with her electronically.

"I think they're dealing with it pretty well. I think it's taking a while to get the word out about how it works," she said.

"We're still providing the same services, just in a different format," said Mosaic Clinic Manager Leticia Hernandez Montano. "We want to keep as many people out of the clinic as possible to keep them home safe to help slow the spread of this virus."

All the clinics are still open for patients who need to be seen in person, albeit with some changes. Mosaic has cut back its open hours to three days per week for six hours instead of eight and with minimal staff on duty.

Madras Medical Group is still open six days per week. Patients are asked to wear a mask and maintain social distancing in the waiting room.

Like at the hospital, staff at the clinics now meet people outside for an initial screening before they can enter the building.

Cold and flu cases have tapered off, but the clinics have taken precautions to prevent the spread of any communicable diseases. At Mosaic, well patients with no symptoms of contagious disease are scheduled for the morning, while patients with such symptoms are scheduled for the afternoon to keep the two groups separate.

Madras Medical Group has sealed off a portion of its clinic to be used solely for patients with possible infectious diseases. The clinic has also been cleaning its waiting room frequently throughout the day.

At all of the clinics, patients who are suspected of having COVID-19 are seen by medical staff at their cars in the parking lot and never enter the clinic at all.

Jones said that Madras Medical Group has taken samples from five or six people suspected of being infected with the coronavirus. The samples are sent to St. Charles Bend, which then sends them on to the University of Washington for processing.

All of the samples taken by Madras Medical Group to date have tested negative for the virus, but Jones said the criteria for testing eligibility is still very stringent due to scarcity of test kits, so it is possible that some coronavirus cases are going undiagnosed.

St. Charles' David Golda said that the hospital in Bend has recently acquired some test kits and test processing equipment that will provide test results on-site in 40 minutes, as opposed to the approximately seven days it takes to get results back from Washington. However, the hopsital doesn't have very many of the 40-minute test kits.

Light of Mosaic Medical uses a checklist to assess candidates for COVID-19 testing. To be eligible, patients must have fever, cough and shortness of breath.

"When we say 'shortness of breath,' what it means is you can't even do normal daily functions, your breathing is accelerated, you can't talk in full sentences," Light said.

In addition to those symptoms, patients are asked whether they are over 60 years old, have existing conditions such as diabetes, have recently traveled overseas, are known to have been exposed to coronavirus, or are first responders. The answers to those questions are factored into the decision of whether a COVID-19 test is needed.

Patients who have COVID-19 symptoms but are not deemed eligible for testing are sent home and encouraged to isolate themselves.

Despite the changes in the way they operate, Hernandez Montano stressed that the clinic is still accepting new patients, with or without insurance.

Mosaic also continues to offer a wide variety of social services such as help with enrolling in the Oregon Health Plan and referrals to community resources like food pantries.

Mosaic has a behavioral health hotline people can call for help with problems like anxiety or depression. The hotline number is 541-408-9562.

Personal Protective Equipment

All of the local health care providers said they have enough personal protective equipment, or PPE — for now.

Golda said that system-wide, St. Charles hospitals have taken steps to conserve PPE, but that the Madras location is well stocked and has an advantage over the other hospitals because it was originally built as a standalone hospital.

"What's unique about Madras compared to the other campuses is that we actually have a warehouse, whereas in Redmond and Prineville, they receive just-in-time warehouse deliveries from Bend to keep them stocked," Golda said.

Still, Golda said, it is important to conserve PPE.

"If we were to use it like we normally would, we would go through it in a couple months," he said. "We're really trying to get to a point where we never have to make that difficult decision of sending a caregiver to do their job without the right equipment."

Despite being in good shape for now, the hospital would still welcome donations of N95 masks from the community "because we really don't know what the coming months have in store for us as it pertains to access to PPE," Golda said.

When it's time to restock supplies of PPE, Golda said, the Madras hospital will benefit from being part of a hospital system.

"We have an amazing system support from our logistics team and our supply chain," he said. "They've been obtaining the equipment we need as we try to prepare for potential surges. Having the system support on that level as well as the financial support is what makes Madras able to rise to the challenge and meet the needs of the community."

Madras Medical Group was already well stocked before the pandemic came to Central Oregon, "not by plan, but just by coincidence," Jones said.

If current conditions continue for more than a month, the clinic will probably encounter a problem replenishing its PPE, he said, but for the present, the clinic is getting by with its current stock supplemented with homemade cloth masks donated to the staff by community members.

Mosaic has taken measures to conserve its supply of PPE, and having its care providers mostly work from home helps a lot, but Hernandez Montano said she can't predict what the future will bring.

Jefferson County Health Department

Although social distancing is working to slow the spread of COVID-19 and other communicable diseases, staff at the Jefferson County Health Department are still working long hours coordinating the county's emergency response to the coronavirus pandemic, receiving and distributing critical supplies, and partnering with Deschutes and Crook counties to trace the contacts of coronavirus victims.

One of the health department's major roles is to facilitate communication between emergency managers, the state health authorities and local hospitals to ensure that state orders and guidelines are adhered to locally.

The department also communicates with local, regional and state entities to prepare Jefferson County for a surge in cases.

"We are communicating with our health system as a whole to ensure that when and if we get more cases, that we are able to respond locally, that all the resources aren't utilized in Deschutes, and that there is a system in place so that we are ready as well," said Michael Baker, health services director for Jefferson County Public Health Department.

As part of the Central Oregon Public Health Partnership, Jefferson County's health department works closely with its counterparts in Deschutes and Crook counties.

Among other things, that entails assisting Deschutes County with contact tracing because some Deschutes County residents who test positive for COVID-19 have come into contact with Jefferson County residents before being isolated, putting those Jefferson County residents at risk for COVID-19.

"We are checking in with them daily, monitoring symptoms, having them take their temperature, making sure that they are self-isolating, not going to work, and things like that," Baker said.

Although Jefferson County has only one confirmed case of COVID-19 and that person is currently out of state, health department staff are responsible for contacting him or her regularly.

The regional health partnership has helped protect residents of long-term care facilities—some of the community's most vulnerable people—from contracting COVID-19 by providing an infectious disease nurse who consults with the facilities in all three counties on how to prevent outbreaks.

Central Oregon's care facilities have remained safe so far, and Baker said that state authorities have been impressed by Central Oregon's handling of the situation.

Supplies of protective equipment such as N95 masks have been trickling into Jefferson County from state and national stockpiles. The health department receives the supplies and distributes them as needed to local health care providers.

To do that effectively, staff at the health department collect inventory data from health care providers and use a matrix that projects equipment needs in various circumstances, such as normal volume of patients or volume of patients during a surge of COVID-19.

While PPE supplies are adequate for now, continuing scarcity of COVID-19 test kits prevents the health department from doing any community testing to get a better idea of how widespread the virus is.

Unfortunately, health department staff spend much of their time following up on rumors in the community.

"By far, the largest drain of resources right now is dealing with misinformation from our own public. We want to make sure any information that's out there in public is accurate, and so when we hear these rumors, we do try to address them. It is amazing how fast one false piece of information spreads versus how long it takes to correct that," Baker said.

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